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

Diagnosis: dental malocclusion

Treatment: braces

The insurer denied coverage for braces

The denial is upheld 

Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and overbite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labia-Lingual Deviation Index Report (HLD), index attaining 27 total points to support orthodontic care. 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 on the Handicapping Labia-Lingual Deviation Index Report (HLD), index attaining 16 points by internal reviewers. 

Upon review of the submitted documentation, it is evident that the patient exhibits a 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 Labia-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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 27 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 16 points on the HLD index (3 overjet, 5 overbite, 5 anterior crowding, 3 labiolingual spread) which is below 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. 

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 braces is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart transplant candidate
Treatment: consumer directed personal assistance services (CDPCA) Services from 21 to 70 hours per week
The insurer denied coverage for: consumer directed personal assistance services (CDPCA) Services from 21 to 70 hours per week
The denial is: Upheld  

This is an adult who is a heart transplant candidate.  The patient lives with aging mother, who is the paid caregiver and also provides informal care. The patient requested an increase in consumer directed personal assistance services (CDPCA) Services from 21 to 70 hours per week; denied by the insurer and leading to an external review.  

The Uniform Assessment System (UAS) report is present for review. The patient's cognitive skills are described as "Modified independent."  The patient's ability to complete much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping; reportedly varies from maximal to extensive assistance. The patient reportedly requires extensive assistance for bathing. Limited assistance is reportedly needed for personal hygiene, and dressing. The patient is otherwise independent for eating, bed mobility, locomotion, toilet transfer/use and ambulation. The patient is also fully continent of bladder and bowel.

The clinical records do not support the patient's condition and functional deficits at a level or unpredictable as to require the requested consumer directed personal assistance services (CDPCA) 70 hours/week. The patient is essentially independent with much of their activities of daily living. This physician would agree that the patient may benefit from monitoring for safety; particularly due to the underlying heart condition. However, CDPCA services for companion care or safety supervision without the direct provision of activity of daily living (ADL) task assistance is not a covered service. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved CDPCA services 21 hours/week.

(Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).   

From a physical medicine and rehabilitation perspective, overturning the denial of coverage for Increase Consumer Directed Personal Care Assistance services, for a total of 70 hours per week 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 consumer directed personal assistance, a total of 70 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Melanoma in-situ of the right mid scapula biopsied
Treatment: Medical necessity of excision in a hospital setting  
The insurer denied coverage for: Medical necessity of excision in a hospital setting
The denial is: Upheld

The patient is an adult with a diagnosis of melanoma in-situ of the right mid scapula biopsied.  The lesion was excised with no residual melanocytic lesion noted on histopathological evaluation. The patient had excision performed in an ambulatory surgical setting rather than in an office setting. The request is for medical necessity of excision in a hospital setting.  

Based on the clinical documentation, the excision and repair of the lesion is medically necessary; however, these procedures are routinely performed in an out-patient setting and do not require a hospital or Ambulatory Surgery Center (ASC) facility. In this situation, the lesion is a melanoma in-situ which does not require wide local excision, sentinel lymph node biopsy, or any further treatment or work-up. A 5-millimeter (mm) margin of safety is generally taken, rather than a wide local excision. The clinical documentation indicates that the lesion was excised with local anesthesia and a final length of wound of 4-centimeter (cm) using polydioxanone suture (PDS) 2'0 subcutaneous (SQ) sutures and fast gut 5-0 superficial sutures. An excision and primary closure performed in an out-patient office setting are standard of care. As such, and without further extenuating circumstances being delineated, the excision and repair can be performed in an out-patient setting as the standard of care. While an excision and repair are medically necessary, it is not medically necessary to perform these procedures outside an office setting.  

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 code 12032 repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 2.6 centimeter (cm) to 7.5 cm performed in a hospital setting rendered is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer
Treatment: genetic testing
The insurer denied FoundationOne CDx test 
The health plan's determination is overturned. 

This is a female with metastatic adenocarcinoma of the lung. The patient has undergone resection. The FoundationOne CDx assay was obtained and is under review.

