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

Diagnosis: Parkinson's disease, rheumatoid arthritis, osteoarthritis, dysphagia, sialorrhea, and orthostatic hypotension. 
Treatment: Live-in home health care aide 7 days per week. 

The insurer denied coverage for a live-in home health care aide 7 days per week. 

The denial is overturned. 

This patient has a history of Parkinson's disease, rheumatoid arthritis, osteoarthritis, dysphagia, sialorrhea, gallbladder disease, iron deficiency, and orthostatic hypotension. She receives home health care services with a personal care aide 4 days per week, 10.5 hours per day. The request was made for a live-in home health care aide 7 days per week. The insurer approved 7 days per week, 7 hours per day. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; noted 

"(a) Definitions and scope of services. 

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph 

(b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse. 

The patient will no longer be having the informal family support she once had. She is incontinent, wears diapers and has functional limitations that would affect her ability to self-toilet. She needs help with mobility, transfers as well. Provision for safety in her case is part of the provision of assistance and her request is approved. 

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

Based on the above, the medical necessity for the Home Health Care (HHC) services 7 days per week live-in is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatitis and Gastritis

Treatment: hospital admission

The insurer denied coverage for hospital admission

The denial is overturned.

The patient presented with epigastric pain, diarrhea and body aches. She was afebrile and the vital signs were stable. Epigastric tenderness was present but there was no rebound or guarding. A computed axial tomography (CAT) scan of the abdomen was negative for acute disease and did not show pancreatitis. There was no leukocytosis. The lipase was 417 (normal to 78). The liver enzymes were normal. The renal function was normal. She was able to tolerate a diet. She was diagnosed with pancreatitis and gastritis. Proton pump inhibitor (PPI) therapy was given for gastritis. Her symptoms improved.

Clinical indications for admission for Pancreatitis M-250 inclined having 2 of the following: abdominal pain such as epigastric pain, a lipase level greater than 3 times the upper limit of normal, and characteristic findings on imaging studies. In this case, there was epigastric tenderness and a lipase level greater than 3 times the upper limit of normal. This met Milliman Care Guidelines (MCG) criteria for admission.

This patient had epigastric pain with a high lipase and improved with treatment. She was given a diagnosis of acute pancreatitis. Since she met the MCG criteria for admission for Pancreatitis, the health care plan did not act reasonably or with sound medical judgement. An inpatient medical stay was 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 hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Symptomatic Anemia

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld.

This patient has a history of end-stage renal disease (ESRD), kidney transplant (on immunosuppressant therapy), chronic kidney disease stage 5, hypertension, and anemia. The patient presented to the emergency department (ED) with complaints of chest pains, shortness of breath, chills, and palpitations. His hemoglobin (HB) was 4.1, white blood cell count (WBC) was 3.81 and platelets were 121.  A blood transfusion was initiated, and the patient was admitted for further management of symptomatic anemia. Two more units were transfused on the floor, after admission. The gastroenterologist performed an esophagogastroduodenoscopy (EGD) and colonoscopy. That was negative. The patient was discharged home in stable condition.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. There was an in-hospital delay. The entire inpatient hospital admission is not considered medically necessary for this patient.

The patient was admitted during weekdays and could have had an EGD and colonoscopy on the same day. Note that these are ambulatory procedures and in fact the patient was discharged the day the procedures were done.

The health plan acted reasonably with sound medical judgment 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: Upheld

Diagnosis: Tooth Agenesis

Treatment dental implants for teeth #3, #4, #5, #18 and #19

The insurer denied coverage for dental implants for teeth #3, #4, #5, #18 and #19

The denial is upheld

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above.  The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. The insurer has denied the services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants.  The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further, the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

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

The insurer's denial of coverage for dental implants for teeth #3, #4, #5, #18 and #19 is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Low Thyroid Levels. 
Treatment: Tirosint (brand). 

The insurer denied Tirosint (brand). The health plan's determination is overturned. 

The patient is a female with hypothyroidism. The provider stated that levothyroxine that was taken previously caused diarrhea and abdominal pain. Tirosint (brand) was prescribed. The patient has been on this medication for 4 years. Under review is the use of Tirosint (brand). 

The patient had side effects (diarrhea, abdominal pain) when taking levothyroxine. In summary, the formulary drug has been ineffective by virtue of causing side effects and would have adverse effects if taken again. The patient has been on Tirosint for 4 years without issues. Switching her to a different medication at this point would not be appropriate. Therefore, a formulary exception is indicated in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment:  D8080 Braces, D8670 Monthly Visit x 12, Pre-service
The insurer denied the  D8080 Braces, D8670 Monthly Visit x 12, Pre-service
The denial is overturned.

The patient is a male. The request is for orthodontic benefits. He has a Class I malocclusion with a severely deep overbite. The reason for denial was only 13 points on the handicapping index scale.

