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

Diagnosis:  Chest pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male for whom an inpatient hospitalization is under review. There was history of hypertension, CAD (coronary artery disease), and medication noncompliance. He presented with chest pain. He also had some nausea. The patient's BP (blood pressure) was elevated. Other vital signs and the oxygen saturation were normal. He had some lower extremity edema improved with Lasix in the setting of known CHF (congestive heart failure) with a normal LVEF (left ventricle ejection fraction). The ECG (electrocardiogram) demonstrated LVH (left ventricular hypertrophy). Troponins were reported as stable. The patient's BP (blood pressure) improved. He underwent cardiac catheterization and left circumflex artery stenting. He remained stable and was discharged.

The Inpatient Hospital Admission was not medically necessary.

This patient presented with chest pain and remained stable. There was no CHF (congestive heart failure), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a PE (pulmonary embolism) or aortic dissection, need for prolonged IV (intravenous) medications or oxygen support, introduction of high risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e. severe bleeding, CVA [cerebrovascular accident]), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG (electrocardiogram). In the setting of this case, an acute inpatient level hospitalization, compared to for example observation, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit x 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12

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 anterior crossbite and impacted permanent anteriors among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying conditions of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present and impacted permanent anteriors where extraction is not indicated. 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. 

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 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 automatic qualifying conditions of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present and impacted permanent anteriors where extraction is not indicated. These automatically qualifying conditions are met and supports comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the HLD 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 reversed. 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 x 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal prolapse	
Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

According to the documentation submitted, this is the case of a patient with a history of hysterectomy and prolapse repair. The patient presented for elective robotic Sacro colpopexy, the patient was admitted due to post robotic Sacro colpopexy operative management. The patient was hemodynamically stable and discharged to follow up with urology.

The insurer has denied coverage for inpatient admission. In their Final Adverse Determination letter, they write that the patient presented to the hospital for a scheduled procedure elective robotic Sacro colpopexy, lysis of adhesions and cystoscopy (repair of prolapse- when one or more of the organs in the pelvis slip down from their normal position and bulge into the vagina). The procedure went well and there were no reported complications. The patient remained stable while being monitored.

This patient was appropriately admitted on an inpatient basis for the urgent management of status post (S/P) robotic Sacro colpopexy that could not be safely managed in a lower level of hospital care or in an outpatient setting. The patient presented for robotic Sacro colpopexy admitted s/p procedure for pain control, intravenous (IV) fluid infusion, and foley care. Inpatient admission for this patient was appropriate resulting in favorable outcome after receiving acute inpatient treatment. Only after intensive treatment was, the patient was deemed appropriate for discharge.

This is a patient who presented to hospital for a robotic Sacro colpopexy for repair of recurrent pelvic organ prolapse, lysis of adhesions, cystoscopy. The procedure was carried out without issue or complications. The patient recovered uneventfully; the patient tolerated diet well, voided successfully after foley removal. The patient had mild tachypnea and hypotension postop which were treated successfully. The patient was discharged home with outpatient follow up. The insurer has denied coverage for the inpatient admission as not medically necessary, as the procedure went well without reported complications. The appeal on behalf of the hospital is noted and read in detail. Per Milliman's Care Guidelines Health (27th): 

	Repair of pelvic organ prolapse - patient meets the discharge parameter within 24 hours post procedure (1).

	Urologic surgery or procedure - patient meets the discharge parameter within 24 hours post procedure (2).

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The inpatient admission is not considered medically necessary for this patient.

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular Accident
Treatment: Motorized Wheelchair
The insurer denied the request for the motorized wheelchair.
The health plan's determination is overturned.

The patient is a female with a history of 2 strokes and gait impairment. The most recent stroke left her with loss of balance/coordination, weakness, reduced endurance, severe cramping in the hands and vertigo. The notes also indicate a fall risk score of 90 which is high risk. She lives alone in a one bedroom apartment on the 13th floor.

