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

Diagnosis: Malignant neoplasm of cervix.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient had presented with abnormal cells on a Pap smear. She was recommended for a radical hysterectomy with sentinel lymph node assessment for adenocarcinoma in situ of the cervix. She underwent an exploratory laparotomy, bilateral salpingo-oophorectomy and sentinel lymph node dissection. There were no intraoperative complications. At issue is the medical necessity of the inpatient stay.
The patient underwent an exploratory laparotomy, bilateral salpingo-oophorectomy and sentinel lymph node dissection. The surgery did not have any intraoperative complications. The patient was afebrile, with stable vital signs, had a non-focal exam, normal lab results, and was able to ambulate, and take oral medications and an oral diet. The patient would have been appropriate to transition to oral pain medication as she was able to tolerate an oral diet and would have been appropriate to take oral pain medication as well. Thus, she did not have any conditions that would render a continued inpatient level of care medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cancer.
Treatment:  Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS). 

The insurer denied an increase in the Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS).  The health plan's determination is overturned. 

The patient is a female with past medical history of multiple myeloma with ongoing treatment, back pain, neck pain, anemia, chronic dizziness, anxiety and depression, who had been assigned 4 hours/day, x 5 days/week and 3 hours/day x 1 day/week to total 23 hours/week of CDPAS/PCA service hours.  There was a request to increase CDPAS (Consumer Directed Personal Assistance Program) hours, and the patient had a telephonic assessment tool.  This assessment noted the patient lives with her spouse and two children but is alone while they are at work and school.  The patient uses a cane/walker for ambulation (but later in assessment it is noted that the patient isn't using her cane), has bath/shower chair, Hoyer lift, hospital bed and incontinence supplies.  The patient needs assistance of another person to ambulate.  CDPAS hour increase is requested due to dizziness, unsteady gait, fatigue, shortness of breath and pain. 

The Increase of Consumer Directed Personal Assistance Program (CDPAP) Personal Care Services (PCS) - Housekeeping/Personal Attendant (Level 1 and Level 2), 12 Hours per Day/6 Days per Week is medically necessary for this patient. 

There is documentation provided by her PCP and her oncologist of medical necessity for the increased PCA hours.  The telephonic assessment tool underestimated the patient's assistance needs.  The plan noted denial of increased hours, as there was no change from the prior assessment tool.  The patient does not have informal helper and is left alone when her husband and children are at work and school.  The patient's children work after school, and the patient is left alone for a period of 12 hours per day.  CDPAS/PCA service hours are not solely for supervision and safety but to assist the patient with activities of daily living (ADL) and instrumental activities of daily living (IADL).  The increased personal care service hours are medically necessary under Medicaid when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.  This is the case for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite
Treatment: Braces
The insurer denied the braces.
The denial is overturned. 

The patient is a female.  The request is for orthodontic benefits.

Yes, the proposed braces are medically necessary. 

The patient has an anterior crossbite between teeth #'s 10 and 23, with gingival attachment loss. This is an "automatic qualifier" for orthodontic benefits according to the handicapping index scale.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted Molars  
Treatment: D9243 IV Sedation each 15  
 
The insurer denied D9243 IV Sedation each 15. The denial was overturned. 

This is a male patient presented for extractions of impacted third molars #17 and #32 with intravenous (IV) sedation.  The insurer has approved the IV sedation but not an additional 15 minute interval.  They denied this service stating that the medical record does not indicate a specified medical/physical/emotional issue or complexity of dental treatment that would justify this service and therefore it does not meet medical necessity criteria.  

It appears that this patient has complex extractions of impacted teeth to be performed and presented to the oral surgeon for completion of such.  Sedation services are considered a standard of care in in this circumstance as noted in the policy and procedure manual and evidenced by approval by the insurer for the IV sedation.  The issue is the duration of the IV sedation.  In this case an additional 15 minute interval was requested due to complexity of the surgical services and is therefore medically necessary.  Further the service recommended fulfills the insurer criteria for medical necessity.  

Reverse denial and approve coverage for D9243 IV sedation each 15 as it is a standard of care in practice in this clinical situation.  

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

D9243 IV sedation each 15 minutes is considered medically necessary for this patient.  

