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

Alcohol Abuse and Substance Abuse
Substance abuse-Inpatient 

The patient presented for detoxification and substance-related services, and has a history of severe substance use disorders with alcohol, opioid (buprenorphine), stimulants (crack cocaine and cocaine), and cannabis (marijuana) class substances of abuse.  The health plans determination of medical necessity is overturned in whole.
The requested benefit of Continued inpatient detoxification treatment and withdrawal management and monitoring and other medical services:  could not have been safely or effectively provided at a lower level of care in this case scenario.

The patient in this case was using large quantities of alcohol on a daily continuous basis together with cocaine, cannabis and buprenorphine that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms (tremor, sweats, nausea, anxiety, irritability, restlessness and insomnia) which were being effectively addressed with Librium and supportive measures. The patient had associated clinical features that included lack of sober supports and limited insight, impaired judgment and poor control of impulses. Thus, the adult inpatient stay and continued detoxification treatment of this patient's substance use disorders did necessitate the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. The patients history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines.
Appeal type: Medical necessity
Decision: Upheld

This is a patient is a patient with a skeletal Class I occlusion, class II cupids, moderate maxillary and mandibular crowding, right posterior crossbite, mild overbite and severe overjet. The proposed treatment is braces with extraction of first premolars for 24-30 months. The issue under review is the medical necessity for braces.
The health plan's determination is upheld.
The malocclusion in question does not meet criteria to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 21 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. Thus, braces are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class lll-Hypoplastic Maxilla, Vertical Growth Pattern, mixed Dentition, Severe Maxillary Crowding, Severe Mandibular Crowding, and Impacted Maxillary Right Canine (and possibly other teeth).  Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin
 
Treatment: Comprehensive Orthodontic Treatment

The insurer denied - Comprehensive Orthodontic Treatment. The denial was reversed. 

This is a young female patient who presented to an orthodontist for an evaluation for orthodontic care. The patient had a lateral cephalometric radiograph, panoramic radiograph, extraoral and intraoral images. The patient completed the Handicapping Labio-Lingual deviation (HLD), which resulted to 8 points. 
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.

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 this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.

Each of the consulted 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 carrier's denial of coverage for Comprehensive orthodontic treatment of the transitional dentition is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skeletal Class l, Asymmetric Mandible, Right Side Longer, Vertical Growth Pattern, Permanent Dentition, Mild Maxillary Crowding, Moderate Mandibular Crowding, and Anterior Crossbite with Gingival attachment loss. Crossbite of individual Anterior Teeth when clinical attachment loss and Recession of the Gingival Margin
 
Treatment:  D8080 Braces

The insurer denied the D8080 Braces.  The denial was reversed.  

This is a female patient who consulted an orthodontist for an orthodontic treatment.  An evaluation was performed that included lateral cephalometric radiograph, panoramic radiograph, and a montage of extraoral and intraoral clinical images.  A Handicapping Labio-Lingual Deviation (HLD) test was done, which revealed a score of 18 points.  It was determined that the patient was a candidate for orthodontic treatment due to an automatic qualifying condition.

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 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 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 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.  

Based on the above, the medical necessity for the D8080 Braces is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cracked tooth
Treatment: Crown on tooth #12
The crown on tooth #12 was not medically necessary.

The x-rays do not show any fractured off piece of tooth structure, necessitating a crown. The x-rays are very poor quality. Also, it is hard to see things properly, as sometimes a fracture can be seen on an x-ray. However, the x-ray is too blurry to properly visualize anything like a fracture. A photo of the tooth showing the missing portion of tooth structure would help prove the need for a crown, but this was not provided. There is not documented evidence of the fracture in tooth #12.

Without good x-rays, and a photo of the fractured tooth, there is no evidence provided that a crown was needed.
Appeal type: Experimental/Investigational
Decision: Overturned


This case involves a female who was seen for a reflectance confocal microscopy.  The clinical note indicated that the patient received a confocal microscopy to the left shoulder for a 2 x 2 millimeter lesion and right pre-tibia for a 2 x 1 mm lesion.  Lesion one had a dark brown irregular macule and lesion had been there for 4 years and was recently darker.  The appeal letter indicated that the patient received the service due to suspicious lesions found on the right pre-tibia.  The evaluation showed skin with an atypical honeycomb pattern, polycyclic rete, wrinkled and edged pattern and no atypical cells.

The medical literature notes that reflectance confocal microscopy (RCM) is a novel technology that provides noninvasive, in vivo imaging of the skin at nearly histologic resolution.  The combination of RCM imaging with dermoscopy has improved the accuracy of skin cancer diagnosis while reducing the number of biopsies of benign skin lesions.  