Yes, the braces and monthly visits are medically necessary.
The patient has a severely deep, impinging overbite with soft tissue trauma to the palatal tissues. This is an automatic qualifier according to the handicapping index scale. The patient also has very pronounced upper front teeth. These teeth are very prone to fracturing due to their being extremely protruded. Both of these things need to be corrected with orthodontic treatment. Medical necessity has been established for this case.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: M48.062 - Spinal stenosis, lumbar region with neurogenic claudication Z00.6 - Encounter for examination for normal comparison and control in clinical research program
Treatment: Percutaneous Laminotomy/Laminectomy (MILD)
The insurer denied the Percutaneous Laminotomy/Laminectomy (MILD).
The denial is overturned.

The patient is a male with history of chronic low back pain due to lumbar stenosis with associated neurogenic claudication. MRI (magnetic resonance imaging) of the lumbar spine showed ligaments Hypertrophy at L3/L4 (third lumbar spine vertebra/fourth lumbar spine vertebra) and L4/L5 (fourth lumbar spine vertebra/fifth lumbar spine vertebra) with moderate stenosis at L4/L5 and L5/S1 (fifth lumbar spine vertebra/first sacral vertebra).

The patient has failed conservative measures, including lumbar epidural steroid injections, lumbar facet Radiofrequency Ablation, and Naproxen.

Yes, the health plan should cover the requested Percutaneous Minimally Invasive Laminotomy Decompression (MILD) of the lumbar spine based on evidence in the literature of clear and significant effectiveness of the procedure in treating lumbar spinal stenosis.

According to Lumbar Spinal Stenosis Consensus Group Guidelines for Minimally Invasive Spine Treatment, there is a Level 1 evidence for percutaneous image-guided Lumbar Decompression as superior to lumbar epidural steroid injections, including 5 controlled prospective studies and 17 other retrospective studies, case series, meta-analyses, etc published in peer-reviewed journals.

The MILD (minimally invasive lumbar decompression) procedure has been shown to be at least as effective for other pain procedures, less invasive, effective in improving pain and is achievable in standard conditions of medical practice as published in multiple peer-reviewed journals, some listed in the references below.

Yes, the requested procedure is more beneficial than any standard treatment for lumbar stenosis.

The patient has failed conservative measures including Naproxen, exercise program, lumbar facet blocks/Radiofrequency Ablation, Lumbar Epidural steroid injections, etc. It is less invasive than the main highly invasive surgical laminectomy, which could lead to osteophyte formation and scar tissue, leading to recurrence of stenosis in a short period of time.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: M48.062 - Spinal stenosis, lumbar region with neurogenic claudication Z00.6 - Encounter for examination for normal comparison and control in clinical research program
Treatment: Percutaneous Laminotomy/Laminectomy (MILD)
The insurer denied the Percutaneous Laminotomy/Laminectomy (MILD).
The denial is upheld.

The patient is a male with neurogenic claudication secondary to spinal stenosis, in whom the MILD (minimally invasive lumbar decompression) procedure has been recommended. The patient has failed NSAIDs (nonsteroidal anti-inflammatory drugs), PT (physical therapy), epidural steroid injections, facet joint injections, and RFA (radiofrequency ablation).

The patient's exam was unremarkable. MRI (magnetic resonance imaging) shows no central stenosis at L3-4 (third lumbar spine vertebra - fourth lumbar spine vertebra), and shows NF (neural foraminal) stenosis at L4-5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra) secondary to left paracentral disc protrusion.

The procedure was denied as the requested procedure was deemed experimental/investigational by the health plan.

No, the health plan should not cover the requested health service.

The patient does not have severe spinal stenosis secondary to ligamentum flavum hypertrophy as seen in the attached documentation.  He did have a good response to the RFA (radiofrequency ablation). Given the severe NF (neural foraminal) stenosis at L4-5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra), and the paracentral disc bulge, and the lack of severe stenosis caused by ligamentum flavum hypertrophy, it is likely MILD (percutaneous laminectomy) will not be of benefit.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Septosplasty, submucous resection inferior
turbinates, repair of nasal vestibular stenosis)
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This female patient has a history of bleeding disorder (von Willebrand type II). She underwent elective septorhinoplasty, turbinectomies and vestibular stenosis repairs.

No, the inpatient admission was not medically necessary.
This female had an uncomplicated nasal surgery. According to the appeal letter, the patient's hematologist recommended admission to monitor for bleeding following surgery. However, the hematology consultant's note does not document a need for admission following the procedure. Moreover, monitoring for bleeding does not require an inpatient level of care. 

