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

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a medical history of testicular cancer status post orchiectomy and retroperitoneal lymph node dissection, appendectomy, and hernia repair. He presented to the emergency department with abdominal pain, nausea, and vomiting. He had just been diagnosed with a small bowel obstruction at another hospital but left against medical advice. His vital signs were unremarkable. The physical examination was notable for a soft, nondistended abdomen with periumbilical tenderness to palpation.  A computed tomography scan of the abdomen and pelvis showed dilated small bowel with transition point in the midline lower abdomen suggestive of small bowel obstruction, dilated stomach which may represent gastric outlet obstruction, mild distal esophageal mural thickening, trace pelvic ascites, 8 millimeter (mm) nodule in the gallbladder fundal wall, and a 5.1 x 3.1 x 9.8 centimeter (cm) fluid collection (decreased from prior size) posterior to the abdominal aorta which may represent postoperative seroma, lymphangioma, or abscess. He was treated with intravenous Dilaudid, pantoprazole, ondansetron, and fluids. He was made nil per os (nothing by mouth). A nasogastric tube was placed and 400 milliliters (mL) of fluid was removed. He was tolerating a diet and having bowel movements. He was discharged with a plan for Primary Care follow-up. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care is not medically necessary, and the care provided could have been provided at a lower level of care. The patient presented with abdominal pain, nausea, and vomiting; he had rapid improvement in symptoms with conservative therapy, with tolerance of diet and bowel movements on the day after presentation. Additionally, there was no documented hemodynamic instability, persistent gastrointestinal bleeding, bowel perforation, peritonitis, sepsis, or other complications which would warrant the inpatient level of care. All of the measures that were undertaken, including monitoring, labs, imaging, intravenous fluids, and gradual advancement of diet, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Dental Issues
Dental/orthodontic

Diagnosis: Class II Division 1 malocclusion 
Treatment: Braces, Monthly Visits, and a Retainer 
The insurer denied Braces, Monthly Visits, and a Retainer.
The health plan's determination is overturned. 

The patient in question is a young female with a Class II Division 1 malocclusion with maxillary and mandibular crowding. She has 8 millimeter (mm) overjet and 0 mm overbite. Tooth 6 is in crossbite and tooth 13 is in buccal (reverse) crossbite. She is treatment planned for Braces, Monthly Visits, and a Retainer.

Braces, Monthly Visits, and a Retainer are medically necessary for this patient.
Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. This patient, like fifteen percent of the population, exhibits an Angle's Class II bite.1 Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjet, which this patient has. 3 For these reasons, the requested orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient ischemic attack. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The health plan's determination is upheld. 

The patient is a pregnant female who presented to the hospital with complaints of difficulties expressing her thoughts. 
While she was riding in a car with her husband, she suddenly experienced a 5 to 10-minute episode during which she had difficulty expressing her thoughts. She reported knowing what she wanted to say but was unable to articulate it. At times, she repeated words or left thoughts unfinished. There were no accompanying changes in her vision, headache, decreased sensation, or weakness in her extremities. She had been in her usual state of health and denied fever, chills, cough, phlegm, throat issues, chest pain, shortness of breath, abdominal symptoms, joint problems, altered urinary habits, increased anxiety, worsening depression, or any suicidal or homicidal thoughts. 

The inpatient hospital admission was not medically necessary. 
The review of the medical records demonstrated that the patient was likely having a migraine that was not associated with severe or persistent altered mental status, severe or persistent vomiting, or severe or persistent dehydration. The imaging studies did not demonstrate that the headache was associated with unruptured but symptomatic aneurysm of vascular malformations, venous sinus thrombosis, increased intracranial pressure, or cerebral spinal fluid leak. 
In the hospital, the patient was examined by a neurologist who did not indicate the presence of papilledema, cerebral edema, mass effect on the imaging studies, cerebral bleeding, ischemia, hydrocephalus, or uncontrolled seizures. The symptoms were attributed to migraine with aura. The diagnosis of transient ischemic attack (TIA) was much less likely. There was no mention that the patient had focal neurologic signs.
There was no mention that the patient had any complications of her pregnancy requiring admission at the acute inpatient level of care. Taking into consideration all these facts, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

