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

Diagnosis: Deep Impinging Overbite.

Treatment: full braces.

The insurer denied coverage for full braces.

The denial is overturned.

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 recommended comprehensive orthodontics due to 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. 

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 claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care as on examination of the intraoral clinical images there is evidence of multifocal palatal gingival recession due to direct impingement of the teeth on the gingival soft tissues. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 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 clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

The healthcare 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 full braces is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ovarian Torsion.
Treatment hospital admission.
The insurer denied coverage for hospital admission.
The denial is upheld.

The patient presented to the emergency room with abdominal pain. There was a concern for ovarian torsion. The patient underwent a laparoscopic detorsion with ovarian cystectomy. The procedure was uncomplicated.  She was discharged later that day.

The patient presented with severe abdominal pain, an ovarian cyst and findings suggestive of torsion. She underwent an uncomplicated laparoscopy.
A laparoscopy is an ambulatory procedure.

According to Milliman Care Guidelines, Inpatient and Surgical Care, Laparoscopic Gynecologic surgery, including myomectomy, oophorectomy, and salpingectomy, laparoscopic procedures are ambulatory procedures. Inpatient stay may be needed for:
1)Older patients (> 65)
2)Conversion to abdominal procedures
3)Surgical complications
4)Comorbidities.

This patient did not have any of these criteria. Her procedure was uncomplicated. There was no evidence of any injury to other organs. She was tolerating oral intake and voiding adequately. 
 
Please note that a laparoscopic procedure is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required.
Based on the above, the inpatient admission was not medically necessary.

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

The hospital admission is not considered medically necessary for this patient. 

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

Diagnosis: Necrotizing infection.
Treatment: Skilled Nursing Facility admission.
The insurer denied the Skilled Nursing Facility admission.
The denial is upheld.

The patient is a male. He has a past history of debility, diabetes, hypertension, hyperlipidemia, and cocaine abuse. He underwent debridement for a necrotizing infection of the right buttock and subsequent closure. Wound cultures had grown MRSA (methicillin-resistant Staphylococcus aureus). He underwent IV (intravenous) antibiotic treatment and wound VAC (vacuum-assisted closure) placement.

The patient had admitted orders at the Beth Abraham Center for wound care, diabetes management, and general medical care. A progress note indicated the patient was ambulating and the VAC (vacuum-assisted closure) would get dislodged. Progress note indicated he was undergoing occupational therapy due to decreased functional mobility. The right buttock wound had the following measurements and treatments:

No, the Skilled Nursing Facility admission for wound management was not medically necessary.
The patient was ambulatory, causing the wound VAC (vacuum-assisted closure) to be dislodged. There were no complications related to the wound. The wound continued to improve. There was no need for prolonged antibiotics. There was no indication that weekly wound assessments could not have been performed as an outpatient along with home health for wound VAC (vacuum-assisted closure) changes.

As noted above, the patient was ambulatory causing the wound VAC (vacuum-assisted closure) to be dislodged which suggests he was not fully debilitated. There were no complications related to the wound. The wound continued to improve. There was no need for prolonged antibiotics. There was no indication that weekly wound assessments could not have been performed as an outpatient along with home health for wound VAC (vacuum-assisted closure) changes (ref 1). The use of a VAC (vacuum-assisted closure) in the home health setting is routine practice and safe, and is often used in conjunction with routine monitoring (ref2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal/xiphoid pain	

Treatment CT (computed tomography) scan of the chest

The insurer denied coverage for CT scan of the chest.

The denial is upheld.

This case involves a male with a history of smoking and gallstones.  In a clinical note, it was stated that the patient had an ultrasound of the abdomen which was normal.  The patient endorsed epigastric pain for the last year.  He underwent an EGD (esophagogastroduodenoscopy) that was reportedly normal.  He endorses intermittent shortness of breath and pain on palpation.  His pain was relieved by high-dose ibuprofen.  He denied dysphagia, abdominal pain, nausea, and vomiting.  The exam findings of the patient noted that the patient was in no acute distress.  There was xiphoid pain on deep palpation.  The abdomen was soft.  There was no costovertebral angle tenderness.  He had a normal gait.  The provider recommended that the patient have a formal CT of the chest without contrast and then return to the office for additional recommendations.