The carrier's denial of coverage for D9243 IV Sedation each 15 is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Impacted left upper cuspid.
Treatment: Opening area to allow tooth to come out (exposure of an unerupted tooth) and putting on a button to help move the tooth (placement, device to facilitate eruption) for tooth #11 and tooth removal (extraction) for tooth H.

The insurer denied the Opening area to allow tooth to come out (exposure of an unerupted tooth) and putting on a button to help move the tooth (placement, device to facilitate eruption) for tooth #11 and tooth removal (extraction) for tooth H.
The denial is overturned. 

The patient is a female with an over-retained upper left deciduous cuspid and an impacted tooth #11 with an enlarged follicle. The provider plans to remove tooth H and expose and bond #11 so that it can be brought into normal position orthodontically. This has been denied as not medically necessary per the Medicaid policy.

Yes, the proposed treatment, opening area to allow tooth to come out (exposure of an unerupted tooth) and putting on a button to help move the tooth (placement, device to facilitate eruption) for tooth #11 and tooth removal (extraction) for tooth H, is medically necessary.

Canines in the upper jaw usually erupt in the mouth between the age of 11 to 12 years. In two percent to three percent of the population, these teeth fail to erupt into the mouth and become lodged in the roof of the mouth (palate), they are then referred to as 'palatally impacted'. Root resorption of maxillary lateral incisors caused by erupting canines is well known and a relatively common phenomenon. Their impaction can cause damage to the roots of neighboring teeth and the damage may be so severe that these neighboring teeth are subsequently lost. Management of this problem involves surgical exposure (uncovering) followed by fixed braces for two to three years to bring the canine into alignment within the dental arch. To align those teeth in the dental arch that cannot erupt or are displaced, they must be surgically exposed. After the traction device is attached, the tooth is again covered with the mucoperiosteal flap to protect the tissues involved. The tissue around these impacted canine teeth can also undergo cystic change. Studies show that correct alignment and good periodontal status were obtained with this technique.

The upper left cuspid is impacted. It has the potential for causing pathological problems. It needs to be brought into proper alignment to normalize the occlusion and avoid these problems. The treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Foreign Body of Alimentary Tract.
Treatment: Inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is upheld. 

This is a patient who presented to the Emergency Room (ER) after swallowing a penny.  A chest x-ray was performed that confirmed that the penny was in the mid esophagus. He was admitted to the hospital for further evaluation.  The patient underwent a esophagogastroduodenoscopy (EGD) with foreign body removal; a penny. He tolerated the procedure well and was discharged home


Per Joyamaha, D., & Conners, G. P. (2015), "Foreign body ingestion is common among children. A variety of foreign bodies are ingested, most of which are harmless and pass spontaneously through the gastrointestinal (GI) tract. There are a few particularly harmful and life threatening objects that should be identified and removed immediately to avoid serious complications."

The penny required removal and it was removed within 24 hours of presentation. This is sound medical care. He was placed nothing by mouth (NPO) and given intravenous (IV) fluids overnight but the penny did not fall into the stomach, so it needed removal and this was done appropriately. However, the patient did not need a formal inpatient admission. He could have received identical excellent treatment using an observational admission. The patient had no fever, had normal vital signs, had no surgical problem, had no infection. Overall he was clinically stable. The NASPGHAN guideline (2015) states that esophageal coins should be removed withing 24 hours, as done in this case. This procedure can be considered an outpatient procedure. The procedure is considered to be done using general anesthesia, so usually the procedure cannot be done immediately. In addition, often when the patient is placed NPO overnight, the coin falls into the stomach and no removal is necessary. Medical care was done correctly, but the patient did not meet criteria for a formal inpatient admission. This could have been done using observational status. Therefore, the inpatient hospital admission is not considered medically necessary for this patient.

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

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

Diagnosis: Preeclampsyia  (high blood pressure during pregnancy)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female, G6P1403, who presented to labor and delivery at 29 5/7 weeks with preeclampsia with severe features including elevated blood pressures at home in the 170's/110's and scotomata.  Past medical history was significant for prior history of eclampsia and multiple pregnancies complicated by preeclampsia.  Protein/creatinine (P/C) ratio was 0.64 and blood pressure 161/115.  