According to the triage note, the patient was brought via Emergency Medical Services (EMS) status-post (s/p) fall with a blood pressure (BP) of 177/104 and heart rate (HR) 102. The patient was walking their dog and tripped, hitting their head. The patient stated they had loss of consciousness (LOC) and complained of headache and vomiting multiple times since the fall. As per EMS, the patient became aphasic and began seizing. The patient was unable to answer questions. Trauma consult saw the patient and noted the history of fall and seizure. The seizure was broken in the Emergency Department (ED) with 2 milligrams (mg) of Ativan. The patient's Galsgow Coma Scale (GCS) was 15. Neuro exam did not reveal any focal defects. The patient was alert oriented and following commands. Trauma recommended C (cervical) spine, echo, and Ativan as needed (prn). The attendant saw the patient and noted that due to vital sign stability and GCS 15 with no major injuries noted, the patient was downgraded to level 2 trauma. The plan was to admit to monitor for post-concussive or seizure. Neurology evaluation was being requested. C-spine was cleared. 

Neurology was consulted and saw the patient and noted the history of chronic strokes, and history of bipolar disorder. Exam revealed pupils equal, round, and reactive to light (PERRL), partial right ptosis due to edema. Labs were reviewed. The assessment was seizure likely provoked from trauma post-concussion. Routine electroencephalogram (EEG) did not show epileptiform activity or seizure. Neurology recommended magnetic resonance imaging (MRI) brain and complete chronic stroke workup as an outpatient, as well as physical therapy (PT) and ophthalmology as an outpatient.

Trauma saw the patient and noted the labs and X-ray results. Neurology noted that the patient's sister requested that the patient stay overnight until services were available. However, it was reported that patient was told they could leave, and the patient did leave.

Based upon the information provided, the hospital inpatient admission is not approved at the acute inpatient level as the patient should have been treated on an observation level without an acute inpatient admission.  The patient did not meet criteria based upon Milliman Care Guidelines (MCG) guidelines. 

In fact, the neurologist did note the history of chronic strokes, and history of bipolar disorder and an unremarkable exam. The assessment was seizure likely provoked from trauma post-concussion; and routine EEG did not show epileptiform activity or seizure. Neuro recommended MRI brain and complete chronic stroke workup as outpatient. Thus, admission was not warranted at the acute inpatient level but rather as an observation status. 

Based on the above, the insurer's denial must be upheld. 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 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned.

The patient is an adolescent female. The request is for orthodontic benefits with monthly visits. The patient has a Class I malocclusion with upper and lower crowding. There is a narrow upper arch with bilateral posterior open bites and crossbites. The prior denial was due to a handicapping index score of 10.

The requested health service is medically necessary.

The patient has bilateral (left and right) posterior crossbites. This means that her upper teeth in the back are "inside" of her lower teeth, which is backwards to how it should be. When the patient goes into a chewing cycle, instead of her lower teeth gliding properly along the insides of her upper teeth in a passive way, her lower teeth will bang into her upper teeth in a traumatic way. Over time, fracturing and/or loosening of teeth will occur. Pain will most probably develop in her temporomandibular (TM) joints due to increase stresses to the joints. 

These things need to be corrected with orthodontic treatment. Monthly visits are necessary to make sure progress is on track. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic Heart Failure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This is the case of a patient that presented to the hospital for elective electrophysiologic (EP) study. The patient's past medical history was significant for ischemic heart failure with reduced ejection fraction.  Following treatment with guideline directed medical therapy, the patient's ejection fraction recovered to 58% (percent).  The patient underwent stress echocardiography and a 22 second run of monomorphic ventricular tachycardia was noted. The patient underwent an uncomplicated EP study where triple extra-stimuli at two rates and two sites were performed.  No ventricular tachycardia was induced, and the patient was discharged the following day. 