In a provider response, it was stated that the patient's CT of the chest was denied due to an approval on the similar procedure requested.  However, the patient never had a CT performed.  The provider stated that the CT would be utilized for preop planning.

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

Per the Oxford Health Insurance Inc. Guidelines and the Benefit Plan Language, muscle skeletal pain syndromes can be diagnosed by clinical exam.  Certain other chest wall pain syndromes can be diagnosed clinically.  Cartilage inflammation or other muscle skeletal syndromes do not require computerized tomography of the chest for diagnosis.  

Per the referenced literature (Schumann & Yelland), Costochondritis is a diagnosis based on clinical findings on physical exam and by ruling out other causes such as acute or chronic coronary disease and other musculoskeletal disorders.  Workup usually means a chest x-ray and EKG (electrocardiograpm) but does not involve a CT of the chest.  In this case, the patient had lower chest wall pain and tenderness.  The symptoms were relieved by nonsteroidal anti-inflammatory medication.  A computerized x-ray of the chest was recommended.  The provider indicated that the CT would be utilized for preop planning.  However, Cartilage inflammation or other muscle skeletal syndromes do not require computerized x-ray of the chest for diagnosis.  The requested imaging would not show specific findings that would change the patient's treatment.  While there is mention of preop planning, the documentation did not identify what specific procedure the patient was being recommended for.  Thus, the clinical documentation did not substantiate the medical necessity for the request.  As such, the coverage for computerized tomography (CT) scan of the chest is not medically necessary.

The insurer's denial of coverage for computerized tomography (CT) of the chest is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a male with systemic lupus erythematous (SLE), end-stage renal disease (ESRD) on hemodialysis (HD), and hypertension who presented to emergency room with worsening shortness of breath. The patient was found to be in hypertensive emergency, with acute hypoxic respiratory failure due to flash pulmonary edema. The patient was seen by nephrology for emergent dialysis as well as cardiology for elevated troponin levels. The patient was placed on bi-level positive airway pressure (BIPAP) as well as on high fraction of inspired oxygen (fio2). The patient was admitted to acute in hospital level of care.

Yes, the proposed inpatient admission was medically necessary.
The patient had worsening shortness of breath due to acute hypoxic respiratory failure due to flash pulmonary edema. The patient also had hypertensive emergency. The patient's acute respiratory failure worsened in the emergency room and the patient needed bi-level positive airway pressure (BIPAP). The patient was started on emergent dialysis and received multiple doses of intravenous (IV) blood pressure medications including nitroglycerin drip. Although the patient's condition improved in 24 hours and the patient was discharged in 48 hours, the patient had impending respiratory failure that was life threatening and the care could not have been safely provided at a lower level of care. The acute in patient hospitalization for acute hypoxic respiratory failure due to flash pulmonary edema and hypertensive emergency is standard of clinical practice. The proposed treatment was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth

Treatment: Intravenous Moderate (conscious) Sedation/Analgesia - First 15minutes (D9239)
Intravenous Moderate (conscious) Sedation/Analgesia - Each Subsequent 15 Minutes Increment (D9243)
Sinus Augmentation With Bone Or bone Substitutes Via A Lateral Open Approach (D7951)

The insurer denied the Intravenous Moderate (conscious) Sedation/Analgesia - First 15minutes (D9239)
Intravenous Moderate (conscious) Sedation/Analgesia - Each Subsequent 15 Minutes Increment (D9243)
Sinus Augmentation With Bone Or bone Substitutes Via A Lateral Open Approach (D7951)

The denial is overturned. 

This patient is under the care of an oral maxillofacial surgeon (OMS) for the replacement of teeth #3 and #4. To place dental implants in preparation of tooth replacement, the patient will require bone grafting. To augment the area of teeth #3 and #4 will also include sinus lift with bone grafting. The patient has also been treatment planned for intravenous sedation as the anesthetic of choice for this difficult surgery.