According to Milliman Care Guideline (MCG) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient."  This patient was medically stable and could have been monitored for bleeding at an observation status level of care. Per the Milliman Care Guidelines (MCG), 25th Edition, rhinoplasty, uncomplicated nasal surgery does not require admission.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Admission was not required following rhinoplasty surgery for this patient. The records do not document any complications or issues that required inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia/rectal bleed
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male with a past medical history remarkable for hypertension, depression, hyperlipidemia, anxiety, and alcohol abuse, who was admitted for blood in the stool. Review of system was positive for blood in the stool, fatigue, weakness, and tiredness.
The patient was afebrile, described as alert and in on acute distress. His blood pressure was 152/82, heart rate of 113, respiratory rate of 18 and oxygen saturation of 98% on room air. Physical examination on admission was unremarkable for positive findings.
Laboratory evaluation demonstrated a sodium of 137, potassium of 3.8, chloride of 103, carbon dioxide (CO2) of 24, blood urea nitrogen (BUN) /creatinine of 11/1.13, glucose of 106, white blood cell count (WBC) of 8.3, hemoglobin of 8.2, hematocrit of 27.7, platelet of 363, and international normalized ratio (INR) 1.0. A computed tomography (CT) of the abdomen and pelvis revealed no acute findings.
The patient was admitted for possible lower gastrointestinal (GI) bleed and alcohol abuse. 

The inpatient hospital admission was medically necessary. 
The patient was admitted for rectal bleeding associated with anemia (decrease in hemoglobin/hematocrit), tachycardia and fatigue/weakness (symptomatic anemia). Furthermore, the patient has a known history of bleeding with prior colonoscopy showing diverticulosis, colonic polyps, and hemorrhoids. Despite hemodynamic stability, he had multiple risk factors for severe colonic bleeding and ongoing blood loss. The intensity of care and duration of monitoring required was beyond the scope of observation level of care. The Inpatient level of care was warranted based on the presence of symptomatic anemia, significant decrease in hemoglobin/hematocrit, presence of tachycardia and multiple comorbid conditions (diverticulosis, hemorrhoids, colonic polyp, and alcohol abuse).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Glioblastoma
Treatment: Continued stay in an acute care facility
The insurer denied the continued stay in an acute care facility.
The denial is upheld.

The patient in this case is a male who was initially admitted to an acute care facility. He has a history of terminal glioblastoma that was treated with resection, followed by radiation and Avastin. He is noted to have pain in his back and legs, not related to his cancer. Records indicate that pain and anxiety are well controlled on his current regimen. He is taking Fentanyl patch and oral hydromorphone for pain. His vital signs are unremarkable and records note that all medications are either oral or topical. No acute medical issues are documented.

No, the continued stay in an acute care facility is not medically necessary.

This patient has glioblastoma and has not been on treatment. He has been at an inpatient acute care facility. Records fail to document any ongoing acute care medical issues and also fail to document that he meets criteria for inpatient hospice care. Given these considerations, continued inpatient acute care is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: Braces and Adjustments of Braces
The insurer denied the  braces and adjustments of braces.
The denial is overturned.

The patient is a female. The request is for orthodontic benefits. She has a class I malocclusion with a deep, impinging overbite. The health plan's denial is because the handicapping index score is below 26.

Yes, the braces and adjustments are medically necessary.

The patient has a deep, impinging overbite with soft tissue damage to the palatal tissues. This can be seen in the photos and on the cephalometric x-ray presented. This is an "automatic qualifier," according to the handicapping index scale.

Therefore, the braces and adjustments are medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. Please see the rationale, above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female who presented with two days of right upper quadrant (RUQ) pain. She was hemodynamically stable, with right upper quadrant (RUQ) tenderness on exam, and labs revealed a mild elevation in alkaline phosphatase. Ultrasound revealed normal gallbladder and fatty liver. Computed tomography (CT) revealed non-specific gallbladder (GB) wall thickening and a question of mild ascending colon colitis. 

The patient was admitted, and kept nothing by mouth (NPO). She was treated with intravenous pain medication and seen by gastroenterology (GI) and surgery. White blood cell (WBC) count was normal, hepatobiliary iminodiacetic acid (HIDA) was negative, and her pain improved. Her diet was advanced, the patient was discharged for further workup with outpatient colonoscopy and esophagogastroduodenoscopy (EGD).

No, the proposed inpatient admission was not medically necessary.
The patient presented with right upper quadrant abdominal pain. As she was hemodynamically stable, without intractable vomiting, gastrointestinal (GI) bleeding, dehydration, sepsis, obstruction or a need for urgent surgical intervention, observation status was medically necessary, and criteria for acute inpatient stay was not met. Observation status was medically appropriate, the patient was stable for discharge to outpatient care. Therefore, the proposed acute inpatient hospital stay was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
As acute inpatient hospital stay was not medically necessary, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces; monthly visit x12; retainer
The insurer denied Braces; monthly visit x12; retainer.
The determination is overturned.

The patient has a Class II malocclusion with significant spacing and protrusive maxillary incisors. She has a 7 millimeter (mm) overjet and a very deep overbite. She is treatment planned for 24 months of orthodontics to correct the spacing and protrusion. Braces; monthly visit x12; retainer were denied by the health plan and are under review for medical necessity.

There is strong medical evidence that correction for patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Closing the space present will make the teeth significantly less protrusive. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with a 6 plus (+) mm overjet, which this patient has. (2) For these reasons, the requested orthodontic treatment is medically necessary.