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

Diagnosis: Migraines
Treatment: Formulary exception for Nurtec 75mg OR TBDP, Pre-service
The insurer denied the Formulary exception for Nurtec 75mg OR TBDP, Pre-service
The denial is upheld. 

The patient is a female with migraine headache disorder. She has tried and failed sumatriptan and rizatriptan for abortive therapy. The provider is requesting Nurtec.

The requested medication was denied coverage as the patient has not tried the preferred formulary medications.

No, the health plan should not cover the Formulary exception for Nurtec.
There is no documented reason as to why the patient cannot be treated with the available formulary agents for the acute treatment of migraine. There is no identified contraindication to the use of any of the preferred agents. She has not tried and failed all available formulary medications for her condition. There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Nurtec relative to the preferred oral agents.

Therefore, given the above, the health plan should not cover the formulary exception for Nurtec.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Arm cellulitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient is an adult male with past medical history significant for polysubstance abuse, Hepatitis C virus (HCV), and methicillin-resistant staphylococcus aureus (MRSA) infection who presented to the Emergency Room (ER) with complaints of left arm pain and swelling.

Vitals on presentation included temperature of 37.5 degrees Celsius, blood pressure (BP) of 116/68, pulse 81, respiratory rate (RR) 18, oxygen (O2) saturations were 94% (percent) on room air (RA). Laboratory results included white blood cell (WBC) count 18.23, hemoglobin (Hgb) 13.3, hematocrit (HCT) 39.9, creatinine 0.62, and glucose 109.
The patient was started empirically on intravenous (IV) antibiotics (vancomycin, clindamycin) for a left arm cellulitis. Imaging studies of the left upper extremity (LUE) revealed a retained needle. Doppler exam of the upper extremity was negative for deep vein thrombosis (DVT). Infectious disease (ID) consulted. No surgical intervention was deemed necessary. The patient remained afebrile and hemodynamically stable. He left the hospital against medical advice (AMA).

According to documentation, the patient returned to the Emergency Department (ED) with a left arm cellulitis. Otherwise, he was afebrile and hemodynamically stable. Laboratory results showed an elevated WBC. He was seen in the ED the day before, discharged on oral antibiotics, but according to ED notes- "unclear if he took the pills (antibiotics) or not..." Imaging studies showed a retained needle tip in his left arm, which the patient reported it had been there 6 years. Surgery consulted and no surgical intervention was required, since no evidence of abscess or collection. Based on these findings, the patient did meet criteria for observation level of care; and he did not meet criteria for acute hospital admission.   

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

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

Diagnosis: Right Scrotal Hernia

Treatment hernia repair surgery with unusual procedural services (procedure code 49507 with modifier 22)

The insurer denied coverage for hernia repair surgery with unusual procedural services (procedure code 49507 with modifier 22)

The denial is upheld

This is the case of patient with a medical history of right scrotal hernia, diabetes mellitus, hypertension, hiatal hernia, obesity, and arthritis. The listed diagnosis is K40.90, unilateral inguinal hernia without obstruction or gangrene not specified as recurrent. General Surgeon writes in the history and physical note, that the patient had a very large right scrotal hernia that he could not completely reduce. The patient underwent right inguinal hernia repair surgery; the operative note documented procedure code 49507, modifier 22 - very challenging case.

Modifier 22 is used to document increased complexity of surgical procedures that are above and beyond what are typical and expected. Details regarding a specific procedure add to its complexity. Length of time, amount of scar tissue, aberrant anatomy, the amount of inflammation, patient's size, and presence of malnutrition, immunosuppression, or other comorbidities can be reasons why a procedure becomes more difficult and time-consuming. Modifier 22 is the only method in which a surgeon can get additional reimbursement for extra time in the operating room. Appropriate documentation must be provided to support use of modifier 22. [1] Documentation should note the following:

A description of the extenuating circumstances encountered during the procedure that differentiated the surgery from others of a similar type, including severity;
The technical aspects of and effort required for the increased procedural services (e.g., extensive lysis of adhesions, control of unexpected bleeding); and
The amount of time, beyond what is normally expected for the procedure performed, that the surgeon spent addressing the extenuating circumstances intra-operatively. [2]

Per clinical documentation, this patient has a large right inguinal hernia extending into the scrotum. The patient underwent open right inguinal hernia repair. Modifier 22 is being requested for increased surgical services. It was noted that the surgery required the placement of three prolene plugs. A surgical first assist was used during the procedure. However, the operative note does not describe the extenuating circumstances encountered during the procedure that differentiated the surgery from others of a similar type, the technical aspects and effort required, nor the amount of time beyond what is normally expected. Therefore, modifier 22 is not appropriate. The health plan acted reasonably. Documentation provided does not support the medical necessity of modifier 22 for this patient.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient.