The documentation indicated that the patient did have lesions to the pre-tibia on the right as well as the left shoulder.  Due to suspicious lesions found, the reflectance confocal microscopy was appropriate as had the potential side no skin lesions with high accuracy and without biopsy.  Therefore, the reflectance confocal microscopy for date of service specified using codes 96931, 96934 does have the appropriate scientific evidence and peer-reviewed literature to support a result of improvement in health outcome and does have final approval from the appropriate regulatory bodies.  The patient is a good candidate for reflectance confocal microscopy.  The reflectance confocal microscopy was the best available treatment for the patient at that time.  Therefore, the reflectance confocal microscopy is likely be more beneficial than any other standard procedure for the patient.  

The carrier's denial of coverage for reflectance confocal microscopy provided for dates of service specified using the following codes:  96931 and  96934 should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

According to the documentation submitted this female patient was seen by a dermatologist with concerns about two areas; left shoulder and right pre-tibia.  Confocal evaluation report showed left shoulder melanocytic nevus and right pre-tibia lentigo-solar.

The insurer has denied coverage for reflectance confocal microscopy using the following codes:
1) 96931- Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, first lesion

2) 96934- Reflectance confocal microscopy (RCM) for cellular and sub-cellular imaging of skin; image acquisition and interpretation and report, each additional lesion (List separately in addition to code for primary procedure) 

According to Farnetani, F., et al, (2015), "The study highlights key RCM diagnostic criteria for melanoma and basal cell carcinoma that are reproducibly recognized among RCM users. Diagnostic accuracy increases with experience.  The higher accuracy of majority diagnosis suggests that there is intrinsically more diagnostic information in RCM images than is currently used by individual evaluators."

Per Levine, A., Markowitz, (2018), "RCM may improve the diagnostic accuracy and early detection of equivocal skin lesions and reduce the number of unnecessary excisions of benign tumors, thereby decreasing its associated morbidity and health care expenditures.  In a clinical setting, RCM imaging will benefit patients by providing same-day diagnosis of a cutaneous disease as well as confirmation of treatment efficacy, or as a perioperative tool to aid in cutaneous surgeries. RCM's ability to scan the entire lesion and noninvasively determine the most diagnostically and prognostically significant area to biopsy will help to reduce the risk of sampling error and false-negative rates owing to heterogeneity within lesions.  RCM imaging is a novel technology in dermatology that will continue to evolve and become more widespread in upcoming years."

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. This patient is a good candidate for reflectance confocal microscopy.  Reflectance confocal microscopy is the best available treatment for this patient at this time.     There is a multitude of scientific literature in medical textbooks and journal articles which documents reflective confocal microscopy is accurate, safe and effective for the diagnoses of a multitude of skin lesions.  The advantage is that it is noninvasive.  

The requested testing is likely to be more beneficial than any other procedure.

The carrier's denial of coverage for reflectance confocal microscopy provided for dates of service specified using the following codes: 96931 and 96934 should be reversed.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Left shoulder melanocytic nevus and Right pre-tibia lentigo-solar.

Treatment: reflectance confocal microscopy

The insurer denied coverage for reflectance confocal microscopy. The denial was reversed.

This patient is a female patient who presented for evaluation of a lesion on the right Pretibia. The provider requests coverage for Reflectance Confocal Microscopy (RCM), which is under review.

There is insufficient evidence to draw conclusions about the effect of computer-based optical devices on patient management or health outcomes.  No studies were identified that addressed the use of computer-based optical imaging for serial assessment of lesions or for defining peripheral margins of lesions prior to surgery.      

Reflectance confocal microscopy (RCM) is a US Food and Drug Administration (FDA) approved optical imaging technology.     

This patient is not a good candidate for RCM. RCM is not the best available treatment for this patient at this time.  RCM does have FDA approval, but it is still not standard practice.  The gold standard remains biopsy and histopathology for analysis of suspicious lesions.

According to Ahlgrimm-Siess, V., et al. (2018), "Barriers to the adoption of RCM technology are the black and white contrast imaging and limited penetration depth.  The rule of thumb of optical imaging is that the deeper it penetrates, the lower the resolution.  To this end, use of multi-wavelength RCM may allow incorporation of wavelengths that penetrate deeper as well as wavelengths that penetrate more superficially but with higher resolution; assignment of pseudo-colors to images is also a possibility with multi-wavelength imaging, because the same structures may reflect differently at various wavelengths.  As key RCM features of skin neoplasms are increasingly recognized, RCM is expected to significantly improve our diagnostic ability.  However, at present, RCM does require expertise and experience in image interpretation, while image acquisition is fairly straightforward.  

Rao, B. K., et al. (2019) states, "Histopathology is the current standard to diagnose skin disease".     
  
The requested service is not likely to be more beneficial than any other standard procedures.