Yes, the proposed treatment is medically necessary.
For proper function, the patient wants to replace his missing teeth. There are two ways. One is removable denture and the second is with dental implants. The only fixed option is with the placement of dental implants. The proposed treatment is medically necessary and follows the standard of care. The fixed option will most closely replace the missing teeth and allow for a more normal and proper function. This is the preferred treatment. The use of partial dentures has decreased drastically due to difficulty with function and is fraught with complications.  

The requested procedure is the most successful and long term choice for replacement of missing teeth. This includes the sinus grafting, anesthesia, and dental implant placement. Due to the degree of difficulty and need for additional bone in the areas of the proposed implants, the use of anesthesia is medically necessary to aid in pain control and proper patient management. The sinus grafting is used to build up the missing bone in preparation for placement of the dental implants. The use of a bone graft, anesthesia and implants are more successful and predictable that the use of removal dentistry.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Long-term custodial care. 

The insurer is denied coverage for long-term custodial care. 

The denial is overturned. 

This female patient has a history of hypertension, dementia, unsteadiness, generalized epilepsy, nontraumatic subarachnoid hemorrhage, uterovaginal prolapse and cardiac pacemaker. 

While the medical record indicates that during the examination, she was able to respond, one has to look at this individual globally in terms of her having Alzheimer's disease and periods of confusion and that she had a subdural hematoma. She has a pacemaker.  It seems unreasonable to expect the family to render 24-hour safe care to this individual. The requested institutionalization is reasonable and appropriate. 

While the indication was that the patient could feed herself, the medical record does in fact show that there are periods of mental confusion and that she has Alzheimer's disease. She has comorbid conditions of hypertension and a pacemaker, and recently had a subdural hematoma. It seems that this individual is at great risk for falling and sustaining another subdural hematoma. It is unreasonable to expect the family to have 24-hour care in this very fragile individual. As such the request for institutionalization is reasonable and appropriate. 

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

The carrier's denial of coverage for the long-term custodial care is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: postpartum preeclampsia

Treatment: inpatient hospitalization 

The insurer is denied coverage for inpatient hospitalization

The denial is overturned. 

This is a female patient without a pertinent past medical history.

While this patient did not have a diagnosis of preeclampsia. She had significant elevation in her blood pressure and there were some concerns about an intracerebral bleed based on the history of severe headache and blurry vision and there was also concern about heart failure based on the decreased ejection fraction. Neurology, cardiology and gynecology consultations and management were needed.

Because of this patient's complex presentation, concern about heart failure, intracerebral bleed and need to control a very high blood pressure admission was medically necessary to rule out more serious conditions and to manage her existing symptoms.

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

The carrier's denial of coverage for the inpatient hospitalization is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep pockets. 
Treatment: Periodontal Root Planning and Scaling Four or More Teeth per Quadrant, Four Quadrants, Pre-service. 

The insurer denied the Periodontal Root Planning and Scaling Four or More Teeth per Quadrant, Four Quadrants. 

The denial is upheld. 

The patient is a male requesting benefits for four quadrants of scaling and root planning. The patient is stated to have pocket depths of four to six millimeters in each quadrant. 

No, the proposed treatment is not medically necessary. 

While there are pocket depths ranging up to six millimeters in each of the four quadrants, the x-rays provided do not show any bone loss, and very little calculus (tartar) present. The pockets are likely "pseudopockets", meaning the gums are just swollen and inflamed, giving the illusion of pocketing. Without bone loss and with no tartar present, the need for deep scaling and root planning is not there. The requested scaling and root planning by quadrants (times four) is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III malocclusion.
Treatment: Braces and 12 monthly office visits, Preservice.
The insurer denied the braces and 12 monthly office visits.
The denial is overturned.

The patient is an adolescent female with Class III malocclusion who cannot occlude on her back teeth, that is,  they do not touch together.  This appeal is requesting braces and 12 monthly office visits. 

Yes, the request for braces and 12 monthly office visits is medically necessary.

