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

Orthopedic / Musculoskeletal - Back Pain
Surgical Services (All)

The patient is a female who has lost weight following revision gastric bypass surgery performed two years ago. She complains of rashes and back pain. Photos show a female with a large pannus that hangs to her thighs. Panniculectomy is planned. The subject under review is the medical necessity of the planned procedure.

The health plan's determination is upheld.

The panniculectomy is not medically necessary. The medical records do not provide any documentation in the form of primary care physician (PCP) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. Supervised medical management for rashes is not documented in any of the progress notes. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. A dermatologist has not evaluated the rashes. The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications. The excess skin has not jeopardized health. Physician supervised treatment is the simplest, safest and most cost-effective method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al. the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. In addition, panniculectomy is not a standard treatment for back pain. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial upheld.

This patient is a male who has a medical history to include hypertension as well as hyperlipidemia and immune disorder.  The patient presented to the Emergency Department (ED) complaining of a severe headache with numbness and tingling to the left side of his face and arm and left-sided facial droop.  There is a lack of official hospital notes submitted however an appeal letter indicated the patient on examination had a blood pressure of 143/103 with a pulse of 79 and respiration rate of 19.  The patient did undergo laboratory studies revealing a BUN of 20 with creatinine 1.33.  The patient was noted to be positive for cocaine and an EKG showed a sinus rhythm with 1-degree atrioventricular (AV) block.  Labs and imaging were also recommended.  He was admitted to telemetry out of concern for an evolving right MCA lacunar infarct.  He was placed on aspirin and statins and blood pressure were monitored.  The patient continued with monitoring and was noted to have a diagnosis of complicated migraine with cocaine abuse.  He was discharged the following day with instruction to follow-up. This patient with a clinical history of hypertension presented with left-sided facial numbness, left-sided upper extremity numbness with left-sided facial droop with elevated blood pressure of 143/103 with positive toxicology testing for cocaine with EKG showing 1-degree AV block.  He was admitted to the hospital with concern for stroke.  

According to the referenced literature the patient may be admitted to inpatient services when there is evidence of vasculitis, severe CNS infection, cerebral aneurysm, new onset severe neurologic findings, multiple sclerosis or other acute demyelinating disease requiring inpatient care or complications of neurologic devices.  Within the submitted documentation the above is not present. The patient presented with headache and elevated blood pressure.  Imaging study was negative for stroke.  He could have been seen in the ED, observed in the ED and/or on an observation basis while stroke was excluded along with expeditious outpatient follow up with neurology; admission was not medically necessary. 

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 admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Overbite
Treatment:  Braces

The patient is a female requesting orthodontic benefits.

The braces are medically necessary.  The patient has a "deep impinging overbite with severe soft tissue damage".  This is an automatic qualifying condition for benefits.
Appeal type: Medical necessity
Decision: Overturned

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a female with an anterior crossbite on teeth 10 and 22. She presents with a skeletal Class I malocclusion and significant crowding. Tooth 11 is completely blocked out to the labial. Her treatment is planned for 24-30 months of orthodontics with extraction of teeth number 5, 12, 21 and 28 to address the crowding and crossbite. The use of braces was denied by the health plan and is the subject of this review.

The health plan's determination is overturned. Braces are medically necessary for this patient. This patient presents with an anterior crossbite on teeth 10 and 22, as well as severe crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, braces are deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Abscess
Inpatient hospital
This is the case of a patient with past medical history of bipolar disorder, eczema, prior ankle abscess and methicillin-resistant staphylococcus aureus (MRSA) infections, who presented to the emergency room (ER) with chief complaint of left pain and redness with purulent drainage and difficulty walking on his foot. He denied fevers, chills, nausea, vomiting, or other complaints. On presentation, the patient was noted to be afebrile with blood pressure (BP) 121/80, heart rate (HR) 98, sating 96% on room air (RA). Examination otherwise noted a left foot with pus and discharge from the lateral medial malleoli with surrounding erythema and excess warmth extending to the medial and lateral dorsal foot and right foot with small ulceration between the 1st and 2nd MTPs with minimal whitish discharge.