The requested health service/treatment of a motorized wheelchair is medically necessary for this patient. Mobility assistance may be required for a variety of reasons and for varying durations because the etiology of the disability may be due to a congenital cause, injury, or disease. Some patients may need mobility assistance on a short-term basis, while those with chronic conditions or enduring disabilities may require mobility assistance on a permanent basis. Manual wheelchairs are used for patients who are unable to walk but have sufficient upper extremity function to propel a wheelchair. Power wheelchairs are used for patients who are unable to walk, or have upper extremity impairment, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), spinal cord injury, stroke with dense hemiplegia, severe Parkinson's disease, and amyotrophic lateral sclerosis (ALS). The power operated vehicle is a three or four wheel non-highway motorized transportation system for patients with impaired ambulation. Considering this patient's chronic medical condition, documentation of severe functional limitations, and mobility restrictions, the power wheelchair is appropriate.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol Detoxification and Diaphoresis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male who presented complaining of alcohol detoxification. His last drink was the day prior. He complained of diaphoresis. There was no history of seizures. He 
reported taking oxycodone for great toe pain. The patient's vital signs were stable, and he was afebrile. His heart rate was 103. Clinical Institute Withdrawal Assessment (CIWA) score was four. Exam was remarkable for 2-plus bilateral lower extremity edema and tender left great toe. X-ray (Radiography)of the great toe was concerning for osteomyelitis. The patient was admitted with alcohol withdrawal. Plan of care included Clinical Institute Withdrawal Assessment protocol. On the next day, the patient's vital signs were stable. Clinical Institute Withdrawal Assessment 
score was four. Infectious disease consult recommended magnetic resonance imaging (MRI) and to hold antibiotics. On day #3, the patient's vital signs were stable. Clinical Institute 
Withdrawal Assessment (CIWA) score was four. The patient felt shaky. Magnetic resonance imaging (MRI) was negative for osteomyelitis. The patient was on day 2 of 7 of intravenous antibiotics. The plan was for discharge to rehabilitation on day #4. On day #4, there was no active withdrawal. The patient was pending alcohol rehab placement. There was no significant charge through day #9.

The proposed treatment was not medically necessary.

This patient was admitted with alcohol withdrawal. He was not acutely intoxicated. He was hemodynamically stable and afebrile. Labs were unremarkable. Intravenous (IV) antibiotics were started for possible osteomyelitis of the toe. He did not have a systemic infection or comorbid conditions that required inpatient admission. He had not failed treatment in the emergency department. He remained medically stable during the hospital stay while awaiting rehabilitation placement. The Milliman Care Guideline for Substance-Related Disorder, Adult ORG:M-595 (ISC) is not met. The patient did not have signs of alcohol withdrawal with high-risk indicators the include history of delirium, seizures, or other significant medical history. The patient did not require inpatient treatment because he did not have an inadequate response to pharmacotherapy in the emergency department of other lower level of care or signs that a lower level of care was not feasible or appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Lymphedema. 
Treatment: Full hospital admission. 
The insurer denied coverage for the full hospital admission. 
The denial is upheld. 

Patient is an adult with a past medical history significant for hypertension, diabetes mellitus, anemia, asthma, chronic lymphedema, elephantiasis, hyperlipidemia, pneumonia, and venous insufficiency who presented to the emergency room with complaints of pain and bleeding of right leg. Vitals on presentation included: Temperature 99.2 degrees Fahrenheit (F), Blood Pressure 130/75, Pulse 110, Respiratory Rate 20, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell count (WBC) 13.2, hematocrit (HCT) 33.3, creatinine 0.97, and glucose 175. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin) for possible secondary infection of chronic lymphedema. A computed tomography (CT) of the leg showed chronic plaque-like nodularity within the skin about both lower extremities. Circumferential confluent edema/fluid within subcutaneous adipose tissue without enhancement or evidence of abscess, which may reflect chronic cellulitis, anasarca, or fluid accumulation from venous insufficiency or congestive heart failure. Antibiotics were discontinued. Dermatology recommended topical lotions and wound care. Vascular Surgery recommended no further intervention. The patient improved clinically; they remained afebrile and hemodynamically stable. The patient was discharged for outpatient management. 

According to documentation, the patient presented to the emergency department with bleeding from chronic lymphedema and elephantiasis lesions of their lower bilateral extremities. Otherwise, the patient was afebrile, hemodynamically stable with no evidence of acute infection and therefore antibiotics were discontinued. The patient required outpatient management by a lymphedema specialist including aggressive topical dermatologic intervention, compression garments and lymphedema pumps. Based on above findings, the patient did not meet criteria for acute hospital 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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis; vomiting
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is the case of a young male who presented to the emergency department (ED) with complaint of vomiting. ED vitals were T (temperature) 38.4oC, heart rate (HR) 166, respiratory rate (RR) 30, and O2 saturation 95% on room air.
Exam was unremarkable with normal capillary refill and good hydration. Initial BG (blood glucose) was 61, and bicarbonate 19. The patient was given Zofran. Due to persistent tachycardia, intravenous fluids (IVF) were started. The patient was observed in the ED. He vomited when awaking from a nap, so the decision was made to admit for IVF and treatment of persistent vomiting with hypoglycemia.

Inpatient admission was not medically necessary for this patient. This patient presented with acute gastroenteritis and hypoglycemia associated with vomiting. He was treated with IVF in the ED but continued to vomit and so he was admitted. The patient needed continued monitoring and treatment; however, based on this child's presentation and anticipated duration of therapy, he could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Durable medical equipment

Diagnosis: abnormal head shape
Treatment: Durable Medical Equipment: Helmet 
The insurer denied Durable Medical Equipment: Helmet. 
The health plan's determination is overturned. 

The patient is a female infant born via vaginal delivery following a complicated pregnancy. Complications included pre-eclampsia with subchorionic hematoma, preterm labor with bed rest from 29 weeks, hyperemesis, and amniotic fluid leakage. The neonatal period was complicated by persistent urinary tract infection from birth. The baby was noted to have abnormal head shape, prompting 4.5 months of repositioning as well as increased tummy time. She underwent evaluation for abnormal head shape. Despite repositioning, she had ongoing abnormalities. 

