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

The patient is a female infant born prematurely at 35 weeks' gestation, history of respiratory distress syndrome, ventriculomegaly (possible hydrocephalus), and patent foramen ovale that was transferred to the emergency department (ED) from an outside facility after experiencing a cyanotic episode that lasted less than one minute. She appeared stiff but had no shaking. Review of systems included no fevers, no vomiting, no decreased oral intake, but she had eaten about 30 minutes before the episode.

The health plan's determination is upheld. The inpatient stay was not medically necessary. This young child born prematurely with PFO and possible hydrocephalus experienced a brief cyanotic spell about 30 minutes after feeding. General work-up was unremarkable, but she was deemed high risk because of the prematurity, congenital heart issue, and family history of sudden cardiac death in an uncle. She was admitted to the hospital for overnight observation. While it was reasonable to monitor her overnight for possible recurrence or development of other symptoms, she was overall alert and hemodynamically stable, with no fevers, and no dehydration. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse
Treatment:  Continued inpatient admission

The Continued inpatient admission was medically necessary for this patient.

The Continued inpatient admission could not have been effectively provided at a lower level of care in this case scenario.  The patient in this case was using heroin with up to one gram of heroin daily with IV administration that did warrant the admission and the continued inpatient level detoxification with withdrawal management and inpatient level monitoring.  Detoxification with a methadone taper, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been 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 limited past substance use disorder treatment with no history of sobriety that supported the need for inpatient structure and a supervised and medically monitored detoxification treatment.  The patient presented with a lack of sober supports and limited insight, impaired judgment and poor control of impulses that also supported the admission and the continued inpatient level detoxification in order to prevent relapse and complete his detoxification which allowed for his preparation for a recovery effort and referral to rehabilitation services.  Thus, the continued detoxification treatment of this patient's substance use disorders did warrant the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring. 

In summary, medical necessity is met in this case for the Continued inpatient admission, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria/Guidelines-referenced below.

The requested benefit of Continued inpatient admission is clinically appropriate, medically necessary and warranted and should, therefore, be covered in this case scenario.  The admission and the continued inpatient level treatment through discharge could not have been effectively provided with lower level services, as noted above.  Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including consideration of ASAM Criteria and application of NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abscess
Treatment: Inpatient admission

The Inpatient admission was not medically necessary.

Cellulitis is an infection with inflammation of the subcutaneous layers of the skin, including the loose connective tissue, with limited involvement of the dermis and sparing of the epidermis. The most common bacterial agents include Streptococcus pyogenes and Staphylococcus aureus. Clinical presentation includes edema, warmth, erythema, and tenderness. The borders are not clearly demarcated. Regional lymphadenopathy may be present, and the patient may experience constitutional symptoms such as fever, chills, and malaise. Complications include abscess formation, joint involvement, bacteremia, and necrotizing fasciitis. Culture is indicated to allow for identification of the causative agent. Ultrasound should be limited to suspected subcutaneous abscess. Empiric therapy should be directed to the history of the illness, location, and severity, as well as age and immune status of the patient.

MRSA (methicillin-resistant Staphylococcus aureus) causes both nosocomial and community-acquired infections. Guidelines have been developed for management of this potentially severe and debilitating condition. For skin abscesses, the first line of treatment is incision and drainage. Antibiotic therapy is generally recommended for severe disease, extensive disease, or rapidly progressive disease. Empiric therapy of outpatients with purulent cellulitis in the absence of drainable abscess involves five to ten days of therapy. Oral antibiotic choices include clindamycin, Bactrim, doxycycline, and Zyvox. 