The FoundationOne CDx test is medically necessary.
The use of next generation sequencing (NGS) gene panels to guide the treatment of patients with metastatic non-small cell lung cancer is recommended by American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) Guidelines, the latter of which state "...t is recommended at this time that when feasible, testing be performed via a broad, panel-based approach, most typically performed by next generation sequencing (NGS).... The assay in question is Food and Drug Administration (FDA) approved and evaluates the cancer for the recommended biomarkers.
The authors of UpToDate state "...GS (generation sequencing) overcomes many of the shortcomings of direct sequencing and allele-specific testing...It retains sensitivity even in specimens with low tumor cellularity, which is an improvement over direct sequencing, and can identify new abnormalities, which would not be detected by allele-specific testing. Moreover, NGS can often detect abnormalities that would historically be tested by FISH (Fluorescence in situ hybridization)...". Finally, the NGS panel testing has been demonstrated in multiple trials, to be less expensive than single gene testing for the recommended biomarkers.  
For these reasons, the use of this assay in this scenario meets criteria for medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: erectile dysfunction
Treatment: Hyperbaric Oxygen Treatment
The insurer denied Hyperbaric Oxygen Treatment
The health plan's determination is upheld.

The patient is a male with erectile dysfunction after a radical prostatectomy. He has requested coverage for hyperbaric oxygen therapy (HBOT). 

Hyperbaric oxygen treatment is not medically necessary for this patient.
The American Urological Association (AUA) and National Comprehensive Cancer Network (NCCN) Guidelines do not recommend HBOT for the improvement of erectile dysfunction after a radical prostatectomy. Reliable evidence of benefit is lacking. Its use is not standard practice and therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain (sickle cell disease)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adolescent male who was admitted to the hospital. The patient has a diagnosis of sickle cell anemia.

The requested health service was not medically necessary.

The patient in this case presented to the hospital with diagnoses of hemoglobin S beta thalassemia, moderate persistent asthma, migraines, developmental delay, and chronic right lower extremity pain. He was seen in the clinic and developed 8/10 pressure and pain in his right lower extremity similar to previous presentations. The patient was given Tylenol and ibuprofen. The patient was hemodynamically stable and had 99% room air saturations. On exam, the patient had tenderness to palpation of the right suprapatellar region and right calf without swelling erythema or deformity. The patient was admitted to the hospital and put on oxycodone 5 milligrams as well as intravenous Tylenol and intravenous fluids. The patient was discharged the following day.
In this case, acute inpatient level care would not be considered medically necessary for this patient. The patient was hemodynamically stable and did not have a stroke, acute chest syndrome, priapism, splenic sequestration, severe anemia, or prolonged intractable pain requiring intravenous narcotics beyond an observation period of time. As such, the patient could have been safely managed under observation level of care and acute inpatient level care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental malocclusion

Treatment: D8080 braces, D8670 monthly visits x 12, and D8680 retainer

The insurer denied coverage for D8080 braces, D8670 monthly visits x 12, and D8680 retainer

The denial is upheld

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 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 16 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstances does not meet insurer and plan criteria to justify orthodontic care.

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 D8080 braces, D8670 monthly visits x 12, and D8680 retainer is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 Braces

The insurer denied coverage for D8080 Braces

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to excessive overjet among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required stating the patient exhibits the automatically qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet this required handicapping malocclusion medical necessity requirement on the HLD index, attaining a score of 14 points on review by internal reviewers. 

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition is met and supports comprehensive orthodontic care. In this case, the clinical circumstances do 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 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 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld

This is a male patient with a history of chronic pancreatitis who presented to the emergency room (ER) with abdominal pain and nausea. He had multiple prior admissions for similar symptoms. He had mild anemia, and hyperkalemia and an elevated lipase. A computed tomography (CT) scan showed chronic pancreatitis and pancreatic pseudocyst. He was admitted as an inpatient and started on intravenous (IV) fluids, analgesics, a proton pump inhibitor (PPI), anti-emetics and intravenous (IV) antibiotics. He was evaluated by a gastroenterologist who recommended supportive care and a magnetic resonance cholangiopancreatography (MRCP). The patient eloped from the hospital.
At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient admission is not medically necessary for this patient.
This patient did not have a fever or peritoneal signs, symptoms of cholangitis or acute pancreatitis or evidence of hemodynamic instability to warrant continued admission in acute level of care. Inpatient admission for acute abdominal pain is medically necessary for one or more of the following: -
-	Inability to maintain oral hydration
-	Fever
-	Severe pain (eg, not controllable with oral medication or oral medication not tolerated)
-	Hypoxemia
-	Hemodynamic instability
The patient had none of the above. Therefore, he could have been managed at a lower level of care rather than acute inpatient level of care and discharged to home once he was able to tolerate oral nutrition and medications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is an adult male with a past medical history that included hypertension (HTN), hyperlipidemia (HLD), diabetes mellitus (DM). He presented to the emergency department (ED) with two days of chest pain and shortness of breath. There is a history of a negative stress echocardiogram.

He was evaluated in the ED for two days of central chest pain 8/10 in intensity along with orthopnea and progressive exertional dyspnea. His chest pain had been right-sided, reproducible with palpation, worse with cough, leaning forward, or deep breathing. Vital signs were reassuring with a trivially elevated blood pressure, and morbid obesity with BMI > 40. The pulse oximeter was 98%.  Exam of the lungs noted no rales/rhonchi.  There was no peripheral edema. The electrocardiogram (EKG) showed T wave changes that are nonspecific. Troponin (Tn) of 0.03, stable over 3 consecutive lab draws. The Tn levels are flat and not reflective of an acute ischemic event. The B-Type Natriuretic Peptide (BNP) was 180 which is mildly elevated. The chest x-ray (CXR) showed lungs with  diffuse interstitial opacities which may represent pulmonary edema vs pneumonia.  Echocardiogram showed an ejection fraction (EF) of 53% with normal segmental left ventricular contraction. There was mild/moderate mitral regurgitation (MR) with left atrial enlargement. He was treated with Lasix and azithromycin. It was noted that on arrival to the floor, he felt much better. "Still has "chest tightness" and dyspnea if he lies down. But when he is lying still and slightly upright he is comfortable." Exam noted breath sounds were normal, no accessory muscle usage. No respiratory distress. No wheezes, no rhonchi and no rales. Did note pain with palpation of the right side of the chest.  

This patient presented with symptoms atypical for an acute ischemic event.  His complaint of orthopnea could reflect an element of congestive heart failure (CHF); however, the normal oxygenation, no jugular venous distention (JVD) and clear lungs on repeated exam do not support acute CHF. In addition, the BNP was only mildly elevated.  Similarly, there were no findings to support pneumonia requiring inpatient management. In sum, the findings do not support the need for an acute inpatient admission. The patient could have been observed and when there were no objective markers of an acute ischemic event, managed as an out 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: cellulitis
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a male who presented with fever, malaise, myalgia, and left pain and swelling beginning that morning. In the emergency department (ED), temperature was 100.3, blood pressure (BP) 97/57, heart rate (HR) 106, respiratory rate (RR) 22, and oxygen saturation 96% on room air (RA). He was not in distress, heart was regular, he was breathing comfortably with clear lungs, and was alert and oriented. The left calf had erythema. He was diagnosed with sepsis from cellulitis.

The inpatient hospital admission was medically necessary. The patient presented with cellulitis but also had severe sepsis with systemic inflammatory response syndrome (SIRS) (fever, elevated white blood cell count (WBC), tachycardiac, tachypnea) as a manifestation of severe sepsis (hypotension). The Guidelines would suggest that cellulitis with a severe systemic response requires intravenous (IV) antibiotics, requiring an inpatient admission and close inpatient monitoring to ensure patient is responding and doesn't develop worsening organ failure and require intensive care. While his blood pressure (BP) had improved by the following day, he had persistent SIRS, including fever. Given his more severe presentation, the guidelines would suggest he did require an inpatient admission for IV antibiotics and close monitoring.