Durable Medical Equipment: Helmet is medically necessary and appropriate for this infant.
"Positional plagiocephaly" and "deformational brachycephaly" are broad terms used to encompass abnormal head shape due to a wide variety of etiologies. Prenatal causes include resting of the fetal head against a hard surface (such as the mother's pelvis or the limb of a sibling in a multiple gestation pregnancy) for a prolonged period. Postnatal causes are more common and include congenital torticollis, vertebral anomalies, neurologic impairment, or forced sleep position. Presentation ranges from mild to severe. Mild and even moderate cases may respond to mechanical adjustments and exercises. However, there are some cases that are severe and refractory to repositioning. Although rare, some cases are severe enough to require surgery for correction. Although positional head deformity is generally not a life-threatening condition, up to 10 percent of infants may have permanent deformity with subsequent complications.
The current standard of care for treatment of mild head shape abnormality includes repositioning, physical therapy, and increased time in the prone position. Most physicians currently still recommend cranial orthoses for their infant patients with moderate to severe skull deformity because research in the long term shows distinct benefit from helmeting compared to repositioning. Significant or severe plagiocephaly is characterized by cranial vault asymmetry greater than or equal to 10 mm, severe brachiocephaly with cephalic index greater than 90%. Graham et al recommended, "for those infants who do not make progress with repositioning and tummy-time, with severe persistent brachycephaly at age 5 months, use of an orthotic helmet will correct the brachycephaly and any associated plagiocephaly." For infants with extreme occipital flattening, prolonged treatment may be necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post Lumpectomy
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult female with anxiety, depression, and volvulus. She also had right breast cancer status post neoadjuvant chemotherapy and right lumpectomy, sentinel node biopsy, and tissue advancement. Inpatient admission was denied coverage by the health plan as not medically necessary. An appeal is being made stating that inpatient level of care was needed for pain control, close hemodynamic monitoring, and drain management.

The Inpatient admission was not medically necessary.

The patient had appropriate pain post-operatively, rated at 5/10. Her heart rate remained stable, under 100. There is no documentation of complication during the peri-operative period. Therefore, an inpatient level of care is not necessary. There is no documentation that the patient experienced severe infection, altered mental status, arrhythmia, hypotension or hypoxemia. The patient had a drain with which she was discharged, with drain teaching. This is all routinely done post-operatively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep bite
Treatment: D8080 Braces, D8670 Monthly Visit, D8680 Retainer
The insurer denied: D8080 Braces, D8670 Monthly Visit, D8680 
Retainer
The denial is upheld.

The patient is a teenage male who is otherwise healthy. He presented for orthodontic treatment to treat skeletal and dental class II deformity with deep bite.

The D8080 Braces, D8670 Monthly Visit, D8680 Retainer are not medically necessary.

The Handicapping Labiolingual Deviation (HLD) Index/Salzmann/Ortho Score of 14 points provided is accurate and appropriate for this patient. The patient is able to bite and chew food appropriately with his current bite. There is not any evidence provided of deep impinging overbite with soft tissue damage. There are no photographs of soft tissue trauma with tissue erythema and ulceration. Therefore, given the above, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Inpatient hospital admission

The health plan denied: Inpatient hospital admission 
The determination is: Overturned

The patient is a male with a past medical history of diabetes mellitus type 2 (DM2), gastroesophageal reflux disease (GERD), and human immunodeficiency virus (HIV) who was admitted with complaints of (c/o) having his insulin stolen and weakness. His vital signs and physical exam were unremarkable. His lab work was notable for a blood glucose of 955, positive respiratory syncytial virus (RSV), a potential hydrogen (pH) of 7.30, and calculated serum osmolality of 297. His imaging studies and chest x-ray (CXR) showed no acute pathology. The patient was diagnosed with severe hyperglycemia and hyperglycemic hyperosmolar state with elevated serum osmolality and was treated with intravenous fluids (IVF), Lantus, and Humalog. The patient was discharged in stable condition.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is overturned, in whole.
The requested health service/treatment of inpatient level of care was medically necessary. This patient presented to the emergency department (ED) with weakness associated with medication non-adherence due to stolen medications. He was found to have profound hyperglycemia and diagnosed with hyperglycemic hyperosmolar state with borderline pH, and neurologic dysfunction (weakness). For patients with hyperglycemic hyperosmolar state, all but the mildest cases should be admitted to the hospital for close clinical monitoring due to rapid shifts in fluids and electrolytes and potential for deterioration in mental status and arrhythmias, in addition to frequent serial labs. Additionally, this patient's clinical status was complicated by the presence of immuno-suppression due to both uncontrolled diabetes and HIV with concomitant RSV. Overall, this patient could not have been safely treated and monitored at an alternative level of care.