The carrier's denial of coverage for reflectance confocal microscopy provided for dates of service specified using the following codes: 96931 and 96934 should be upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with atrial fibrillation on Coumadin. She had had a Ross procedure with aortic valve and root replacement, right ventricular outflow reconstruction, and mitral valve repair. She was admitted to an outside hospital in with dyspnea and rapid atrial fibrillation. She was found to have severe mitral stenosis. She was planned to have a percutaneous mitral valvuloplasty but was found to have a left atrial appendage thrombus. The procedure was deferred. An echocardiogram then showed resolution of the left atrial thrombus, moderate mitral stenosis, and moderate mitral regurgitation. She presented for a mitral valvuloplasty which was performed under transesophageal echocardiography. She was found to have severe mitral stenosis with valve area of 0.6 square centimeters (cm2) by 3 dimensional (D) echocardiogram and mitral valve gradient of 18 millimeters of mercury (mmHg). Balloon valvuloplasty was performed with a 26 mm balloon. The mitral valve gradient was decreased to 7 mmHg and there was an increase in mitral valve area to 1.3 cm2 by 3D echocardiogram. The health plan's determination is upheld. Although prolonged monitoring was required, this could have been performed at a lower level of care rather than a full admission.
The patient had an interventional procedure which has the potential of serious complications. The procedure itself was without complications. A patient requires intensive monitoring after the procedure which requires hospitalization. However, this period of observation, expected to be less than 24 hours can be accomplished at a lower level than inpatient status. The patient was observed uneventfully overnight. Thus, an inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cystic Fibrosis Related Metabolic Syndrome/CF Screen Positive Inconclusive Diagnosis
 
Treatment: InCourage Airway Clearance Therapy High Frequency Chest Compression Device

The insurer denied coverage for the InCourage Chest Compression Device. The denial was upheld.

The patient is a female child who has been diagnosed with Cystic Fibrosis Related Metabolic Syndrome/CF Screen Positive Inconclusive Diagnosis (CRMS/CFSPID).  She has a chronic productive cough. The fecal elastase is normal, indicating that the child is pancreatic sufficient.  Recently she had her first sweat test which was 29 and 32. Sputum culture did not detect any CF pathogens and pulmonary function testing was normal.  There is a past history of a ventricular septal defect repair and surgery to remove the tonsils and adenoids.  The child has had chronic nasal congestion with recurrent sinusitis which has required repeated treatments with oral antibiotics.  She has been treated with inhaled Pulmozyme, albuterol, 7% hypertonic saline and Flovent. She has been treated with the Vest airway clearance device in the home. 

The InCourage vest is not considered the standard of care for children with a diagnosis of CRMS/CFSPID. The patient at this time does not have a diagnosis of Cystic Fibrosis.  She does have a borderline sweat test and a VVCC CF mutation which may cause manifestations of Cystic Fibrosis in the future.  The symptoms of nasal congestion and recurrent sinus infections can be seen in children with a CRMS/CFSPID diagnosis but these symptoms do not require treatment with the In Courage Vest.  

The carrier's denial of continuation of coverage for InCourage Airway Clearance Therapy High Frequency Chest Compression Device (E0483) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epilepsy
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The vagal nerve stimulator is a procedure that can be performed in an outpatient/ambulatory setting.  The patient had medically refractory epilepsy, but the fact of her having undergone this short procedure would not necessitate her having to be admitted overnight for management of seizures, which were occurring daily, already.  She had no documented respiratory issues, which would be the primary reason to keep a child overnight after undergoing general anesthesia for a relatively minor procedure.  This procedure did not require 24 hours of IV antibiotics, and an oral antibiotic could have been substituted, at the provider's discretion.  Thus, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of Crohn`s disease. Patient has been well maintained on Remicade (infliximab). The provider requested continuation of Remicade (the brand medication). The available scientific evidence showed no significant clinical evidence when using the generic product instead of the brand version of infliximab. Renflexis and Inflectra are both considered biosimilars to Remicade. Based on the available scientific evidence, these generic alternatives are equivalent to Remicade in terms of efficacy and safety and can be used instead of Remicade in treating Crohn`s disease. This patient is unlikely to have any change in disease status or response to treatment if switched from Remicade to the generic biosimilar. The health plan determination is upheld in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
Ipatient level of care was not medically necessary.

This was an electively scheduled, uncomplicated cardiac catheterization and intervention. The community standard and guidelines suggest this is an outpatient procedure; and in many institutions, same day discharge. Nearly every cardiac catheterization can be classified as ASA III as the patient has probable CAD. An ASA score represents a potential for clinical problems, not actual care.  No clinical issue occurred in this patient, nor does the patient satisfy the definition of unstable angina as he was electively scheduled, hemodynamically stable without acute electrocardiogram (EKG) changes or elevated cardiac enzymes. Orders did not include medical therapy for acute coronary syndrome (ACS) such as intravenous (IV) heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).  

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care.

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. The physicians' treatment did not reflect any concern about patient's cardiac condition being unstable.

The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care post uncomplicated PTCA provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of CAD. In fact, all tests showed absence of ischemia.  While always a potential for an adverse event (and in this case a low probability), one did not happen and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present. All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.