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

Diagnosis:  Encounter for screening for genetic and chromosomal anomalies.
Treatment:  Genetic testing.
The insurer denied coverage for genetic testing. The denial is overturned.

The patient is an adult male with a son diagnosed with non-syndromic hearing loss. The son had genetic testing and was found to be homozygous for a mutation in GJB2 (Gap junction beta-2 protein). The son also had a likely pathogenic variant and variants of uncertain in USH2A (Usherin). In order to determine if the son could have effects of Usher syndrome from the USH2A variants and to determine if the patient and his partner would be at risk for hearing and vision issues they had testing ordered by the son's genetic counselor and medical geneticist.

Genetic testing was considered medically necessary for this patient. His son was recently diagnosed with non-syndromic hearing loss and found to carry mutations in two hearing loss genes, GJB2 and USH2. GJB2 mutations cause "nonsyndromic hearing loss and deafness (DFNB1) characterized by congenital non-progressive mild-to-profound sensorineural hearing impairment. No other associated medical findings are present" (Smith, R. J. H., & Jones, M. K. N., 2016). 

Additionally, "Usher syndrome type II (USH2) is characterized by the following:
-Congenital, bilateral sensorineural hearing loss that is mild to moderate in the low frequencies and severe to profound in the higher frequencies.
-Intact or variable vestibular responses. Retinitis pigmentosa (RP); progressive, bilateral, symmetric retinal degeneration that begins with night blindness and constricted visual fields (tunnel vision) and eventually includes decreased central visual acuity; the rate and degree of vision loss vary within and among families" (Koenekoop, R., et al. 2020). Per this same review, "Molecular genetic testing is recommended for the parents of a proband to confirm that both parents are heterozygous for an USH2-causing pathogenic variant and to allow reliable recurrence risk assessment. (De novo variants are known to occur at a low but appreciable rate in autosomal recessive disorders)" (Koenekoop, R., et al. 2020).

As "Usher syndrome type II (USH2) is characterized by moderate-to-severe sensorineural hearing loss at birth and retinitis pigmentosa (RP) that begins in late adolescence or early adulthood" (Koenekoop, R., et al. 2020. In Usher syndrome, it is recommended that affected individuals have "annual ophthalmologic evaluation from age 20 years to detect potentially treatable complications such as cataracts, refractive errors, and cystoid macular edema" (Koenekoop, R., et al. 2020).

Based on this, genetic testing for the USH2 variants is medically necessary for this patient.                                                         

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 genetic testing services is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Osteoarthritis and dementia

Treatment is Consumer Directed Personal Assistant Services (CDPAS) Basic-15 minutes for a total of 84 hours per week

The insurer denied coverage for Consumer Directed Personal Assistant Services (CDPAS) Basic-15 minutes for a total of 84 hours per week
 
The denial is modified

The patient is an elderly female with chronic medical problems including osteoarthritis and dementia. She lives alone in a 1-bedroom apartment. She is currently receiving 38 hours/week CDPAS and requesting an increase to 84 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are "moderately impaired." She requires extensive assistance with bathing, lower body dressing and locomotion. Limited assistance is required for personal hygiene, upper body dressing, and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. The patient is independent with bed mobility and eating. Contrary to the assertions of the insurer, there has been a functional decline when compared to the UAS report. At that time, her cognition was only minimally impaired. Limited assistance was required for walking/locomotion. Personal hygiene and toilet transfers required only supervision. The combination of cognitive and functional decline supports an increase in CDPAS. Her condition and functional needs are not at a level or unpredictable as to require the requested 84 hours per week. This physician would also agree that the patient may require increased monitoring. However, safety monitoring (e.g., for dementia) under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested CDPAS Basic-15 minutes for a total of 84 hours/week is not medically necessary; however, an increase in CDPAS to 8 hours/day, 7 days/week totaling 56 hours/week is medically necessary.  