The health plan's determination is overturned. This patient presented with recurrent ankle abscess with leukocytosis requiring incision and drainage (I&D) in the setting of prior MRSA infection. Though he was afebrile on presentation, he subsequently developed fever in the setting of ongoing cellulitis despite being on IV antibiotics and having had I&D. The physican plan was that he stay in the hospital for ongoing antibiotics and monitoring which would extend beyond a reasonable period of 48 hours, but the patient instead elected to leave AMA. Even though he left AMA, inpatient IV antibiotics and monitoring was medically necessary for this patient with recurrent ankle abscess on recent antibiotics with prior history of MRSA, and his decision to leave AMA does not negate this medical necessity of the inpatient hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion 

Treatment:  Braces (D8080) and monthly periodic dental visits

The insurer denied coverage for Braces (D8080) and monthly periodic dental visits. The denial was reversed.

This patient is a female who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, asymmetric mandible, Class II canines, maxillary crowding and mandibular crowding, and anterior crossbite with gingival attachment loss (left mandibular canine).  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  The insurer has denied coverage for orthodontic treatment as not medically necessary attaining only 6 points on review by internal reviewers.

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, 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 employed 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  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 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.  
The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient. Comprehensive orthodontic treatment of the adolescent dentition is considered medically necessary for this patient.

Based on the above, the medical necessity for Comprehensive Orthodontics Treatment of Adolescent dentition is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate cancer

Treatment: Cancer screening for prostate cancer (Oncotype DX)

The insurer denied coverage for cancer screening for prostate cancer (Oncotype DX). The denial is upheld.

This patient is a male diagnosed with prostate cancer. In considering different treatment options, an Oncotype DX GPS was ordered, to assist the patient in the decision of immediate intervention versus active surveillance. The result of the genetic test indicated that the patient had low risk prostate cancer. The insurer has denied coverage for the Oncotype DX test for prostate cancer.

While tissue based genomic biomarker tests such as Oncotype DX PCA may offer an additional measure of risk stratification in patients with prostate cancer, they are not uniformly endorsed by the professional organizations which issue management guidelines for prostate cancer.  While the National Comprehensive Cancer Network (NCCN) guidelines state that men with low or favorable intermediate risk prostate cancer and at least a ten year life expectancy may consider the usage of Oncotype DX PCA, they also note the absence of randomized prospective trials pointing to improved health outcomes by the usage of this test.  The American Urological Association (AUA) Guidelines are considerably more negative on utility of this test, stating that: "tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer, and are not necessary for follow-up."  The impact of tissue based gene expression tests such as Oncotype DX PCA, on clinical practice and long term patient outcomes remains to be empirically demonstrated.  Prospective studies of these tests yielding a true clinical benefit when implemented in clinical practice are still lacking.  There is no long term data showing the clinical utility of this test.

The healthcare plan acted reasonably and with sound medical judgment and n the best interest of the patient. The Oncotype DX testing for prostate cancer is not considered medically necessary for this patient.  Further studies are needed to investigate the clinical benefit of this technology, the financial ramifications, and how they should be utilized in clinical practice. 

The carrier's denial of coverage for the genetic testing for prostate cancer (Oncotype DX) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Abdominal/Stomach Pain
Emergency Care/Emergency Room

The patient with a history of insulin dependent diabetes, gastroesophageal reflux disease, and pelvic mass diagnosed on an magnetic resonance imaging (MRI) 2 months prior to the  visit. The patient  presented for evaluation of pain with vaginal discharge and nausea for 3 weeks. The patient  was seen and described having moderate, crampy and sharp, fluctuating, abdominal pain for 3 weeks that was worse after eating and associated with decreased appetite, pellet-like stools, and thick yellow vaginal discharge. The patient  also described elevated glucose readings at home, nausea, dizziness, hot and cold sweats, and intermenstrual period vaginal spotting. the  patient denied any fever, constipation, diarrhea, or vomiting. 
The health plan's determination is overturned. The emergency room visit was medically necessary for this patient.
The patient presented with upper and lower abdominal pain with vaginal discharge for 3 weeks, for which the differential diagnosis is vast. Multiple life and organ threatening diagnoses must be considered in a patient  of child bearing age with abdominal and pelvic pain, including ectopic pregnancy, ovarian torsion, pelvic inflammatory disease, and ruptured ovarian cyst.
Additionally, the patient  reported some kind of mass, possibly arising from uterus noted on an MRI done previously, bringing up the possibility of cancer/metastatic disease. The medical decision making section of the record noted the physician was also considering renal stone, ureteral stone, cholecystitis, and pyelonephritis. The patient also reported elevated blood sugars, and the  levels were above 300 when measured, putting the patient  at risk for diabetic ketoacidosis if not treated promptly with insulin and fluids. The examination , blood work, urine testing, and imaging are all consistent with an appropriate work up of this patient's complaints. The emergency room visit was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Decay/Root Involvement
Dental/Orthodontic Procedure

The patient is a female who presents for evaluation and treatment of tooth #18. Provided for review are previous letters of denial and appeal, correspondence from the patient, full mouth radiographic images, and American Dental Association (ADA) claim forms. From the radiographic documentation, the patient suffers from extensive decay on tooth #18 involving the pulp of the tooth as well as a necrotic pulp as a result. The planned procedures of root canal therapy for #18 (D3330), and porcelain fused to metal crown (D2751) are under review. 

