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

This is a female patient who is a resident of Colorado. Records indicate that while the patient was visiting her family in Arizona she was taken to the hospital in Arizona for possible pneumonia. She reportedly had extreme weakness and fatigue. Her discharge diagnoses were bronchitis and influenza A for which she was given Tamiflu. She was noted to have weakness and was full assist during transfers. She was participating in rehabilitation with physical therapy and occupational therapy for strengthening and balance issues. It was determined that she should return to Colorado for continued care with her established physician and support in a long-term care facility. The distance between the discharging and admitting facilities was stated to be over 800 miles and it was apparently felt that the patient did not meet the expectations for health for commercial travel or guidelines for ground transport because of her weakness. The health plan denied the air ambulance transport as not medically necessary. The health plan's determination is upheld. 

Records provided indicate that the patient was visiting family in Arizona when she was taken to the hospital and given a discharge diagnosis of bronchitis and influenza A. She was noted to have a history of recurrent hip infection. She was participating in rehabilitation with physical therapy and occupational therapy for strengthening and balance issues. She was noted to have weakness. It was noted that her family requested that she return to Colorado for continued care with her established providers in a long-term care facility. She was then transferred via land and air ambulance from Arizona to Colorado. However, this was for non-emergency transportation. Transferring the patient from Arizona to Colorado was for the convenience of the family and was not medically necessary. There are multiple facilities in Arizona that were closer at which the patient could have participated in rehabilitation and would have been able to receive an appropriate level of care for this patient. She was medically stable with no need for emergency transportation. Transportation was not to the nearest facility that was able to adequately care for the patient.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a class II occlusion, mild mandibular crowding, mild maxillary spacing, moderate overbite and overjet. The proposed treatment is braces with interproximal reduction (IPR) and possible extractions for 18-24 months. 

The subject to be determined is the medical necessity for braces (comprehensive orthodontic treatment).
The health plan's determination is upheld.

The treatment of braces (comprehensive orthodontic treatment) is not medically necessary for this patient. 

Using the standard Handicapping Labio-Lingual Deviation (HDL) index, the malocclusion in this case would score a 15 with no auto qualifier present. The malocclusion in this patient does not meet the standard medical necessity criteria to be classified as handicapping, and therefore treatment would not be considered medically necessary. Using this standard of care criteria, the patient would require a score of 26 or greater for treatment to be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal Class ll- Retruded Mandible, Normal Vertical Growth Pattern, Permanent Dentition, Mild Maxillary Spacing, Mild Mandibular Crowding, and Moderately Excessive Overjet, and Deep Impinging Overbite with Severe Soft Tissue Damage 

Treatment: Orthodontic Treatment

The insurer denied the Orthodontic Treatment. The denial was upheld.         

This is a young female patient who presented for an orthodontic evaluation. As per patient documentation she had skeletal Class ll- retruded mandible, normal vertical growth pattern, permanent dentition, mild maxillary spacing, mild mandibular crowding, and moderately excessive overjet, and deep impinging overbite with severe soft tissue damage. The patient had a Handicapping Labio-lingual Deviation (HLD) index that resulted 13 points (5 points overjet, 6 points overbite and 2 points labio-lingual spread). It is evident that the patient exhibits a significant malocclusion. 

To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a HLD Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 
In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

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

The patient has a history of Bipolar I disorder (d/o), cannabis use and cocaine use. In 2015, the patient was diagnosed with depression and after a trial of Bupropion became manic. The patient reportedly did not tolerate Aripiprazole "it made patient depressed" and eventually was treated with Li 900 milligrams (mg) po (by mouth) twice daily (bid) and Risperidal 1.5 mg po qhs. The patient had two inpatient psychiatric admissions, most recently for substance use and medications non-compliance. The patient was discharged recently with the plan to follow up with outpatient care but did not comply with the medications after discharge. The patient presented with rapid/pressure speech, grandiosity and psychomotor agitations. Lithium (Li) level on admission was subtherapeutic 0.38. After receiving Li 900 mg twice/day on consistent basis and after Risperidal was increased from 1.5 mg at night to 2 mg/day, the patient became more appropriate.

The health plan's determination is upheld. The Inpatient Mental Health Treatment was not medically necessary for this patient. The patient was admitted for a manic episode. Li level on admission was sub-therapeutic at 0.38. After Li 900 mg bid was consistently given, it was re-checked Li level and was going upward therapeutic 0.74. The half-life of lithium is approximately 24 hours. Thus, it takes at least four or five days for serum lithium concentrations to reach steady state after the dose is changed. The patient's symptoms correlated with the Li level, and the patient became more cooperative and was gaining insight into his or her own condition.
As of the dates in question, the patient's condition did not require 24 hours psychiatric services. The patient was not a danger to self or others, and did not exhibit command AH (auditory hallucinations) or persecutory delusions. The patient was not engaged in disorganized behaviors, was participating in treatment, and was making progress.
Appeal type: Medical necessity
Decision: Overturned