The health plan acted reasonably and with sound medical judgement and in the best interest in the patient.  This patient underwent an uncomplicated electrophysiologic study and no inducible arrhythmia was noted. The procedure was performed without complication and the patient was discharged the following day. Several studies have demonstrated that same day discharge is safe and feasible in patients undergoing electrophysiologic study with and without catheter ablation (1-3). In conclusion, full hospital inpatient admission was not medically necessary in this case.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes and osteoarthritis. 
Treatment: Increase in Personal Care Service (PCS) hours to 12 hours a day, 7 days a week for a total of 84 hours per week. 
The insurer denied coverage for increase in Personal Care Service (PCS) hours to 12 hours a day, 7 days a week for a total of 84 hours per week. 
The denial is overturned. 
 
This is an adult male with chronic medical problems including hypertension, diabetes and osteoarthritis.  He lives alone in a 2-bedroom apartment.  The insurer approved personal care services (PCS) 7 hours/day, 7 days/week (49 hours/week total). The request is for PCS 12 hours per day - 7 days per week (84 hours/week total), leading to an external review. 

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognition was described as moderately impaired.  The patient has and is able to operate a Personal Emergency Response System (PERS). He reportedly requires maximal assistance to total dependence for completing Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. He reportedly requires maximal assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. However, ambulation ability was also described as "with a walker and contact guard assistance." Extensive assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and eating.  He reports being frequently incontinent of bladder and infrequently incontinent of bowel. The patient's ability to perform activities of daily living and self-sufficiency have reportedly declined and deteriorated, respectively, over the prior 90 days. There has been 1 reported fall over the prior 30 days. 

The patient's clinical condition and functional deficits are at a level and unpredictable as to require the requested PCS 12 hours per day - 7 days per week (84 hours/week total).  A letter from the patient's treating physician describing a recent fall and resultant fracture was reviewed. The doctor noted that the patient is only able to ambulate 5 steps with a walker. In addition, he had dementia, has a neurogenic bladder and had multiple episodes of bowel incontinence per day. 

Based on the submitted clinical records, the patient's health and safety are appropriately provided and maintained at home by the requested is for PCS 12 hours per day - 7 days per week (84 hours/week total). 

Based on the above, the insurer's denial must be reversed. 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 an increase in Personal Care Service hours to 12 hours a day, 7 days a week for a total of 84 hours per week  is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short Stature
Treatment: Genotropin
The insurer denied: Genotropin
The denial is upheld.

The case involves a school aged male who was prescribed growth hormone (Genotropin) for idiopathic short stature. His prior evaluation included passing a growth hormone stimulation test with a peak growth hormone of 12 nanograms per milliliter (ng/mL) last year. His initial insulin-like growth factor one (IGF-1) level was 34 (-1.6 z-score) and he also had other normal screening laboratory studies. A bone age six months ago was read as 6 years which was slightly greater than his chronological age, while a bone age last year was read as 4 years and 6 months which was slightly less than his chronological age. His heights and height velocities have varied with height nine months ago on the first percentile with a -2.25 z-score while more recently three months ago it improved to between the second and third percentile with a height z-score of -1.95.

The requested health service is not medically necessary.

On most recent point on the growth curve three months ago the patient's height is 106.5 centimeters (cm) which places him between the second and third percentile with a z-score of -1.95. Given his bone age, a predicated adult height is unable to be calculated, but his current z-score for height from three months ago is above criteria for idiopathic short stature.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia (BPH). 
Treatment: Prostate artery embolization (PAE) (a procedure to treat enlarged prostate gland). 
The insurer denied coverage for prostate artery embolization (PAE) (a procedure to treat enlarged prostate gland. 
The denial is overturned. 

This is a patient with benign prostatic hyperplasia (BPH) voiding symptoms, not greatly relieved by medical therapy. The patient was appraised of all of the treatment options.  Initially the patient thought about having a transurethral resection of the prostate (TURP) done, then chose to be treated by prostate artery embolization (PAE) instead. PAE was Food and Drug Administration (FDA) approved for BPH treatment in July 2018, and has a favorable treatment result and safety profile. The insurer has denied coverage for PAE as it has not been medically proven to be effective for BPH treatment. The appeal on behalf of the patient is noted and read in detail. 

