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

Diagnosis:  Pulmonary Embolism
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.  

This is a female patient who presented to the Emergency Department (ED) with a complaint of sharp 3-4/10 intensity level chest pain located under the right breast.  The patient's chest pain had been continuing for about 1.5 weeks - the pleuritic type.  The patient was seen in her primary medical doctor's office and noted to have an elevated D Dimer.  The patient was afebrile and hemodynamically stable.  Her heart rate was 83, her respiratory rate was 20, her blood pressure was 131/85 mm Hg, and her oxygen saturation was 99%. The patient was alert and in no acute distress.  Her lungs were clear.  The patient had a recent renal biopsy.  The patient's past medical history included SLE, Raynaud's phenomenon and lupus nephritis.  
A CT angiogram revealed a right lower lobe subsegmental pulmonary embolism and a right middle lobe wedge-shaped opacity.  The patient's Well's score was 4.5 putting her at moderate risk.

The patient was afebrile, hemodynamically stable and not hypoxic.  She had a subsegmental pulmonary embolism.  There were no EKG changes of ischemia.  Labs were within normal limits.  The patient was tolerating oral intake.  The patient was in no acute distress.  She could have been placed in Observation setting while diagnostic testing and treatment were initiated.  The patient remained stable after admission. The patient was stable for discharge after diagnostic testing was completed.  She was tolerating oral intake; therefore, she was stable for discharge on oral anticoagulation.

The carrier's denial of coverage for the inpatient hospital services at the acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post fall
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This young infant was unrestrained in a car seat on a counter top and fell approximately three feet to a hardwood floor. There was no loss of consciousness, no vomiting, and no crying. She was taken to the ED via EMS and referred to higher level of care for repair of an eyelid laceration. She was admitted for observation as well as work-up for non-accidental trauma (NAT). She did well pre- and post-operatively. An NAT evaluation was undertaken and was negative. She had no intracranial injuries and no fractures. She remained hemodynamically stable throughout the hospital stay. She was subsequently cleared by all surgical specialists and social services for discharge. 

While it was reasonable to monitor this infant overnight for any sequelae from the fall (as well as for completion of the NAT evaluation), she was overall stable and did not require acute inpatient admission. She could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of diabetes, coronary artery disease, severely reduced left ventricular ejection fraction (LVEF), heart failure, atrial fibrillation and aortic valve replacement. He presented to the emergency department complaining of dyspnea, orthopnea and edema. His serum troponin level was markedly elevated. His serum sodium level was low.  The health plan's determination of medical necessity is overturned. 
This patient presented with acute decompensated heart failure (ADHF). His serum troponin level was markedly elevated at nearly 7 times the upper limit of normal. In patients with ADHF, elevated serum troponin is associated with an increased short- and long-term mortality. In hospital mortality in this cohort has been shown to be nearly three times that of patients with normal troponin levels (8.0% versus 2.7%).
Moreover, this patient's hyponatremia was an additional high risk feature, associated with an increased risk for adverse outcomes, including death, in heart failure patients hospitalized with ADHF.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the hospital with right sided lower facial weakness, the inability to drink or chew food and she was unable to close the right side, as well as right-sided temporal headaches and dizziness. A head computed tomography (CT) scan was performed on presentation, revealing no acute infarct or bleed. She was diagnosed with a Bell's palsy with house-Brackman grade 4 neuropathy. She was seen by neurology and was discharged on prednisone and acyclovir. The health plan's determination is upheld. This is a patient who presented with a with peripheral facial weakness, involving the upper and lower parts of the face, suggestive of a Bell's palsy. There is no evidence that the patient had a stroke as an isolated or peripheral cranial seven neuropathy as a result of a stroke is unusual. The patient could have been evaluated and diagnosed with Bell's palsy at a lower level of care without the need for acute hospitalization. There was no need for any intravenous medications or hydration. There was no expectation of neurological decline. There was no documentation that the patient required any neurological, hemodynamic, cardiac, pulmonary or other intensive medical monitoring.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension and hyperlipidemia. She presented to the emergency department complaining of two days of intermittent exertional chest pain. Her blood pressure was 151/78 millimeters of mercury (mmHg) with a heart rate of 65 beats/minute. Room air oxygen saturation was 100%. Her cardiovascular exam was normal. Her electrocardiogram was unremarkable. Her serum troponin level was normal. The health plan's determination is upheld.  The patient  did not require intensive monitoring or infusion of intravenous cardioactive medications. There is no indication in the records provided that other potentially serious diagnoses were considered likely. The care this patient received did not require an inpatient admission and could have been provided at a lower level. This approach has been shown to be safe and is in accordance with the 2014 American Heart Association (AHA) /American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nephrotic syndrome
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

There was no documentation of acute kidney injury, volume overload, hyperkalemia, hyponatremia, acidosis, or rapidly progressive glomerulonephritis.  There was no documentation of anasarca or need for continuous infusion of intravenous diuretics.  Renal ultrasound showed normal-sized kidneys with no hydronephrosis.  There was no documentation of provision of high-dose immunosuppressive therapy.  