The insurer's denial of coverage for hernia repair surgery with unusual procedural services (procedure code 49507 with modifier 22) rendered is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mandibular cuspids crossbite

Treatment D8080 braces and D8670 monthly visit x (times) 4

The insurer denied coverage for D8080 braces and D8670 monthly visit x 4	

The denial is upheld

This teenage patient treatment planned for braces. The treating physician noted both with the maxillary lateral incisors and both mandibular cuspids show recession and loss of attachment by bleeding. This should be an automatic qualifier under the Handicapping Labio-Lingual index (HLD) System.

The insurer has denied coverage based on an HLD is 20 based on the crowding in the upper and lower anteriors. 

The provider states that the patient automatically qualifies as there is an anterior crossbite. 

To qualify with an anterior crossbite, there must be clinical attachment loss and recession of the gingival margin. There is no clinical attachment loss and recession of the gingival margin evident on the photographs which are dark and non-diagnostic.

Per An Introduction to Orthodontics by Laura Mitchell, one or more of these dental traits that would have an adverse effect on the longevity of dentition, indicating high need for correction:

1)	Increased Overjet
2)	Increased traumatic Overbites
3)	Anterior crossbites causing decreased periodontal support
4)	Unerupted impacted teeth (where there is danger of pathology)
5)	Crossbites associated with mandibular displacements

Per the clinical records, the patient does meet any of the above. The provider states that there is gingival recession but the submitted photographs do not clearly demonstrate this. Base on the available information, the braces and monthly visits are not necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient as an automatic qualifier is not met and this reviewer concurs with the handicapping labiolingual index scoring of 20 point which is below the required 26 points.

Based on the above, the medical necessity is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath

Treatment inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is upheld

The patient is a gentleman with a history of hypertension, diabetes mellitus systolic congestive heart failure and atrial fibrillation that presented to the hospital complaining of worsening dyspnea over a three-day period after running out of medication. In addition, he reported lightheadedness that lasted for 15 minutes before resolving spontaneously. Upon arrival, Blood Pressure was 152/88 and pulse was 110.   Electrocardiogram (ECG) revealed atrial fibrillation (AF) with ventricular rates of 90-100 without acute ST-T (intervals on ECG) wave changes and poor precordial R (interval on ECG) wave progression. Echocardiogram revealed severely dilated atria and a mildly reduced left ventricular ejection fraction (LVEF) of 50% (percent).  On physical exam the patient had 2 plus pitting edema up to the mid-calf and wheezing over the right lung field.  Chest x-ray revealed mild pulmonary vascular congestion and brain natiuretic peptide (BNP)was elevated at 575. Serum blood testing revealed a blood urea nitrogen (BUN) of 25 and a creatinine (CR) 1.5 mg/dl (milligram per deciliter). Of note, the patient was discharged from the hospital several weeks prior to presentation and he noted significant weight loss while on furosemide therapy.  The patient was admitted to the hospital and started on oral lasix and ultimately discharged. 

The health plan acted reasonably and in the best interest of the patient. This patient presented with dyspnea and a mildly elevated pro BNP level. He also reported an episode of lightheadedness but had no significant hypotension, tachycardia or bradycardia to explain such symptoms.  Dyspnea was temporally related to medical non-compliance. Following treatment with guideline directed medical therapy (furosemide) symptoms resolved and the patient was continued on his outpatient regimen (Reference 1).  

Masri et al. compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated no difference in mortality between the two groups. (Reference 2). 

This patient responded to treatment with his previously prescribed oral medications. In conclusion, this patient could have been treated at a lower level of care and did not require inpatient admission.

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient. An inpatient admission was not medically necessary. 

The insurer's denial of coverage for the inpatient level of care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gender Dysphoria

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This case involves an adult transgender female who has a past history that includes gender dysphoria as well as depression, anxiety, deviated septum, renal mass, nasal obstruction, narrowing of the airway and dysphonia. The documentation indicated the patient presented for a procedure to create a voice which aligned with her gender identity. The submitted documentation indicated the patient underwent a microlaryngoscopy where there were no documented complications. The documentation does indicate normal postoperative course. She was admitted for postoperative monitoring and discharged the following day with instruction to follow-up. The documentation does not detail any complications during surgical intervention or postoperatively.  

According to current literature the patient may be admitted to inpatient services when there are documented complications from a surgical procedure pertaining to the head or neck. The documentation submitted does not detail the above. The documentation indicated the patient underwent a procedure without complication. The notes indicated the patient was admitted for further monitoring. However, as there is no documented complication during surgical intervention or immediately postoperatively, an observation level of care was appropriate.  

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

This female patient, with no significant past medical history, was admitted to acute in hospital level of care with the diagnosis of pneumonia. The patient had a previous infection with COVID-19 but had recovered from it. The patient was treated with antibiotics as an outpatient without any improvement.

