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

Diagnosis: Cardiac/Circulatory Problems/Hypertension/High Blood Pressure
Treatment: Home Health Care
The health plan denied the requested increase in personal care hours to 40 hours per week. 
The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, glaucoma, hyperlipidemia, urinary incontinence, obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) therapy, and depression who had been assigned personal care assistance (PCA) services 6 hours/day, 5 days/week, to total 30 hours/week. There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of stairs and transportation. With tasks of bathing, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while set up only for tasks of managing finances, managing medication, and phone use. The patient was assessed as independent with tasks of bed mobility and eating. Notes from the assessment stated the patient was having right knee surgery and had no informal help and would require more assistance. Notes also stated the patient attended a day program.
At issue is the medical necessity of an increase in personal care hours to 40 hours per week.

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

Yes. The patient will be having knee surgery with resultant predictable increased care needs for a period of time until recovery and the patient has no informal support. At the time of the assessment the patient required at least limited support with walking, locomotion, transfer toilet, and toilet use. Given the patient's assessment and the predicted need for increased assistance after knee surgery, the assessment underestimated her post surgery care needs. The patient has unpredictable and unscheduled care needs. The patient's care needs cannot be met solely with medical supplies or adaptive equipment. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 8 hours/day, 5 days/week, to total 40 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied Dental Treatment Plan. 
The denial is upheld. 

The patient is a female who presented to the office of her dental provider, for evaluation and treatment of tooth #28. Provided for review are previous letters of appeal and denial, clinical notes, clinical images from, radiographic images from, a single claim form, and health plan language. According to the health plan language, benefits for indirect restorations will only be allowed when there is decay or injury that cannot be addressed with a direct restoration.
At issue is the medical necessity of Dental Treatment Plan, D0220 - Intraoral-periapical-first Film, D2740 - Crown-porcelain/ceramic Substrate and D2950 - Core Build-up, Including Any Pins.

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

The requested health service/treatment of Dental Treatment Plan is not medically necessary for this patient.
Based on the provided documentation there is no decay or injury associated with tooth #28 and there is no indication that there is an indirect restoration necessary. Thus, the core buildup for tooth #28 (2950), and porcelain ceramic crown #28 (2740) is not medically necessary for this patient. 
Therefore, the requested health service/treatment of Dental Treatment Plan is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis (AD)

Treatment: Dupixent 300 milligram (mg)/2 milliliter (ml) syringe

The insurer denied coverage for Dupixent 300 milligram (mg)/2 milliliter (ml) syringe

The denial is overturned.

The patient is a male with a diagnosis of atopic dermatitis (AD). The condition is severe, affecting > (greater than) 10% (percent) total body surface area (TBSA) and includes sensitive areas of the skin, including the inguinal fold. The patient has failed therapy with tacrolimus ointment, clobetasol, fluocinonide, hydrocortisone valerate. The requested medication is Dupixent.  

The patient has severe atopic dermatitis that involve a large surface area, including sensitive areas such as the inguinal fold. As such, light therapy would not be a treatment option. The patient requires systemic therapy given the extent of involvement and the use of Dupixent would appear to be reasonable given that it is Food and Drug Administration (FDA) approved for the treatment of atopic dermatitis and the inability to use systemic light therapy due to sensitive areas of involvement. 

The request for Dupixent is supported by the medical literature and specialty society guidelines. Dupixent is the only systemic therapy approved by the FDA for the management of atopic dermatitis. The FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments. (1-3) According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe AD. Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment with moderate-to-severe AD who are uncontrolled with topical therapies". (1) 

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

The insurer's denial of coverage for the Dupixent 300 milligram (mg)/2 milliliter (ml) syringe is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse

Treatment: medically supervised inpatient detoxification admission

The insurer denied coverage for medically supervised inpatient detoxification admission

The denial is overturned.

