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

Diagnosis: Anterior crossbite

Treatment: D8080 braces and D8670 monthly visit

The insurer denied coverage for D8080 braces and D8670 monthly visit

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified an anterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (mandibular right canine) when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 16 points by internal reviewers when 26 points are required for approval. 

Upon review of the submitted documentation (study models were not provided for review) 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 I, 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. 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 insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for D8080 braces and D8670 monthly visit is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Curve in Spine
Treatment: Body Sock and the Design with Labor for Back Brace
The insurer denied the body sock and the design with labor for a back brace.
The health plan's determination is overturned.

The patient is a boy with scoliosis related to Friedrich's ataxia. He has scoliosis and is thought to be at risk of progression to the point that surgery might be required. He has worn a brace for treatment of his scoliosis, however he has outgrown this brace and his physician has ordered a new one.

The health plan in its determination of medical necessity did not act reasonably, with sound medical judgment and in the best interest of the patient.

The health service/treatment of the body sock and the design with labor for a back brace is medically necessary for the patient. The body sock is an essential part of brace treatment. It is simply an undergarment which is worn beneath the brace to protect the skin from the pressure being applied by the brace. The quality and material of the fabric, and the placement of seams, are designed to provide protection in a way that is also comfortable and tolerable to the patient. Lack of comfort in the brace may lead to less brace wear and a less effective brace. The body sock should be considered medically necessary.

The fitting of a scoliosis brace requires a minimum of an in-person assessment of the patient by the orthotist, often accompanied by a review of the x-rays and sometimes by review of a computed tomography (CT) scan, from which data may be used to fabricate the brace. The orthotist must then trial the brace on the patient and make adjustments to facilitate comfort and ensure effectiveness. The labor involved in this process is medically necessary, as it is an essential part of brace treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient Stay
The insurer denied the Inpatient Stay.
The determination is overturned.

The patient has a developmental delay and presented with first time seizures. The patient was in their usual state of health until 2 days prior to presentation when they developed stiffening of their body for 3-5 seconds and then was back to baseline. The next day a second similar episode occurred so the patient was subsequently brought to the emergency department for evaluation. The patient's family history is significant for a seizure disorder in her father.

In the emergency department (ED) the patient had another episode with generalized clonic movements with right sided gaze that lasted 20 seconds. The patient was given Ativan at that time and a loading dose of Keppra. Laboratory values were obtained as well as a head computed tomography (CT) scan. The patient was then admitted to the intensive care unit for further management.

In the hospital, Keppra was continued as well as intravenous fluids. The patient had one episode of emesis while in the intensive care unit and was kept on intravenous fluids and was not allowed to eat or drink for 6 hours. The patient was kept on continuous monitoring with neurology checks and the Neurology team was consulted. The patient was later started on a clear liquid diet. By the 25th, they had no further seizure episodes and were felt to be stable for discharge to home with follow-up as an outpatient. At issue is the medical necessity of the inpatient stay.

The requested health service/treatment of inpatient stay was medically necessary for this patient. The patient has with developmental delay and had 3 afebrile seizure episodes within 2 days, one of which was observed in the emergency department (ED) setting. They required careful evaluation, treatment with anti-epileptic medication, specialist consultation, and close monitoring. They also vomited and required intravenous fluids while they were not allowed to eat or drink. Patients with clusters of new onset seizures without an obvious source require inpatient admission for careful evaluation for potential serious etiologies, initiation of treatment, and close monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right facial and arm numbness.
Treatment: Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult male, who presented to hospital with complaints of three days of right facial and arm numbness and tingling. No focal deficits were noted on neurologic examination. The patient's computed tomography (CT) and computed tomography angiogram (CTA) of the head were unremarkable. Neurology and neurosurgery were consulted. The magnetic resonance image (MRI) of the brain did not show acute intracranial process. Workup revealed cervical radiculopathy with canal stenosis and the patient was discharged 2 days later. The plan denied the inpatient admission, as it did not meet level of care.

The proposed treatment was not medically necessary.

Inpatient admission was not medically necessary. The patient did not have focal neurologic deficits on multiple examinations. Milliman Care Guidelines (MCG) criteria for inpatient admission indicates admission is necessary when there are severe deficits noted on examination. Furthermore, everything that was done for this patient could have been done on an observation basis or in the outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: vaginal bleeding/anemia.
treatment: inpatient stay.
The insurer denied an inpatient stay.
 The health plan's determination is upheld. 

The patient is a female who presented to the emergency room (ER) for a planned transfusion prior to hysterectomy. She was found to have a hemoglobin of 9, whereas her physician has a goal of 10. She was admitted to the hospital and transfused with one unit of red cells. She underwent scheduled laparoscopic hysterectomy the following day and then was promptly discharged.