The patient who presents to the dental office for evaluation and treatment of his sleep apnea with an oral repositioning appliance.
 It has been documented in the provided records that the patient does not have active periodontal disease and that he does not tolerate the continuous positive airway pressure (CPAP) device.The subject under review is the medical necessity of the planned treatment of sleep apnea appliance (EO486).The health plan's determination of medical necessity is overturned in whole.  The patient is documented to currently suffer from mild to moderate sleep apnea, has attempted to use the continuous positive airway pressure (CPAP) and no longer tolerates the device, has a full dentition, does not have active periodontal disease, and is currently under the care of a dentist.Mandibular sleep appliances for the advancement of the mandible are a documented therapy for which there is greater compliance amongst patients who have previously used CPAP either with poor compliance or results. The majority of the literature supports the mandibular advancement device for patients with diagnosed sleep apnea and it is considered to be the standard of care for those who cannot or will not wear a CPAP. Hence, based on the documentation and the medical literature, the treatment of sleep apnea appliance (EO486) is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented for evaluation and treatment of tooth #13.  In question is the medical necessity of the planned treatment of porcelain fused to gold crown for tooth #13. Previous denials have been on the basis that the tooth has a guarded periodontal prognosis due to the loss of periodontal ligament and alveolar bone. The original denial stated that the need for treatment was not evident. The radiographic documentation provided shows bone loss on the distal of #13 involving the apical third of the root. No clinical periodontal indices were provided to indicate a better prognosis beyond the radiographic presentation. 
The health plan's determination is upheld.
The radiographic documentation supports the periodontal prognosis of guarded to poor. In addition, there is not radiographic evidence of decay at the margin to support the need for crown replacement. Therefore, with the absence of radiographic decay and the guarded to poor prognosis of tooth #13, the treatment of porcelain fused to gold crown for tooth #13 is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a history of migraine headaches who presented to the emergency room for evaluation and treatment of an intractable migraine headache.  She had developed the migraine headache seven days prior to being seen in the emergency room.  The headache consisted of throbbing pain across her forehead.  For the headache, she had tried medications at home without relief.  In the emergency room, she was treated with a cocktail of medications, including intravenous Toradol, intravenous Compazine, intravenous Benadryl, and one liter of intravenous fluids.  Despite these treatments in the emergency room, the headache persisted.  The health plan's determination is overturned.
This patient had already received outpatient treatment for her severe pain, and the treatment had failed.  Therefore, it was medically necessary that she be admitted for IV Depacon therapy.  Most patients presenting to an emergency room for evaluation and treatment of migraine headache can be successfully managed in the emergency department and do not require hospital admission.  However, if appropriate treatments are administered in the emergency department, and the severe headache pain persists, then admission to the hospital for further treatment is necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematemesis

Treatment: Inpatient Hospitalization

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

This is an elderly male patient who presented to the emergency department (ED) with complaint of two episodes of hematemesis (bright red blood) with small clots occurring in one day. The patient exhibited normal bowel sounds, abdominal distention, and ascites noted. He has a history of diabetes mellitus, essential hypertension, pleural effusion, gastroesophageal reflux disease (GERD), portal vein thrombosis, shortness of breath, cryptogenic cirrhosis complicated by refractory ascites, requiring Denver hunt status post revision in late 2018, esophageal varices (recent bleeding, repeat hematemesis and esophagogastroduodenoscopy),end stage renal disease (ESRD) on hemodialysis (Monday-Wednesday-Friday), and liver disease.  The patient was admitted overnight and discharged home with plan to follow up with his gastroenterologist.

Per MCG, clinical indications for admission for Liver Disease Complications (M-570) include hepatic encephalopathy that is moderate to severe and unresponsive to observation treatment, infected ascites, severe hepatitis, severe vomiting, and acute hepatic decompensation. The patient did not have these conditions. Gastrointestinal (GI) bleeding is an indication for admission. However, in this case, there was no evidence of active GI bleeding either by history or based on the endoscopic findings. The patient did not have any high risk endoscopic features and was hemodynamically stable. The patient only reported a minimal amount of blood after he vomited. This patient had cirrhosis. There was no indication of an active GI bleed. 

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

Diagnosis:  Deep Vein Thrombosis

Treatment:  Inpatient Admission

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

This is an elderly male patient, who presented to the emergency department with a one-week history of right leg swelling, pain, and tenderness to palpation.  He stated he could not walk on his right leg due to pain.  He had a medical history of hypertension.  It was recommended the patient undergo laboratory studies and an ultrasound.  The patient's laboratory studies revealed an elevated D-dimer of 8.55.  The ultrasound revealed an occlusive deep venous thrombus of the sapheno-femoral junction, proximal, mid, and distal superficial femoral veins and popliteal vein likely sub-acute status.  His chest x-ray was negative for acute pulmonary process.  It was recommended the patient be admitted for further care.  The patient was treated with Lovenox, Amlodipine, and Eliquis.  It was reported that the patient was alert, oriented, and was able to ambulate.  The patient experienced no significant adverse events during his hospital admission.  He was discharged when deemed medically stable with recommendations for follow up. 