This child was referred to the ED for further management of MRSA cellulitis and suspected abscess of the buttock because of spreading erythema and induration despite antibiotic therapy with clindamycin. He underwent I&D in the ED under sedation with placement of a drain and was admitted for IV antibiotic therapy. Incision and drainage is the treatment of choice for suspected abscess. Because of the rapidly progressive nature of the cellulitis, treatment with antibiotics was also reasonable and consistent with current standard of care. However, he was overall hemodynamically stable, with no evidence of sepsis or severe infection (e.g., necrotizing fasciitis). He did not require acute inpatient admission, and he could have been safely managed at a lower level of care, such as observation.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for human immunodeficiency virus (HIV) with CD4 count of 600, who presented to the emergency department (ED)  with a chief complaint of a cough productive of greenish sputum, a fever, body aches, and nasal congestion. He also reported 3 episodes of nausea and vomiting.
On presentation to the ED, the patient was noted to be febrile to 102.6 degrees Fahrenheit, with heart rate (HR) 104, respiratory rate (RR) 20, and blood pressure (BP) 127/80. His exam was otherwise notable for bilateral rhonchi. The patient was given antibiotics, Tamiflu, and intravenous fluids (IVF), and subsequently brought into the hospital.
Overnight, the patient improved on IV fluids, antibiotics, and nebulizers. The health plan's determination is upheld. Acute inpatient admission was not medically necessary. The patient did not have hypoxia or signs of sepsis with his influenza and pneumonia (lactic acid was normal, he had no leukocytosis, no persistent tachypnea, no tachycardia, no hypotension). His CURB-65 [Confusion, Blood urea nitrogen, respiratory rate, blood pressure, age 65 or older] and Pneumonia Severity Index score were low. He did not fail observation treatment. Treating this patient at a lower level of care was appropriate and admission to the acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mid Thoracic Pain 
 
Treatment: Therapeutic Procedure, 1 or more areas, each 15 minutes; Therapeutic Exercises to develop Strength and Endurance, Range of Motion and Flexibility 

The insurer denied the Therapeutic Procedure, 1 or more areas, each 15 minutes; Therapeutic Exercises to develop Strength and Endurance, Range of Motion and Flexibility. The denial was upheld.   

This is a female patient who presented to her Chiropractor for treatment of thoracic pain that she developed after a poor night's sleep. She reported that the pain was a 9/10 in intensity on the pain scale. She expressed difficulty with her activities of daily living, sleeping, reaching, deep breathing, personal care, and house duties. There was some asymmetry in the posture and tonicity in the right rhomboids, infraspinatus, supraspinatus and paraspinals. Deep tendon reflexes and, as extremity isometric testing and maximum foraminal compression were in normal limits.

The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) clearly indicate that the 97140 (Manual Therapy) procedures includes soft tissue mobilization, manual muscle work, myofascial release, connective tissue massage, trigger point therapy and/or (Joint Mobilization) and is listed as a timed code.  When this procedure is performed, it must be performed in a separate body region.  

The documents submitted did not support this procedure being correctly identified or correctly coded and performed in the same anatomical region as the CMT (thoracic region).   For the dates of service in question, the records support the procedure 97140 being performed (Active Release Technique was performed on the External Intercostals, Infraspinatus, Latissimus Dorsi and Rhomboid Major and Scapulothoracic Mobilization) and not a 97110 procedure in the same region that a CMT was performed (Thoracic region).

Based on the above, the medical necessity for the 97110-Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Confusion
Treatment: Inpatient admission

The Inpatient admission was not medically necessary. 

The patient is a male. He presented to the emergency ward on with the complaint of confusion. At presentation, his CT brain was negative. His NIH (National Institutes of Health) stroke scale was 2. He had no focal neurological deficits. His subsequent MRI was negative. 

The patient presented with confusion but was not a candidate for acute stroke intervention. The diagnostic studies, monitoring and treatment for his condition could have been safely and effectively provided at a lower level of care. This would have been consistent with standard of care guidelines for TIA (transient ischemic attack).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet
Issue under review: Braces

Determination:
The Braces are medically necessary.

The patient's handicapping score is above the threshold of 26. He has severe overjet, which makes his upper front teeth stick out and subject to increased trauma over time (i.e., fractures). He has a Class II malocclusion, with a retruded lower jaw. This will subject him to increasing pressure on his TM (temporomandibular) joints over time, increasing the chances of temporomandibular joint problems (degeneration). He has unerupted lower second molars, which can cause periodontal problems in the future. All these factors make this case medically necessary for orthodontic treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea 
Treatment: Hypoglossal nerve stimulator

The hypoglossal nerve stimulator is medically necessary.