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 the Consumer Directed Personal Assistant Services (CDPAS) Basic-15 minutes for a total of 84 hours per week is modified. An increase of CDPAS to 8 hours/day, 7 days/week totaling 56 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lipedema
Treatment: Surgical excision of excessive skin and tissue (with lipectomy) of the thigh and arm and suction assisted lipectomy of the lower extremity, trunk, and upper extremity (codes 15877-15879, 15832, 15836)
The insurer denied coverage for surgical excision of excessive skin and tissue (with lipectomy) of the thigh and arm and suction assisted lipectomy of the lower extremity, trunk, and upper extremity (codes 15877-15879, 15832, 15836).
The denial is overturned.

According to the medical records, the patient is a female with a history of lipedema, varicose veins of the bilateral lower extremities, hypertension and excess atrophy of thighs and legs refractory to conservative treatment.

According to the medical records she has been wearing low extremity compression as ordered for years. She wears a tactile lymphatic pump for both legs and arms and she uses it four times daily. She uses dry brushing, self-lymphatic drainage massage, a vibration plate for lymphatic drainage, and deep tissue massage. She also had six months of conservative therapy. Therefore, surgical excision of excessive skin and tissue (with lipectomy) of the thigh and arm and suction assisted lipectomy of the lower extremity, trunk, and upper extremity would be medically necessary.

"Liposuction is a very effective treatment for lipedema when conservative therapies fail. In this procedure, lipedema fat is removed, sparing the lymphatic vessels." (Vyas, A. et al. 2022)

"These guidelines improve the understanding of the loose connective tissue disease, lipedema, to advance our understanding towards early diagnosis, treatments, and ultimately a cure for affected individuals." (Herbst, K. L. et al. 2021)

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 surgical excision of excessive skin and tissue (with lipectomy) of the thigh and arm and suction assisted lipectomy of the lower extremity, trunk, and upper extremity (codes 15877-15879, 15832, 15836) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure.
Treatment: Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is overturned.

The patient is an adult female with a past medical history of hypertension, hyperlipidemia, diabetes, paroxysmal atrial fibrillation, heart failure with reduced systolic function, coronary artery disease status post coronary artery bypass grafting (CABG), and valvular heart disease.  She presented to the emergency department for evaluation of progressively worsening shortness of breath and palpitations.  On arrival to the emergency department, her twelve-lead electrocardiogram (EKG) showed T-wave inversions in the lateral leads.  Initial labs were notable for elevated troponins which were uptrending.  She was admitted to the inpatient unit for treatment of heart failure exacerbation and possible acute coronary syndrome.

The proposed inpatient hospital admission was medically necessary.

This patient with a complex past cardiac history, which includes severe cardiomyopathy and known history of multi-vessel coronary artery disease presented to the emergency department for evaluation of progressively worsening shortness of breath. Her initial labs were notable for elevated troponins which were uptrending, and her electrocardiogram (EKG) showed lateral T-wave inversions (which may be suggestive of ischemia). By definition, this patient's presentation was concerning for a non-ST elevation myocardial infarction given angina-equivalent symptom of worsening shortness of breath, ischemic electrocardiogram changes, and elevated (and uptrending) troponins. Patients who present with non-ST elevation myocardial infarctions (especially in this patient with severe cardiomyopathy) are at an increased risk of developing sustained ventricular arrhythmias and cardiac events. Consequently, prompt care, which includes antiplatelet/anticoagulation therapy, close hemodynamic monitoring, and possible revascularization is extremely important. Therefore, care could not be safely rendered in observation level of care and admission to acute inpatient level of care was appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sinus Tachycardia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is an adult who presented to the hospital following a fall. She reported alcohol use on the night of the event and could not remember how she fell. She was found the following morning on the floor, unable to get up. Past medical history was significant for hypertension, congestive heart failure, and chronic obstructive pulmonary disease (COPD). Vital signs on arrival were stable (Blood Pressure 124/78, Pulse 97). Physical exam was significant for gait instability. A 12-lead electrocardiogram (ECG) revealed sinus tachycardia with left axis deviation and no ischemic ST (interval on ECG) or T (interval on ECG) wave abnormalities. Serum blood testing was significant for a mild elevation in Creatine phosphokinase (CPK) (305mg/dl [milligrams per deciliter]). Computed tomography (CT) of the chest revealed no evidence of pulmonary embolism. The patient was admitted to the hospital for monitoring and treatment. She was treated with intravenous (IV) and physical therapy.