In summary, inpatient admission was not medically necessary.  The health plan did act reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath, Chest Pain 

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.    

The is a middle aged woman who presented to the ER with complaints of shortness of breath, chest pain, cough, lower extremity edema, and rectal bleeding, who was then admitted. She had a pulmonary embolism previously and also had a past medical history notable for congestive heart failure, anemia, anxiety, fibroids, depression, and former tobacco abuse. Vital signs were stable. Physical examination was unremarkable. CT angiography of the chest was negative for pulmonary embolism. She had negative cardiac biomarkers. Electrocardiogram (EKG) showed normal sinus rhythm. Stress testing was done, which showed no infarction or ischemia. She was later deemed appropriate for discharge.

The patient presented with chest pain, however the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing prior to discharge. Further evaluation was warranted, however inpatient admission criteria was not met.  Although the patient had new onset symptoms, criteria were not met for any other additional extenuating circumstances. There were no other high-risk comorbidities. 

Based on the above, the medical necessity for the inpatient hospital services is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain due to Coronary Artery Disease
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This is a male patient who presented to the Emergency Department in early 2019 describing a one hour episode of chest to left arm discomfort at rest, with nausea and dyspnea. He has a history of hypertension, hyperlipidemia and coronary artery disease, with myocardial infarctions, normal left ventricular systolic function, percutaneous intervention with stents in the mid left anterior descending (LAD) and ostial/proximal right coronary artery (RCA), and coronary angiography on earlier that month revealing patent stents and minor coronary artery luminal irregularities.   Initial vital signs: blood pressure 150/88, heart rate 98, respiratory rate 16, and oxygen saturation on room air 98%.  Chest x-ray was normal and electrocardiogram (EKG) was described as normal sinus rhythm with no ischemic changes.  Laboratory test results included white blood cell (WBC) count 5.2, hemoglobin 10.9, creatinine 0.90 and troponin >0.01, with subsequent troponin was also >0.01.  He was discharged to home on his home medications.

There is no evidence that this patient required an acute inpatient level of care to determine that his chest discomfort was not related to acute coronary syndrome.  This could have been completed in the ED or at an observation level of care. 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 services at the acute level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class lll- Hypoplastic Maxilla, Vertical Growth Pattern, Permanent Dentition, Mild Maxillary Crowding, Severe Mandibular Crowding, and Anterior Crossbite with Gingival Attachment Loss.  
 
Treatment: Orthodontic Treatment of the Adolescent Dentition

The insurer denied the Orthodontic Treatment of the Adolescent Dentition. 
The denial was reversed.  


This patient is a young male with Skeletal Class lll- Hypoplastic Maxilla, Vertical Growth Pattern, Permanent Dentition, Mild Maxillary Crowding, Severe Mandibular Crowding, and Anterior Crossbite with Gingival Attachment Loss resulting in significant malocclusion. He has a completed Handicapping Labiolingual Deviation (HLD) index as required, attaining only 23 points. It is evident that the patient exhibits a significant malocclusion. To assess for severity of the malocclusion and medical/dental necessity for orthodontic care, a HLD Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.
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 carrier's denial of coverage for Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Retruded mandible
Treatment: Braces
The braces are medically necessary.  

The patient has a Class II skeletal malocclusion. This means her mandible is retruded. This situation will contribute to several issues. Firstly, the patient's upper front teeth are too forward and pronounced. This will contribute to the possibility of excessive trauma to these teeth. Fracturing is possible due to their forward position. The retruded mandible can contribute, over time, to temporomandibular (TMJ) problems due to excessive pressure on the joints. The patient also has an impacted, i.e. blocked out, lower right second premolar. This tooth either needs to be extruded from the bone or extracted and the space closed up, or else there will be drifting forwards of the teeth behind it with food impaction developing and excessive decay starting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class I, Moderate Maxillary and Mild Mandibular Crowding, Excessive Overjet, Maxillary and Mandibular Incisor Protrusion and Deep Impinging Overbite.
 
Treatment: Orthodontic Treatment of the Adolescent Dentition (D8080)

The insurer denied the Orthodontic Treatment of the Adolescent Dentition (D8080). 
The denial was upheld.