The procedure and device are FDA approved as referenced below and recognized in the treating community as efficacious and safe for properly selected patients.  This patient with severe desaturations and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, it is not unproven.  This is particularly evident with the withdrawal study by Woodson referenced below which showed the efficacy of the therapy and the reversal of efficacy by discontinuing the stimulation.  

Medical necessity is generally defined as required to diagnose or treat an illness, injury, disease or its symptoms; in accordance with generally accepted standards of medical practice; clinically appropriate in terms of type, frequency, extent, site and duration; not primarily for the convenience of the patient, Physician or other health care provider; and rendered in the least intensive setting that is appropriate for the delivery of the services and supplies. 

For this patient, the proposed procedure is required to treat the sleep apnea, which is not controlled by more conservative measures.  It meets the standard of care and is not for the convenience of the patient.

The principal specialty in Otolaryngology (the American Academy of Otolaryngology- Head and Neck Surgery) has examined the scientific support for hypoglossal nerve stimulator in sleep apnea and concludes:

The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP).  Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.  

This patient has had proper evaluation and meets clinical criteria for this intervention.  Therefore the procedure should be approved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class1; Vertical Growth Pattern; Permanent Dentition; Moderate Maxillary Spacing; Moderate Mandibular Spacing; Severely Excessive Overjet; Moderate Maxillary Incisor Protrusion; Moderate Mandibular Incisor O Skeletal Class1; Vertical Growth Pattern; Permanent Dentition; Moderate Maxillary Spacing; Moderate Mandibular Spacing; Severely Excessive Overjet; Moderate Maxillary Incisor Protrusion; Moderate Mandibular Incisor Protrusion; Impacted Third Molars; and Open Bite. Protrusion; Impacted Third Molars; and Open Bite.
 
Treatment: Braces (comprehensive orthodontic treatment)

The insurer denied the Braces (comprehensive orthodontic treatment). The denial was upheld. 

This is a female patient who presented to an orthodontist for a consultation for orthodontic treatment. The patient's evaluation revealed that she had Skeletal Class1; vertical growth pattern; permanent dentition; moderate maxillary spacing; moderate mandibular spacing; severely excessive overjet; moderate maxillary incisor protrusion; moderate mandibular incisor protrusion; impacted third molars; and open bite. She had a Handicapping Labio-Lingual Deviation (HLD) Index score of 15 points. Orthodontic treatment was recommended. 

To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic index, the Handicapping Labio-Lingual 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. Regarding the validity of the Handicapping Labio-Lingual Index, it has been shown through scientific scrutiny in peer-reviewed journals that this methodology for assessing orthodontic need is a valid approach.

Based on the above, the medical necessity for the Braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment visit) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Food poisoning; diarrhea
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The treatment was medically appropriate but not medically necessary at the level at which it was provided, as explained in detail below.

The patient presented with signs and symptoms of food poisoning.  Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Implantation of a Biventricular Implantable Cardioverter-Defibrillator (ICD)

Treatment: Inpatient Admission

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

This is a male patient who presented to the hospital for an elective implantation of a biventricular internal cardioverter/defibrillator. He has a history of ischemic cardiomyopathy, ejection fraction 30%, left bundle branch block, congestive heart failure, hypertension, diabetes mellitus, and coronary artery disease with prior bypass surgery. The patient underwent the procedure without complications. The patient was admitted for further monitoring. He received intravenous Lasix because he hadn't taken his. The patient was ambulating and tolerating a diet. He was safely discharged home. 

The in-patient admission status was not medically necessary, per MCG Guidelines for Electrophysiologic Study and Implantable Cardioverter-Defibrillator (ICD) Insertion. For uncomplicated pacemaker and/or ICD implantation, this is considered an elective outpatient procedure, with up to 1 night of observational status hospital monitoring permitted. There were no post-operative complications, such as bleeding or infection, nor any clinical or hemodynamic instability. There was no evidence of procedurally-related pneumothorax.