The patient cannot get her left and right back teeth to touch together.  This will cause excessive force to her anterior teeth overtime, which could result in fracturing or loosening of these teeth   In addition, this condition affects her ability to chew properly.  As such orthodontic treatment is necessary to correct the condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sarcoidosis.
Treatment: Humira 40 milligrams.
The insurer denied Humira 40 milligrams.
The denial is overturned.

The patient is an adult male with sarcoidosis who is prescribed Humira.  The patient has difficult to treat sarcoid and is on chronic prednisone.  The patient had a reaction to infliximab.
Humira has been denied because there was no clinical documentation of tuberculosis testing in the past six months. 

The denial has been appealed.

Yes, the requested treatment with Humira 40 milligrams is medically necessary.

The patient has sarcoidosis and is prescribed Humira.  The patient has difficult to treat sarcoid and is on chronic prednisone.  The patient had a reaction to infliximab.  Humira was denied because there was no clinical documentation of tuberculosis testing in the past six months.  However, patient had tuberculosis testing performed in the past six months (purified protein derivative [PPD] testing) which was negative.

Anti-tumor necrosis factor agents (anti-TNFs) have been recommended as third-line therapy for sarcoidosis due to positive outcomes and reduced systemic steroid use.  Available evidence suggests efficacy and safety of Humira in pulmonary, cutaneous, ocular, neurologic, and multisystem sarcoidosis, and in cutaneous and ocular sarcoidosis.  The use of Humira is medically necessary as the patient has tried and failed prednisone as well as infliximab.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Over-bite. 
Treatment:  Braces and Monthly Visit, Pre-service. 

The insurer denied the  Braces and Monthly Visit. 
The denial is overturned. 

The patient is a male.  The request is for benefits for orthodontic treatment (braces), monthly visits, pre-service.  Orthodontic records were created and include x-rays and photos. A clinical consultation was performed.  

The patient presents with a deep impinging over-bite.  The Health plan denied the claim as not medically necessary.  The provider appealed because of the patient's deep impinging over-bite.  

Yes, the proposed treatment of orthodontic therapy (braces), monthly visits, pre-service is medically necessary.  

The patient presents with a deep impinging over-bite of 100 percent--meaning that when the patient's mouth is closed, the upper front teeth completely cover the lower front teeth. Although soft tissue damage is not evident, the overbite itself is so severe it can lead to a host of long term dental problems, including pain in the jaws, difficulty speaking, sleep apnea, tooth decay.  

Orthodontic treatment is the standard of care to treat this severe over-bite; the patient is also at the ideal age for this correction to take place because the jaw is still growing.  

If this condition is left untreated, the patient's overall dental health will be at risk for a myriad of complications as stated above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intractable Headaches with Dizziness. 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This case involves a patient who presented to emergency department with a chief complaint of headache.  The documentation indicated she does have a past medical history of hypertension and endorsed blurry vision.  She indicated she was seen at a different facility a few days prior with a work-up including a computed tomography (CT) scan which was unremarkable.  She was also seen in the office by her neurologist who sent her for a repeat CT scan as well as further laboratory studies.  Upon physical examination there was no significant findings.  The recommendation was made to treat the patient with Benadryl, Reglan, and fluids.  Her CT scan of the head was unremarkable as well as x-rays.  Labs were only significant for mild leukocytosis.  The patient remained stable with a normal neurological examination.  It was recommended she be admitted for further evaluation and treatment.  The documentation indicated she was admitted and continued treatment with medication.  She was treated with antibiotics and the following day she was discharged due to lack of further adverse events and improvement in pain and vision. 

The patient presented with intractable headaches with dizziness, vertigo, and blurred vision. The neurologist ordered a CT of the head which was unremarkable as were spinal x-rays. The patient was treated for presumed sinusitis with antibiotics and was treated for her headaches with several agents in the hospital. There was no evidence for stroke, hemorrhage, or aneurysm. The care provided, including diagnostic imaging, specialty consultation and medical management could have been provided in the emergency department (ED) or at an observation level of care. The care provided did not warrant inpatient admission. Therefore, 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.