No significant cardiac findings were noted on serum blood testing or ECG. The patient was discharged after observation for a two-day period. According to the European Society of Cardiology, this patient was a low-risk patient for future morbidity and mortality (Reference 1). In a study of individuals presenting to the emergency room with syncope and falls, patients that were low risk for cardiac events (no significant cardiac history of acute cardiac findings on initial evaluation) had an excellent prognosis and did not require admission to the hospital for further testing (Reference 2). In this case, the patient falls into a low-risk category and could be managed at a lower level of care.

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 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with recent anemia and negative colonoscopy and upper gastrointestinal endoscopy, scheduled to have a transurethral resection of the prostate (TURP), who was noted to have anemia on his pre-operative labs. The patient was admitted with a hemoglobin (Hgb) of 7.7. There was no abdominal pain, hematemesis, nausea/vomiting (NV), diarrhea, constipation, melena or gastrointestinal bleeding. The patient was hemodynamically stable. He was transfused two units of packed red blood cells (PRBCs) and underwent transurethral resection of the prostate (TURP). The patient's hemoglobin (Hgb) post procedure was 8.1 and he was discharged for outpatient capsule endoscopy.

The proposed inpatient hospital admission was not medically necessary.

The patient had recent anemia with a negative colonoscopy and upper gastrointestinal endoscopy. The patient was hemodynamically stable. He did not have abdominal pain, hematemesis, nausea/vomiting, diarrhea, constipation, melena or gastrointestinal bleeding. Workup of anemia can be performed at a lower level of care with capsule endoscopy as well as hematology evaluation. Acute inpatient hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

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

This case involves a man with prior history of gallstone pancreatitis, who presented to the emergency department (ED) with epigastric pain. The symptoms are intermittent, progressing to constant and severe. The pain was unrelieved with acid suppression medications. The patient denied recent alcohol use.

The inpatient hospital admission was not medically necessary.
Based on the provided documentation, the patient presented to the hospital with abdominal pain of unclear etiology, normal imaging, and fairly stable labs. There was no evidence of pancreatitis. Within 24 hours of admission, the medical team and the gastroenterologist document that the patient's symptoms are under improved control. MRCP was ordered, which mental institutions can take up to 24 hours to complete and be read. The findings were unremarkable. The patient's symptoms improved within the observation timeframe, and there was no indication to admit this patient under inpatient level of care.
Based on Milliman Care Guidelines (MCG) criteria, the patient also does not satisfy clinical indications for admission to the inpatient level of care, as there was no evidence of hemodynamic instability, peritoneal signs, or extended nothing by mouth (NPO) status, systemic illness with bacteremia or toxic megacolon.
Based on medical necessity, undifferentiated abdominal pain would require inpatient admission if there is evidence of cholangitis, sepsis, bowel obstruction, peptic ulcer disease with an active GI bleed and hemodynamic instability, and severe pancreatitis requiring prolonged NPO status and surgical interventions. Given that in this presentation, the patient did not have any such severity of illness, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia, strokes, hypertension and vascular disease. 
Treatment: Repatha
The insurer denied: Repatha
The denial is overturned.

The patient is an adult female with a past medical history of strokes, hypertension and vascular disease. She also has a history of hyperlipidemia with the most recent LDL (low-density lipoprotein) being 131. She has been followed by a cardiologist and has been on Crestor and Zetia. Given that she has had an elevated lipoprotein, more aggressive LDL (low-density lipoprotein) control has been desired. Reportedly, she has not tolerated high doses of statins due to myalgia, and therefore Repatha has been requested for treatment of her hyperlipidemia.

The requested Repatha is medically necessary.
Based on the provided documentation, the patient does have established ASCVD (atherosclerotic cardiovascular disease) given that she has had two strokes in the past. She has not tolerated higher doses of statins. On Crestor plus Zetia combination, her LDL (low-density lipoprotein) has not achieved the desired goal. Consequently, in the setting of her history of ASCVD (atherosclerotic cardiovascular disease), use of Repatha is appropriate and medically necessary for better LDL (low-density lipoprotein) control.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 comprehensive orthodontic treatment of the adolescent dentition and D8670 periodic orthodontic treatment visits x (times) 12
The insurer denied coverage for D8080 comprehensive orthodontic treatment of the adolescent dentition and D8670 periodic orthodontic treatment visits x 12
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist has completed the HLD (Handicapping Labiolingual Deviation) index attaining 9 total points. 