This adult male was admitted to this inpatient detoxification treatment due to alcohol withdrawal symptoms. He reported nausea, anxiety, hot and cold sweats, sleeping problems, and anxiety symptoms. He reported drinking 1 pint of liquor and two 6 packs of beer per day and using $ (dollar) 80 per day worth of cocaine. He had a positive toxicology screen for cocaine and benzodiazepines. He had bipolar disorder and was taking Risperidone and had a past psychiatric hospitalization. He had multiple inpatient detoxification treatments (at least 12 reported) and inpatient rehabilitation treatments and still was unable to stop his large amount of daily alcohol use and cocaine use. He reportedly was homeless for the past 2 months prior to admission. He reported working odd jobs to support his addiction. He was put on a Librium taper protocol and given Librium until discharge. The plan was for him to attend an inpatient substance rehabilitation treatment after detoxification was complete, but he left the facility AMA (against medical advice).
 
According to the LOCADTR (Level of Care Determination), the patient did require 24-hour treatment as he could not safely and effectively be treated in less restrictive detoxification settings as he continued to use large amounts of alcohol daily despite multiple past inpatient detoxification treatments and rehabilitation treatments and he required and took detoxification medication, Librium, to modify and treat withdrawal. He was at risk for worsened withdrawal symptoms if not in this 24-hour setting, including severe and life-threatening withdrawal symptoms. 

It was reported that he had detoxification medication, Librium throughout his stay. He also had a comorbid bipolar disorder with a past psychiatric hospitalization and lacked supports as he was homeless. He lacked coping skills and could not maintain abstinence so he could not safely and effectively be treated in a less restrictive level of care. The risk of life-complicated withdrawal such as delirium tremens can occur 3-4 days after alcohol use, and so he required the entire time in this medical inpatient detoxification setting including when he left AMA despite the recommendation for an inpatient alcohol/substance rehabilitation treatment after this.

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

The insurer's denial of coverage for the medically supervised inpatient detoxification admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot Pain and Flat Feet
Treatment: Custom Shoe Inserts (L3000 x [times] 2)
The insurer denied the Custom Shoe Inserts (L3000 x 2)
The denial is upheld.

The patient is a female who had presented with knee pain and foot pain. On examination, the patient was found to have a Pes planus with an everted heel position. Custom molded orthotics were made for her and dispensed to her.

No, the proposed custom shoe inserts are not medically necessary.
Custom welded insoles are typically utilized when off-the-shelf insoles have been tried and failed for six to 12 months. In addition, physical therapy is usually instituted as well. Randomized clinical trials have not shown a benefit of custom molded inserts versus off-the-shelf inserts.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
As the proposed medical treatment is not medically necessary the health plan did act appropriately.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Chest Pain
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.


This man presented to the emergency department complaining of intermittent dyspnea, nonexertional chest pressure, bilateral ankle swelling and cough. His medical history was remarkable for hypertension and diabetes. His blood pressure was 174/98 millimeters of mercury (mmHg) with a heart rate of 78 beats/minute. His respiratory rate was 18/minute with a room air oxygen saturation of 100%. On physical exam his chest was clear; there was trace ankle edema. A chest X-ray showed no evidence of cardiopulmonary disease. His electrocardiogram was normal, as were his serum troponin and N-terminal pro brain natriuretic peptide (proBNP) levels. The patient was admitted to the hospital to rule out acute coronary syndrome. Rest/stress myocardial perfusion imaging showed no evidence of ischemia. An echocardiogram showed normal left ventricular systolic function with concentric left ventricular remodeling. There was no significant valvular disease. A lower extremity venous studies showed no evidence of deep vein thrombosis. The patient was discharged.
The medical necessity for an inpatient admission is at issue.

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

No. The inpatient stay was not medically necessary.
This man, with coronary risk factors, presented with atypical symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was in normal sinus rhythm, hemodynamically stable, with normal cardiac biomarkers, no ischemic electrocardiographic changes, and no signs of decompensated heart failure. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under an alternate level of care. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines, including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/ Society for Cardiovascular Magnetic Resonance (SCMR) Guidelines for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems-Chest Pain
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.