The patient was admitted and treated with intravenous antihypertensives, magnesium seizure prophylaxis, and betamethasone.  The blood pressures continued to be elevated in the severe range.  Because the nursery at the initial treating facility was not capable of caring for newborns at the estimated fetal weight or gestational age, the patient was transferred for a higher level of care.  

The health plan contends that the admission was not medically necessary due to absence of sustained blood pressure elevations; hemolysis, elevated liver enzymes, and a low platelet count (HELLP) syndrome/severe preeclampsia laboratory abnormalities; end organ damage; or abnormal fetal heart rate tracing and cites MCG 23rd edition ORG: M-285.  The facility contends that the admission was medically necessary based on the clinical findings and MCG 23rd edition guidelines Hypertensive Disorders of Pregnancy ORG: M-285 (ISC).  

Yes, the proposed treatment, inpatient admission, was medically necessary.  

The patient met criteria for preeclampsia with severe features based on degree of blood pressure elevation, visual changes, and P/C ratio.  It is medically necessary and appropriate and standard practice for patient to be admitted for this diagnosis due to immediate life-threatening risk to mother of seizures, intracranial hemorrhage, posterior reversible encephalopathy syndrome and cortical blindness, hepatocellular injury, renal failure, pulmonary edema, microangiopathic hemolytic anemia, abruptio placentae, and other complications including death, as well as to the fetus of intrauterine hypoxia, placental abruption, premature labor and/or delivery, and intrauterine death.  It is also medically necessary and appropriate and standard practice subsequent to admission to be transferred to a higher level of care to ensure safety for the baby if preterm delivery is necessary, and the need for subsequent transfer is irrelevant to the emergent need for maternal admission, treatment, and monitoring at a high level of care.  Therefore, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchitis.

Treatment: Inpatient admission.
 
The insurer denied the inpatient admission.

The denial was overturned.

This is a female patient who was sick for one week with a cough and chest congestion. She had been seen by her pediatrician and diagnosed with an upper respiratory infection. It was reported that she was not tolerating oral feedings well and was having multiple episodes of post-tussive vomiting.  She presented to the Emergency Room (ER) with significant increase in her work of breathing. There were subcostal retractions and on examination with tachycardia and tachypnea.  Her lung examination was significant for diffuse wheezing and crackles. She was treated with inhaled albuterol and saline, high flow oxygen and dexamethasone. She was given an IV bolus of normal saline. Her blood test was significant for a HCO3 of 18; which was low and suggestive of acidosis. When her respiratory rate remained elevated at 66 and the respiratory distress did not resolve with treatment. She was admitted to the PICU for ongoing care with a diagnosis of Bronchiolitis. After treatment and a period of medical stability the patient was discharged home with follow up. 

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

The patient was treated appropriately in the ER and since she was not drinking well because of the increased respiratory rate and she did not improve with treatment in the ER admission to the hospital for ongoing treatment was appropriate. The increased work of breathing, tachypnea, low oxygenation, rand lab testing suggestive of acidosis were significant clinical findings. The increased work of breathing and inability to take adequate fluids by mouth did not respond to treatment in the ER. The decision to admit to the hospital for ongoing treatment with IV fluids, albuterol and oxygen was appropriate and consistent with the standard of care. 

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Impacted tooth
Issue under review:  Tooth extraction

Determination:
The Tooth extraction is medically necessary.

This is an adult female who was denied removal of an impacted tooth.  The denial states that there is no sign of infection, pain beyond normal eruption pain, and it is not in a position that it will not erupt on its own.

The tooth is indicated for removal, and the removal is medically necessary.  The American Academy of Oral and Maxillofacial Surgeons (AAOMS) Parameters of Care states that an impacted third molar that is so positioned that it will probably not erupt by the middle of the third decade constitutes pathology with dental and medical consequences.  To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development.  An impacted tooth with completed root formation that is totally covered by bone in a patient beyond the third decade that does not meet the following indications for removal should be monitored for change in position and/or development of pathology, which may then indicate its removal.  The patient meets criteria, as the tooth is impacted and so positioned that it will probably not erupt by the middle of the third decade.  Even if it does erupt, there is no opposing tooth, and it will continue to erupt until it contacts the opposing arch and will then need to be removed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Impinging bite; overjet
Issue under review:  Braces and follow-up visits

Determination:
The Braces and follow-up visits are medically necessary.