The health plan's determination is overturned. The requested D3330 nerve treatment on molar tooth, tooth 18 and D2751 white glass with metal crown are medically necessary for this patient. From the radiographic documentation, the patient suffers from extensive decay on tooth #18 involving the pulp of the tooth as well as a necrotic pulp as a result. As the patient has extensive decay that has reached the pulp of the tooth and as that requires a diagnosis of necrotic pulp, there is now the need to treat the pulp and replace the missing tooth structure. Hence the requested treatment plan is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department for evaluation of hematuria. The patient  was seen by the urologist in the office who had done manual bladder irrigation and then referred to the emergency department (ED) for a Continuous bladder irrigation (CBI). The past medical history was significant for osteoarthritis, spinal stenosis, varicose veins, herpes cornea, asthma, migraine, morbid obesity, a thyroid nodule, and kidney stones. Past surgical history includes kidney stones status/post (s/p) L Percutaneous Nephrolithotomy (PCNL) .The  health plan's determination is upheld in whole .
No, the inpatient stay is not medically necessary. The majority of patients who present with hematuria can be discharged within 24-48 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management.
The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status does not suggest the need for acute inpatient care. A lower level of care status for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Substance Abuse: Inpatient

The patient is a male with diagnoses of opioid use disorder; sedative, hypnotic, or anxiolytic use disorder who received inpatient rehabilitation level of care. The patient had received inpatient detoxification level of care prior to this admission. He reported that he was continuing to experience cravings despite utilizing medication assisted treatment. Clinical history was significant for five prior treatment episodes related to his substance use disorders. He reported using Xanax beginning at age 21 and had been using four milligrams daily with his last use being six days prior to admission. He had started using heroin at age 21 and was using 15 bags daily with his last use six days prior to admission.

The health plan's determination is upheld. The Inpatient Rehabilitation was not medically necessary for this patient.
Based on the LOCADTR criteria, the Level of Care is:
Outpatient Treatment with Medication Assisted Treatment (MAT)
The patient did not require immediate hospitalization for a life-threatening medical condition or severe psychiatric crisis. There was no evidence of suicidal or homicidal ideation or any unstable medical problems. The substance with the greatest potential for harm was opioids. The patient clearly met criteria for an opioid use disorder as well as a sedative, hypnotic, or anxiolytic use disorder. The patient was not in full remission from a substance use disorder. The patient was no longer using substances with risk of medical complications from withdrawal though had recently been using benzodiazepines that do have a risk of medical complications from withdrawal. The patient did not have serious psychiatric or medical symptoms that required 24 hour inpatient management. At the point of admission to residential care, risk of withdraw was limited to opioids. The patient was receiving medication assisted treatment and could be safely managed at that level.
The inpatient rehab stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System /Neuromuscular Disorder - Parkinson's Disease
Home Health Care

The patient is a male who according to the submitted medical records, has a listed diagnosis of Parkinson's Disease.  Also listed are insomnia, major depressive disorder, unspecified vestibulopathy, lumbar radiculopathy, and dementia.  It is unclear how such diagnoses were established.  There is no history, examination or ancillary test results.  An appeal letter states that the patient has tremors and stiffness, causing difficulties holding and carrying objects, and difficulties with daily activities.  The patient currently receives Personal Care Services, 12 hours a day, 7 days a week, for a total of 84 hours. The patient is requesting 168 hours per week.  This additional time is the subject under review.

The health plan's determination is upheld.

No, the requested Personal Care Services 24 hours a day/7 days per week split shift (168 hours per week) is not medically necessary for this patient.
There is no evidence submitted to support that 12 hours of daily services are insufficient to safely care for the patient, or that the patient cannot be safely cared for with 12 hours per day of services.
The New York Uniform Assessment which was completed was reviewed; there is nothing within the documentation to support the additional hours requested.  The records provided do not document a need for 24 hour split shift services.