Yes, the proposed Inpatient Hospital Admission was medically necessary.
This patient had pneumonia and had tried and failed outpatient treatment. During the hospitalization, the patient had episodes of high fevers and hypotension due to pneumonia. The patient had multi focal pneumonia that was not clinically improving and the antibiotics were changed to intravenous linezolid. Due to multifocal pneumonia, the patient had persistent chest pain and required pain medications. The patient also required consultations by Cardiology, Pulmonary and Infectious Disease. The patient had prolonged hospitalization for difficult to treat pneumonia and it's associated symptoms. The acute in hospital level of care in this case is standard of medical practice. The entire admission was medically necessary.

This patient was admitted to acute hospital level of care. The patient had multifocal infiltrates and had tried and failed outpatient medical management. The patient had evidence of sepsis, likely due to pneumonia, at the time of admission. The patient was started on intravenous antibiotics as well as intravenous fluids. During the hospitalization, the patient had episodes of fevers and pleuritic chest pain that was not improving. The patient was seen by Pulmonary, Cardiology as well as Infectious Disease specialists. Due to persistent fevers, the patient underwent bronchoscopy. The patient was being ruled out for fungal infection as well as hypersensitivity pneumonitis. Since the patient continued to have fevers, the antibiotics were changed. 

As the patient had multifocal pneumonia and had failed outpatient treatment, the acute in hospital level of care is medically necessary. Despite appropriate intravenous antibiotics, the patient continued to have fevers and tachycardia as well as chest pain. This required prolonged hospitalization. The entire admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malignant hypertension and monitoring of chest pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This is the case of an adult female that presented to the hospital with headache, chest pain and poorly controlled hypertension (HTN). She was sent by ambulance after her blood pressure (BP) reading at an urgent care center was 230 systolic. Past medical history was significant for surgically corrected Scimitar syndrome, HTN with recent hospital admission for hypertensive crisis and non-obstructive coronary artery disease. Previous attempts to control HTN with amlodipine and angiotensin-converting enzyme (ACE) inhibitors were not successful. Upon arrival to the Emergency Department (ED), BP was 181/114 and pulse was 61 beats per minute. No abnormal findings were noted on physical examination. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with atrial premature complexes (APCs) and ST-T (intervals on ECG) wave abnormalities in the inferior leads. Serum level of brain natriuretic peptide (BNP) was elevated (225 pg/ml [picograms per milliliter]) and D-dimer (one of the protein fragments produced when a blood clot gets dissolved in the body) was elevated. A computed tomography (CT) angiogram revealed no evidence of pulmonary embolism. Echocardiogram revealed concentric left ventricular hypertrophy and a preserved left ventricular ejection fraction (LVEF). The patient was admitted to the hospital and treated with increasing doses of carvedilol and chlorthalidone. She was discharged after BP was adequately controlled.

This patient presented with hypertensive emergency, headache, and chest pain. She had a history of surgically corrected congenital heart disease. BNP levels were elevated, and ECG revealed T (interval on ECG) wave abnormalities. In addition, previous attempts to control BP with multiple agents were not successful. Hypertensive emergency is defined as BP > (greater than) 180/120 with target organ damage. (1) 

In this patient, ECG revealed inferior wall ST-T wave changes and BNP was elevated, consistent with left ventricular wall stress and target organ damage. Given this patient's previous history, admission to the hospital for aggressive blood pressure management was necessary. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (2) Given this patient's failure to respond to outpatient medical therapy, admission to the hospital for aggressive blood pressure management was necessary.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The acute inpatient admission was medically necessary. 

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

Diagnosis: Deep impinging overbite with severe soft tissue damage.

Treatment: D8080 braces and D8670 monthly visit x (times) 12.

The insurer denied coverage for D8080 braces and D8670 monthly visit x12.

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 deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining 18 points on review by internal reviewers. 

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 claims an automatic qualifying condition of deep
impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met, as there is no evidence of soft tissue damage.

In this case, the clinical circumstance does not meet criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer, attaining 18 points (5 points overjet, 6 points overbite, 3 points ectopic eruption, and 4 points labiolingual spread).

Regarding the validity of the Handicapping Labio-lingual 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.

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

Based on the above, the medical necessity for the D8080 braces and D8670 monthly visit x12 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class II, excessive overjet, maxillary and mandibular crowding, and deep impinging overbite

Treatment D8080 braces and D8670 monthly visits

The insurer denied coverage for D8080 braces and D8670 monthly visits

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 skeletal Class II, excessive overjet, maxillary and mandibular crowding, and deep impinging overbite. The Orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage 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, 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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage. 

In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 17 points (5 points overjet, 5 points overbite, 5 points anterior crowding and 2 points labiolingual spread).
 
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies.

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visits is upheld. Medical necessity is not substantiated.