PAE is FDA approved for treatment of symptomatic BPH, and existing literature supports the procedure to be a safe and effective treatment for BPH and lower urinary tract symptoms (LUTS). It is a single outpatient procedure and has shown clinical improvement in voiding symptoms in the majority of patients in whom medical therapy has failed and where patients wish to avoid or are poor candidates for more invasive prostate surgery. 

In summary, the denial of a prostate artery embolization (a procedure to treat enlarged prostate gland) and coverage for the requested treatment should be reversed. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia (BPH). 
Treatment: Prostate artery embolization (PAE) (a procedure to treat enlarged prostate gland). 
The insurer denied coverage for prostate artery embolization (PAE) (a procedure to treat enlarged prostate gland). 
The denial is upheld. 

The patient has symptoms of benign prostatic hyperplasia (BPH). The provider wishes to perform prostatic artery embolization (PAE), which is the topic of this review.

Evidence from several randomized controlled trials show inconclusive findings or inferiority of prostate artery embolization as compared to established treatments for effectiveness, with some apparent benefit for adverse events. Therefore, the evidence is currently insufficient to consider this technology to be proven as non-inferior or superior to established approaches.      

The patient is a candidate for many other standard therapies for this condition that are currently supported by peer-reviewed literature, such as a transurethral resection of the prostate (TURP), prostatic urethral lige (PUL), high-energy water vapor thermotherapy, and open surgery.

"Compared to TURP, PAE may provide similar improvement in urologic symptom scores and quality of life. While we are very uncertain about major adverse events, PAE likely increases retreatment rates. While erectile function may be similar, PAE may reduce ejaculatory disorders. Certainty of evidence for the outcomes of this review was low or very low except for retreatment (moderate-certainty evidence), signaling that our confidence in the reported effect size is limited or very limited, and that this topic should be better informed by future research" (Jung, J. H., et al., 2022).

"There was no significant difference in outcomes between therapies for International Prostate Symptom Score (IPSS) at the 3, 6, and 12-month follow ups. Although outcomes for Rezum were only available out to 3 months, there were no consistently significant differences in outcomes when comparing Aquablation versus PAE versus Rezum. TURP post-void residual (PVR) was significantly better than Urolift at 3, 6, and 12 months" (Sajan, A., et al., 2022). 

"Eleven articles met our selection criteria and ten independent patient series were included in the final analysis. Pooled estimates suggested no significant difference between TURP and PAE for patient-reported outcomes including International Prostate Symptom Score (2.32 [- 0.44 to 5.09]) and quality of life (0.18 [- 0.41 to 0.77]) at 12 months. PAE was less effective regarding improvements in most functional outcomes such as maximum flow rate, prostate volume, and prostate-specific antigen" (Xiang, P., et al., 2021). 

In summary, the denial of a prostate artery embolization (a procedure to treat enlarged prostate gland) and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental malocclusion. 

Treatment:  braces (D8080- Comprehensive Orthodontic Treatment) and adjustments (D8670 x 8- Periodic Orthodontic Treatment Visit). 

The insurer denied coverage for braces (D8080- Comprehensive Orthodontic Treatment) and adjustments (D8670 x 8- Periodic Orthodontic Treatment Visit). 

The denial is overturned. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified impacted maxillary anterior teeth among other findings including class II malocclusion, overbite, overjet, severe maxillary crowding, and mandibular crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the Handicapping Labio-Lingual Deviation (HLD) index. 

Upon review of the submitted documentation (study models were not provided for review) 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 
In this case, the treating orthodontist completes the Handicapping Labio-Lingual Deviation (HLD) index; choosing the impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance as documented meets this criterion for approval of 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. 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. 

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 braces (D8080- Comprehensive Orthodontic Treatment) and adjustments (D8670 x 8- Periodic Orthodontic Treatment Visit) services is substantiated.