The Inpatient admission was not medically necessary in this case.
The patient was not unstable at any point, and no heavy bleeding was visualized. There is not a question that this patient had a chronic bleeding problem, but it is unusual for such patients to require inpatient admission. There was no mention in the emergency room (ER) or on the floor of the patient being unstable or having acute bleeding. This patient almost certainly would not have been transfused had she not had surgery planned. Transfusions prior to surgery are reasonable, and a hemoglobin of 10 is a reasonable goal. With that said, transfusions are routinely conducted at a lower level of care. Furthermore, the patient was in the hospital less than 24 hours prior to her surgery
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
treatment: Intracept system
The insurer denied the Intracept system. 
The health plan's determination is overturned. 

This is a female who has back pain for over 20 years. Most of her pain is in the back right greater left without significant leg symptoms. She has more pain with prolonged sitting, physical activities and lumbar extension. Pain level 6-8/10. ODI (Oswestry Disability Index) 46%(percent). She had tried physical therapy (PT), traction and injections without improvement. Magnetic resonance imaging (MRI) showed Modic 2 changes at L (lumbar) 5/S (sacral)1 and moderate central canal stenosis at L3/4.

The Intracept System is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intraosseous nerve ablation procedure (INTRACEPT) was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. Her pain is increased by physical activities and severe enough to have a negative impact on her activities of daily living (ADL) and quality of life. Her ODI is 45%, which indicates severe disability. She had tried physical therapy (PT), traction and injections without improvement. Further interventions are medically necessary to improve her pain and functional level. Other potential treatment options are long-term use of medications (opioids) and lumbar decompression fusion surgery. However, none of these options has a high success rate, and all of them carries significant risks and complications. Given this clinical scenario, the Intracept procedure is likely to be more beneficial than standard treatment for this patent.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
treatment: Intracept system
The insurer denied the Intracept system. 
The health plan's determination is overturned. 

The patient is a female with a 23 year history of back pain. She has tried multiple medicines, injections, and physical therapies. Multiple functional deficits are mentioned in the patient's history, and her Visual Analog Scale (VAS) is between 6-8/10. Magnetic resonance imaging (MRI) mentioned in the patient's history includes Modic changes, type I and type II, at the L (lumbar) 5-S (sacral)1 disc space.

The Intracept System is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This procedure was Food and Drug Administration (FDA) approved in 2016. Multiple papers have been written since that time on the effectiveness of the procedure. Clinical trial reports are included at 12 and 24 months.
Indications for this procedure include chronic low back pain rated in 6 months and failed treatment greater than 6 months, along with type I and type II changes of the disc at the target level. This patient meets that criterion.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Back pain
treatment: Intracept system
The insurer denied the Intracept system. 
The health plan's determination is overturned. 

The patient is a female with chronic low back pain for 23 years. No significant radicular symptoms were noted. The physical exam unremarkable. A magnetic resonance imaging (MRI) demonstrated Modic type II changes at L (lumbar) 5 and S (sacral) 1. Prior treatments include injections, activity modification, physical therapy (PT), traction, Tylenol, muscle relaxers, NSAIDS (non-steroidal anti-inflammatory drugs), and narcotics. 

The Intracept System is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
This patient has chronic low back pain with endplate changes per MRI report. This procedure is a low risk, potentially high reward benefit. Medical literature studies involving the Intracept procedure suggest it is a safe and effective procedure. It is Food and Drug Administration (FDA) approved. It has been deemed safe and at least as effective as other treatments available. It has supporting evidence in peer-reviewed journals. It is supported by international spine organizations such as ISASS (The International Society for the Advancement of Spine Surgery). Given this, the current medical literature does support the Intracept procedure. No other non-surgical treatment untrialed by the patient has been found to be more beneficial.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypoglycemia
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld
 
The patient was brought into the emergency department (ED) by the mother for evaluation of fever and congestion for two days and cough with nasal discharge for two months. Per the patient's mother, the patient had been lethargic and had trouble breathing at night, and a rash was noticed on patient's left leg. While in the ED, the rash spread to the patient's chest, arms, legs, and soles of feet. Laboratory results indicated hypoglycemia and imaging demonstrated generalized lung haziness without focal pulmonary consolidation. The patient received a dextrose bolus x 2 in the ED and was started on intravenous (IV) antibiotics for sinusitis. The patient was admitted for dehydration in the setting of acute viral illness and started on IV fluids. The patient's oral intake improved, the patient remained afebrile, and their glucose levels normalized. The patient was cleared for discharge with outpatient follow-up.