This is a young female patient who exhibits a significant malocclusion. She has skeletal Class I, normal vertical growth pattern, permanent dentition, Class ll canines, moderate maxillary crowding, mild mandibular crowding, moderately excessive overjet, moderate maxillary incisor protrusion, moderate mandibular incisor protrusion, and deep impinging overbite with severe soft tissue damage.  Deep impinging overbite with severe soft tissue damage was indicated on the Handicapping Labio-Lingual Deviation (HLD) Index Report.
  
The Orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. To assess for severity of the malocclusion and medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. These clinical circumstances do not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 18 points (7 points overjet, 3 points overbite, 5 points anterior crowding and 3 points labiolingual spread).

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.  

Based on the above, the medical necessity for Comprehensive Orthodontic Treatment of the Adolescent Dentition (D8080) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a diagnosis of Class III malocclusion, appropriate overjet and overbite, and an anterior crossbite of #10 and #22. The upper and lower arches are both moderately crowded. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion. The health plan's determination is upheld.
The patient has an appropriate overbite and overjet. There is moderate crowding but that alone does not rise to the threshold of medically necessary. Tooth number 10 is in crossbite but there is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. There does not appear to be any wear present on the teeth in crossbite. In the absence of a functional problem, orthodontic treatment would not be medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deciduous teeth
Issue under review: General anesthetic

Determination:
The General anesthetic is not medically necessary.

The case is an appeal request to review the medical necessity of the use of general anesthesia in conjunction with routine dental extractions of two deciduous teeth for a pediatric dental patient. The two teeth are requested for removal for elective, orthodontic purposes. 

There is no documentation submitted to demonstrate any prior attempts or failures at removal of the teeth with local anesthesia, or nitrous oxide analgesia, or oral premedication. The teeth are not described as infected, carious, or painful. There is no substantiated medical necessity for the teeth to be removed, as orthodontic removal is entirely elective. There is no demonstrated or described physical, medical or psychological/psychiatric diagnosis provided or documented that warrants the requested service. Deciduous teeth in children are routinely removed with local anesthetic. 

The medical necessity for the requested anesthesia services is not substantiated by the documentation submitted. The procedure is not complex, and is routinely performed under local anesthesia. The documentation submitted does not support or substantiate the requested anesthesia services, and therefore, denial is recommended.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems requiring- Extraction of Tooth C, H, and G (Maxillary Right and Left Primary Canines and the Maxillary Left Lateral Incisor).  
 
Treatment: D9222 (General Anesthetic - first 15 minutes) and D9223 (General Anesthesia - each 15 minutes)

The insurer denied the D9222 (General Anesthetic - first 15 minutes) and D9223 (General Anesthesia - each 15 minutes). The denial was upheld.                    

This case involves a young male who was to undergo tooth extractions. The patient was seen by his dentist and was to undergo extraction of tooth C, H, and G (maxillary right and left primary canines and the maxillary left lateral incisor). It was noted that the patient was very nervous and apprehensive. It was reported that this was his first surgical procedure; which involved multiple extractions. Any anxiety experienced during these procedures may result in emotional traumas for future dental treatments needed.

Per the American Association of Oral and Maxillofacial Surgeons, anxiety, fear, and pain are the main concerns in providing dental treatment and must be controlled satisfactorily during the perioperative period to permit safe and effective completion of the surgical procedure. Indications for general anesthesia during a dental procedure are the "need to depress the patient's level of consciousness, anxiety, pain, and recall sufficiently during a planned procedure."

General anesthesia would have been a medical necessity if other methods of sedation had been attempted and failed.  Other methods that would be considered appropriate are nitrous oxide, oral conscious sedation, and intravenous (IV) sedation.  Only if all these methods were attempted and were not successful would the standard of care be general anesthesia.  There was no indication in the provided records that these methods were attempted.  

The carrier's denial of coverage for D9222 (general anesthetic - first 15 minutes) and D9223 (general anesthesia - each 15 minutes) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department with complaints of numbness and tingling of both upper limbs and lower limbs described as occurring for three days. Work up at the time of presentation included computed tomography (CT) scans of the cervical and thoracic spine that revealed no evidence of acute fracture or subluxation. A magnetic resonance imaging (MRI) scan of the brain was performed and interpreted as usually no acute intracranial abnormality.

The health plan's determination is upheld.  This is a patient who presented with numbness and tingling of the extremities. An intracranial or spinal process required exclusion. Acute intracranial and spinal pathology could be excluded at a lower level of care. Once acute pathology was ruled out, the patient could have been discharged with plans for further evaluation on an outpatient basis. The patient did not require any intravenous medications or hydration. There was no need for frequent neurochecks as there was no neurological deterioration. The patient did not require any pulmonary, cardiac or other medical monitoring.