The patient is a young male.  The patient presents with two "automatic qualifying" conditions, according to the handicapping index scale.  He has a deep, impinging bite with soft tissue damage of the palate.  He also has an overjet of greater than nine millimeters (mm) with incompetent lips.  Either of these alone would qualify for orthodontic coverage with monthly follow up visits.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was admitted to the hospital for abdominal pain and was found to have acute appendicitis on ultrasound, which showed a 9 millimeter (mm) appendix on physical exam.
He was taken to the operating room (OR) and had a laparoscopic appendectomy. The patient was discharged the following morning. The patient had been vomiting preoperatively. At issue is the medical necessity of an inpatient stay.
The health plan's determination is upheld.
The patient underwent a laparoscopic appendectomy. At the time of surgery, an enlarged appendix and some seropurulent fluid were found. It was not recorded as perforated. He received intravenous (IV) fluid overnight as well as antibiotics. He was discharged the next day. This type of treatment can be provided at a lower level of care than inpatient.
An article by Benedict LA, et al concluded that after laparoscopic appendectomy in children with nonperforated appendicitis, same day discharge (SDD) not only reduces postoperative length of stay but also is not associated with higher hospital readmission rates. 
An article from the Journal of Pediatric surgery demonstrates that use of clinical pathways to guide treatment reduces length of stay without adverse outcomes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System/Neuromuscular Disorder
Treatment:  Inpatient Hospital

This is a patient with a past medical history significant for bipolar disorder, depression, and schizophrenia who presented to the emergency department with complaints of muscle cramping sensation in all extremities after performing strenuous exercises.  At the time of the initial evaluation, the patient also reported some delusions.  He stated that another person tried to put a spell on him; therefore, he started to experience these symptoms.  At the time of the initial evaluation, the patient complained of watery diarrhea.  He reported 6-8 bowel movements a day.  The patient denied any suicidal or homicidal ideations.
The review of systems was negative for a fever, nausea, vomiting, cough, runny nose, chest pain, or difficulty breathing.
At the time of the initial evaluation, the patient was afebrile, his blood pressure was 142/89 millimeters of mercury (mmHg), with a pulse rate of 78 beats per minute (bpm), a respiratory rate of 16/minute, and an oxygen saturation of 97% on room air.  The patient was awake, alert, and oriented to person, place, and time.  He appeared to be well-developed and well-nourished.  His cardiovascular exam was unremarkable.  Lungs were clear to auscultation.  The rest of the physical exam was unremarkable.
Laboratory evaluation demonstrated that the creatine phosphokinase (CPK) level was 1418 with a white blood cell count of 19.49; a sodium of 136, a potassium of 4.9, a chloride of 96, a bicarbonate of 21, a blood urea nitrogen (BUN) of 21, a creatinine of 1.67, and a glucose of 97.  The repeat basic metabolic profile demonstrated worsening of the kidney function.  At that time the patient's brain (or B-type) natriuretic peptide (BNP) was 25, and the creatinine was 1.74.  The hemoglobin, hematocrit, and platelets were within normal limits.
In the emergency department, the patient received treatment with intravenous fluids and magnesium sulfate.  Subsequently, the patient was admitted to the hospital with a diagnosis of rhabdomyolysis, kidney failure, and diarrhea.  In the hospital, the patient received treatment with intravenous fluids.
The health plan's determination is overturned.
The patient had acute kidney failure that was triggered by persistent diarrhea and untreated rhabdomyolysis .  A failure to evaluate and treat these clinical conditions in a timely manner could lead to further exacerbation of kidney function.
The patient presented to the hospital with several medical problems that included persistent diarrhea that clearly led to dehydration and acute kidney failure, as well as rhabdomyolysis, deconditioning that also contributed to acute kidney failure.  This patient required admission to the hospital for administration of intravenous fluids, close monitoring of the kidney function and CPK level, and also evaluation of diarrhea that clearly led to dehydration and kidney failure.
Therefore, admission at the acute inpatient level of care was the best option in this clinical situation and was medically necessary.