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

Diagnosis: Moderate to severe stenosis/Status post 2 level anterior cervical discectomy and fusion
Treatment: Inpatient admission 
The Inpatient admission was not medically necessary.

Summary:
The patient is a male with left arm pain, numbness, and weakness. His neck pain subsided with physical therapy.  The patient had two cervical epidurals without relief.  He injured himself at the gym.  He experiences numbness in his left thumb and index fingers. His physical exam reveals left arm weakness and positive spurlings.  

MRI cervical spine shows moderate to severe stenosis at multiple levels. The patient tried epidural injections. The patient was taken to surgery for anterior cervical discectomy and fusion C5-6 and C6-7. The patient had drain placed at end of surgery.  The patient had drain removed and was discharged home on hospital day #2.  

The patient underwent an uncomplicated 2 level anterior cervical discectomy and fusion.  The patient was medically stable, and the patient could have been discharged within 23 hours.  Inpatient stay was not medically warranted or necessary.  There were no complications of the procedure to require an extended stay.  The drain could have been pulled and the patient discharged prior to 23 hours, and the patient was stable for discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever
Treatment: Inpatient admission
The inpatient hospital admission was medically necessary.

Diagnosing a fever of unknown origin can be a challenging process. The patient had over two months of symptoms and many visits as an outpatient without a clear diagnosis. According to recommendations, "Hospitalization may be considered at any time during the evaluation... Approximately 12% to 35% of patients die from an FUO-related cause (generally infection or malignancy) "(1). Standard of care would require admission of such a patient after two months of outpatient evaluation and treatment. Failure to do so can lead to death, as noted above.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia
Treatment:  84 hours of personal care assistance per week

The proposed treatment of 84 hours of personal care assistance per week is deemed medically necessary. 

This is a female with a history of advanced dementia.  Due to this condition, she requires assistance with the majority of her activities of daily living (ADLs).  Per her documentation from her primary care physician, Dr. Carly Borinsky, her dementia is progressively worsening, and she is now experiencing recurrent falls due to worsening gait ataxia.  Hence, she requires increased assistance with using the restroom, transfers into/out of bed and ambulation.  The currently approved schedule of 30 hours of personal care assistance per week is no longer sufficient to meet the patient's needs.  For these reasons, the proposed treatment of 84 hours of personal care assistance per week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia
 
Treatment: Personal care services

The insurer denied the personal care services. The denial was reversed.

This patient has Alzheimer's dementia, glaucoma, urinary incontinence and severe memory impairment. She does not remember to eat without reminders, and does not remember to eat if aides prepare food for her to eat later. She needs help with bathing and dressing.  She has a chronic balance problem and has fallen. She is completely dependent on assistance for ambulation, transfer and toileting.  She has urinary incontinence and is prone to UTIs.  She wears adult diapers and requires assistance to change the diaper and assist with post elimination hygiene.  
                                                                          
Assistance provided by informal caregivers is voluntary as per NYS regulations for personal care services. It appears that the son is trying to be available to the patient when he can; but considering he is requesting 12 hours of care per day, 7 days per week, it is acknowledged that he is not able to provide care for his mother on a consistent basis during those hours. 

Based on the information provided for review, it is medically necessary that the patient has a caregiver to provide assistance with ADLs throughout the day and night as a result of advanced dementia, incontinence, and impaired balance.  The son is the only identified informal caregiver. He is not able to provide assistance to the patient for 12 hours per day, 7 days per week. Therefore, it is medically necessary for personal care services to provide the assistance the patient needs with IADLs and ADLs; including ADLs that occur throughout the day and night (i.e. walking, toileting, incontinence care).

Personal care services for 12 hours per day, 7 days per week are medically necessary. The carrier's denial of coverage for Personal Care services 12 hours per day, 7 days per week is reversed.  The medical necessity is substantiated.