Once the patient was on the floor, the history and physical documents that the "patient was babbling and cooing", "walking around in the room". Clearly in no distress. The ED temperature was 100.2 degrees Fahrenheit. The initial lethargy was attributed to hypoglycemia which was easily treated with a dextrose infusion. There was no concerning diagnosis such as pneumonia, respiratory distress, hypoxia (oxygen saturations > 95 %) and severe dehydration. The basic metabolic panel (BMP) showed a bicarbonate of 17 which was low but still > 15. There was no need for more than 2 boluses. No vasopressors needed. No need to use noxious stimuli to arouse the patient (the lethargy was responding to Dextrose). No need for oxygen or continuous positive airway pressure / bilateral positive airway pressure (CPAP /BiPAP). No need to escalate the therapy while on the floor. There was no evidence of Kawasaki. The Covid test was negative. There was no sepsis and no shock. The working diagnosis was hypoglycemia and sinusitis (treated with Unasyn). If one were to take the Pediatric early warning scoring tool (PEWS) while the patient was on the floor, the PEWS would have been 0 which is desirable. The patient could have been treated in observational status. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autistic disorder

Treatment is Personal Care Assistance (PCA) Level 2 for 54 hours/week, 6 hours x 5 days, 12 hours x 2 days.

The insurer denied coverage for Personal Care Assistance (PCA) Level 2 for 54 hours/week, 6 hours x 5 days, 12 hours x 2 days.
 
The denial is upheld. 

This is a young male child with a history of autistic disorder and learning disabilities. He lives with his mother in a private home. The request is for an additional 4 hours/weekend to prepare for outpatient occupational therapy. The patient is currently approved for 50 hours/week, 6 hours x 5 days, 10 hours x 2 days; Personal Care Assistance (PCA) Level 2 and the request is for 54 hours/week, 6 hours x 5 days, 12 hours x 2 days.

The Uniform Assessment System (UAS) report stated the patient's cognition is described as "moderately impaired." He requires extensive assistance for bathing, personal hygiene, eating, dressing, ambulation, and toilet transfer/use. He is frequently incontinent of bowel and bladder. Limited assistance is needed for bed mobility. The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested PCA Level 2; 54 hours/week, 6 hours x 5 days, 12 hours x 2 days. The requested additional 2 hours on Saturday and Sunday, respectively in order to prepare for occupational therapy may be addressed by modifying the PCA 10 hour/day schedule on Weekends. Based on the enclosed documents reviewed, the patient's health and safety is appropriately provided and maintained by the currently approved PCA Level 2; 50 hours/week, 6 hours x 5 days, 10 hours x 2 days.

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.

From a physical medicine and rehabilitation perspective, the requested increase in PCA services 54 hours/week, 6 hours x 5 days, 12 hours x 2 days; Personal Care Aide Level 2, is not medically necessary.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for 54 hours/week, 6 hours x 5 days, 12 hours x 2 days; Personal Care Aide Level 2 Personal Care Aide services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental abscess
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

Patient has a benign past medical history who presented to the emergency department with complaints of left facial swelling and pain.

Vitals on presentation included: Temperature 99 degrees Fahrenheit, Blood Pressure 101/62, Pulse 80, Respiratory Rate 19, and oxygen (O2) saturation 99% on Room Air. Laboratory values were notable for the following: white blood cell count (WBC) 10.8, Hemoglobin (Hgb) 12.6, Hematocrit (Hct) 38.1, glucose 100, and creatinine 0.83.

The patient was empirically started on intravenous (IV) antibiotics (clindamycin) for a possible odontogenic infection. A maxillofacial computed tomography (CT) scan showed a left maxillary dental abscess. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics and dental extraction as an outpatient. 

According to documentation, the patient presented with left facial swelling likely related to a dental abscess. Otherwise, she was afebrile, stable hemodynamically and laboratory values were unremarkable including a normal WBC (white blood cell count). The patient had no evidence for a disseminated infection and a dental extraction was deferred for an outpatient procedure. Based on above findings, the patient met criteria for observation level of management. She did not fulfill criteria for an acute inpatient admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: Braces and monthly visit

The insurer denied coverage for braces and monthly visit

The denial is overturned
 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, posterior unilateral crossbite and anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 28 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 8 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation it is evident that the patient exhibits a significant malocclusion. The HLD 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 completed the second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support 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. 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. 
Overturn the denial as the clinical circumstance as presented does meet and substantiate the medical/ dental necessity of orthodontic care as it meets the accepted criteria for approval.

The healthcare plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The braces and monthly visit are considered medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for braces and monthly visits is substantiated.