This case involves a patient with a history of hyperlipidemia who presented to the hospital with chest tightness for three weeks. The patient reported no exacerbating or alleviating factors. He denied shortness of breath. The symptoms were both exertional and at rest. No other associated symptoms were reported. Vital signs on arrival included a temperature of 97.8, a heart rate of 69, and a blood pressure of 126/81. Respirations were 16. Laboratory studies revealed normal electrolytes and renal function. Liver function tests (LFTs) are unremarkable as well. Cardiac troponin I was less than 0.015, considered negative. His pro brain natriuretic peptide (proBNP) was 7. Covid testing was negative, and the complete blood count (CBC) was unremarkable.
A 12-lead electrocardiogram (EKG) was performed, which showed no evidence of ST-segment elevation.
The patient was admitted to the hospital with a heart score of 2. 2 more sets of cardiac enzymes were ordered, and cardiology was consulted. The next day, the patient remained asymptomatic. He had no recurrent episodes of chest tightness. Vital signs remained unremarkable, and the physical exam was unchanged. The cardiac troponins remained negative. Cardiology assessed the patient and recommended a stress test and an echocardiogram. The stress test showed no evidence of inducible ischemia or infarct, normal left ventricular (LV) function. The echocardiogram showed an ejection fraction of 55 to 60% (per cent), with grade 1 diastolic dysfunction and no regional wall motion abnormalities. The patient was deemed stable for discharge and released home.

The requested health service/treatment of inpatient stay is not medically necessary for this patient. The patient was admitted to the hospital for chest pain, with a heart score of 2. The medical literature recommends that a heart score of less than 3 does not warrant a hospital admission and can be referred to outpatient cardiac testing within two weeks of presentation to the hospital. Nevertheless, this patient was admitted to the hospital, and underwent cardiac testing within 24 hours, which ruled out coronary disease. There is no reason to consider an inpatient admission in this patient, with an unremarkable work-up and low-risk factors for cardiac disease.
Chest pain evaluations are typically performed in a lower level of care setting, with noninvasive cardiac testing, and if normal results, discharged safely home. This is the standard of care for chest pain evaluation.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Paroxysmal Atrial Fibrillation. 
Treatment: Formulary Exception for Eliquis. 

The insurer denied the Formulary exception for Eliquis. 
The denial is overturned. 

The patient is a male with history of atrial fibrillation with rapid ventricular response. Co-morbidities include CAD (coronary artery disease) with stents, amiodarone use, COPD (chronic obstructive pulmonary disease) and morbid obesity (BMI [body mass index] over 40), Cardiomyopathy with depressed EF (ejection fraction) of 48% (percent). 

The patient has been treated with Eliquis for his atrial fibrillation, but that is not the plan's formulary choice of DOAC (directly acting oral anticoagulants). The request is to continue this medication instead of switching to Xarelto or warfarin. 

Yes, the health plan should cover the Formulary exception for Eliquis. 

Eliquis is preferable to Xarelto or warfarin. 

There is strong evidence that the medication apixaban (Eliquis) is preferable to rivaroxaban (Xarelto) for stroke prevention in patients with atrial fibrillation (AF), with both reduced rates of severe bleeding complications as well as strokes, according to a study published. 

In patients with atrial fibrillation, apixaban was superior to warfarin in preventing stroke or systemic embolism, caused less bleeding, and resulted in lower mortality. A clinical trial called ARISTOTLE looked at the safety and efficacy of Eliquis compared to warfarin. Eliquis was found to be more effective than warfarin in lowering the risk of stroke and systemic embolism. 

Bleeding or an ischemic event in this obese patient could be catastrophic. Therefore, the health plan should cover the formulary exception for Eliquis.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: abdominal pain
Treatment: Inpatient stay
The insurer denied the Inpatient Emergency Admission. The health plan's determination is overturned.