According to the documentation submitted by her pediatrician, the patient has anorexia, an iron deficiency and a vitamin D deficiency secondary to her dental malocclusion.

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 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 any automatic qualifying condition and completes the second portion of the index arriving at 9 points to justify orthodontic care. This reviewer has determined from the records the patient has a Class II right/ I left molar relationship with upper and lower spacing and a prominent maxillary frenum. Her HLD score was determined to be 9 by this reviewer.

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 cited 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.
The clinical circumstance as presented does not meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.  The insurer's denial of coverage for D8080 (braces) and D8670 periodic orthodontic treatment visits x 12 is upheld. Medical Necessity is not substantiated.

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

The medical necessity for D8080 comprehensive orthodontic treatment of the adolescent dentition and D8670 periodic orthodontic treatment visits x 12 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Blood Sugar
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with type 2 diabetes mellitus complicated by neuropathy and chronic kidney disease, peripheral vascular disease, hypertension, and hyperlipidemia. She presented with pain and weakness in her left arm and numbness in left hand. She stopped taking insulin four days earlier after running out. The patient's heart rate was 93, blood pressure 134/87, O2 (oxygen) 97% (percent). The patient was alert and oriented on exam with normal neurological exam with 5/5 muscle strength. Her glucose was 796 mg/dL (milligrams per deciliter), creatinine 2.4, sodium 129, potassium 5.2, pH 7.327. Head CT (computed tomography) showed old infarct. She was treated with intravenous fluid and insulin. The patient's glucose was 225 and creatinine 2.0 early the next morning. The inpatient admission is under review.

The Inpatient admission was not medically necessary.
This patient with type 2 diabetes presented with hyperglycemia due to stopping insulin therapy at home when she ran out of insulin. Her effective serum osmolality based on a sodium of 129 and glucose of 796 mg/dL (milligrams per deciliter) was 302, which is below the cut-off of > (greater than) 320 for a diagnosis of hyperosmolar hyperglycemic state. She also did not have altered mental status and her neurological exam was normal. She had a normal pH and did not meet criteria for diabetic ketoacidosis. She was dehydrated with moderate elevation in her creatinine compared to baseline that improved with hydration. Her hyperglycemia responded quickly to insulin therapy. She did not have infection or another acute illness that required inpatient stay. Her head CT (computed tomography) showed no acute abnormalities. She was hemodynamically stable. Therefore the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right 5th Digit Infection

Treatment: Inpatient Hospital

The insurer denied coverage for inpatient hospital

The denial is overturned

The patient is a female with past medical history significant for asthma, eczema, pelvic inflammatory disease (PID), and methicillin-sensitive staphylococcus aureus (MSSA) infection who presented to the emergency department with complaints of right pinky pain, swelling, and drainage and body rash. The patient had signed out against medical advice (AMA) for prior admission.  Vitals on presentation included: Temperature 98.1 Fahrenheit, blood pressure (BP) -126/77, pulse (P) -106, respiration rate (RR)-16, oxygen saturation (O2 sat) - 98% (percent) on room air (RA). Laboratory results included the following: White blood cells (WBC) - 23.3, hemoglobin (HGB) -11.4, hematocrit (HCT) -36.7, creatinine-0.74, glucose -148.  The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for a right fifth finger infection. Imaging studies of the hand did not show any soft tissue abnormalities or any osseous erosive changes. The patient underwent and incision and drainage procedure by surgery. The patient remained afebrile, hemodynamically stable, and clinically improved. She signed out against medical advice (AMA). 

According to documentation, the patient was admitted with a right 5th digit infection. She was afebrile but had tachycardia to 106. Laboratory results showed an elevated WBC to 23.3.  Based on above findings, in an unreliable and high-risk patient with prior infections, hospital admission was medically necessary for intravenous antibiotics and surgical intervention.

Prior determination of denial of coverage for inpatient hospital services is overturned.

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 inpatient hospital services is overturned. Medical Necessity is substantiated.