The patient is a male with a past medical history significant for gastritis, human immunodeficiency virus (HIV), and tetrahydrocannabinol (THC) use who presented with complaints of epigastric abdominal pain that started on the day of admission. The pain did not radiate. It was constant and associated with nausea and vomiting. The patient was unable to tolerate oral intake. He admitted to the use of THC the night before his presentation. Upon initial evaluation in the emergency department, the patient was diagnosed with leukocytosis. He underwent a computed tomography (CT) scan of the abdomen and pelvis, which was negative for acute pathology. The patient was admitted to the hospital with complaints of abdominal pain, intractable vomiting. The differential diagnosis included acute gastritis versus cannabinoid-induced symptoms. 

The Inpatient Emergency Admission was medically necessary, considering the fact that the patient was immunosuppressed. The immunosuppressed status was a significant risk factor for severe infection, dehydration, worsening kidney injury, electrolyte abnormalities.
According to the nationally accepted standards of care, admission at the acute inpatient level of care is recommended for patients with acute gastroenteritis who are immunosuppressed. Based on the patient's symptoms, he had acute gastroenteritis. This patient was immunosuppressed due to acquired immunodeficiency syndrome (AIDS). At the time of the presentation, he had intractable nausea and vomiting in the setting of severely elevated white blood cell count. He required an inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 (braces)

The insurer denied coverage for D8080 braces

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical image, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, and anterior crowding.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 27 total points. 

Upon review of the submitted documentation 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, 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 completes the second portion of the index arriving at 27 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support 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. This is confirmed by several studies referenced below.

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.

The clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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

The insurer's denial of coverage for D8080 braces is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Acute vaso-occlusive sickle cell crisis 

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is modified

This is the case of a female with sickle cell anemia with a history of acute chest of multiple pulmonary embolisms related to Lovenox therapy, and a history of cerebral vascular accident (CVA). The patient was admitted with right hip, right leg, and back pain. In the emergency department (ED), the patient received multiple doses of intravenous (IV) Dilaudid. Upon serial monitoring, the patient continued to have uncontrolled pain. She was admitted to inpatient care. The patient received IV pain medications, IV fluids, and a hematology evaluation. Once the patient clinically stabilized, and was ruled out for acute chest syndrome, she was discharged 

"The pathophysiology, clinical presentation, and natural history of acute pain in sickle cell disease are unique and require a disease-centered approach that also applies general principles of acute and chronic pain management. The majority of acute pain episodes are managed at home without the need to access health care. The long-term consequences of poorly treated acute pain include chronic pain, adverse effects of chronic opioid usage, psychological maladjustment, poor quality of life, and excessive health care utilization. There is no standard protocol for management of an acute pain crisis in either the hospital or the community. The assumptions that severe acute pain must be managed in the hospital with parenteral opioids and that strong opioids are needed for home management of pain need to be questioned. Pain management in the emergency department often does not meet acceptable standards, while chronic use of strong opioids is likely to result in opioid-induced hyperalgesia, exacerbation of chronic pain symptoms, and opioid dependency. We suggest that an integrated approach is needed to control the underlying condition, modify psychological responses, optimize social support, and ensure that health care services provide safe, effective, and prompt treatment of acute pain and appropriate management of chronic pain. This integrated approach should begin at an early age and continue through the adolescent, transition, and adult phases of the care model." (Telfer, P., & Kaya, B. 2017)

However, the note from the ED says that there is no suspicion for chest syndrome, so that is not a reason for admission. Hematology advised changing Dilaudid to intramuscular (IM) or oral, and tapering. The patient was still in pain. Assessment of a plan of care says that she is okay to go home tomorrow. Subsequent day notes not provided. 

The health care plan acted reasonably in part.

The inpatient hospital admission is partially substantiated. Approve coverage for the first day and deny coverage for continuous admission.  

The insurer's denial of coverage for the inpatient admission modified.