According to current literature a patient may be admitted to inpatient care when there is evidence the patient is considered a high risk for acute complication, such as documentation of a recent surgery, recent Gastrointestinal (GI) bleed, and history of intracranial bleeding, history of active bleeding with anti-coagulation or there is evidence of active substance abuse.  Additionally, if there is a limb threatening infection, then a patient may be admitted.  The submitted documentation did not indicate any of the above conditions.  There is no personal allergic reaction in response to anticoagulation requiring monitoring beyond observation care that would warrant the requested inpatient stay.  There is a lack of submitted documentation detailing why this patient could not have continued care in an observation level.  The patient could have been observed and treated with anticoagulation therapy.  Therefore, the inpatient admission was not medically necessary, and the prior denial remains upheld.  The health plan acted reasonably and with sound medical judgment, in the best interest of the patient.

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

The patient is a male with a Class I occlusion with minimal overbite and overjet. The orthodontist states he has anterior crossbites on teeth 7 and 10. He has a convex profile. He is treatment planned for 24 months of orthodontics with extraction of 5, 12, 21 and 28 to correct his malocclusion. This was denied by the health plan based on lack of medical necessity. The subject under review is the medical necessity for the requested orthodontic treatment.

The health plan's determination is upheld. 

The requested treatment is not medically necessary for this patient.
The patient has an excellent occlusion and appropriate overbite and overjet. There is some minor spacing, but this alone does not rise to the threshold of medically necessary. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. Although the patient has some minor spacing, his teeth are in a solid Class I occlusal relationship. He has minimal overbite and overjet on 7 and 10, but the photographs do not indicate any incisors in a traumatic relationship. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence.1 This patient presents with none of those conditions.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain due to Sickle Cell
Treatment: Inpatient admission
The inpatient admission was medically necessary.

The patient is a teenage male with medical history significant for sickle cell SS disease on a monthly transfusion program, with multiple PICU admissions, including admissions for pain crises and acute chest syndrome. He was referred to the ED for evaluation of abdominal pain. The pain initially started in his knee and shoulder the day prior. It migrated to his abdomen, was periumbilical in location, rate 6/10, and described as stabbing. It was unrelieved by Percocet and ibuprofen. He had no other symptoms, no fevers, anorexia, vomiting. He did report onset of a nonproductive cough. 

The patient's vital signs included temperature 37.2, heart rate 90, respiratory rate 20 with 97% saturation in room air. Examination was significant for no acute distress, clear lungs, and diffuse abdominal tenderness, worst in the periumbilical area. His port was inaccessible, so an IV was started and he was treated with Dilaudid. Laboratory evaluation revealed hemoglobin 9.8 with 2+ sickle like cells, 5.4% reticulocytes, total bilirubin 4.6, AST (aspartate aminotransferase) 63, and WBC (white blood cells) 14.2K with 52% neutrophils and 7% bands. 

The patient was diagnosed with sickle cell crisis with vasoocclusive abdominal pain, and admitted for further pain management. Admit orders included round-the-clock Toradol, maintenance IV fluids, Tylenol as needed for moderate pain, Dilaudid as needed for severe pain, ranitidine for GI (gastrointestinal) protection, folic acid, albuterol for his dry cough, and Hematology consultation. 

The patient's pain was severe overnight, requiring Dilaudid in the morning. He was transfused as per his transfusion program. By the day of discharge, his pain had improved, and he had no tenderness on exam. He was deemed stable for discharge home, to follow-up with Hematology in one to two weeks and pediatrician in one to two days.

This male teen presented with abdominal pain characteristic of previous vasoocclusive crises, preceded by extremity pain, rated 6/10. He had failed outpatient treatment with Percocet, and required Dilaudid in the ED with marginal improvement. He had a cough but was otherwise stable with no fevers. He was due for his routine transfusion. Based on his presentation and the standard of care at the time, acute inpatient admission for parenteral pain management was medically necessary and appropriate. This intensity of care could not have been safely provided at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever, vomiting
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

Myocarditis is an inflammatory disease of heart muscle. There are numerous causes, including infection, autoimmune disease, hypersensitivity reactions, and toxins. In developed countries, the cause is usually viral. Enteroviruses are the classic viral pathogen, but other viral agents may cause myocarditis, including adenovirus, parvovirus, Epstein-Barr virus, and cytomegalovirus. Characteristic symptoms on presentation include tachypnea, abdominal pain, vomiting, chest pain, palpitations, and tachycardia. 

Most patients present with resting tachycardia. Electocardiographic findings include ST-T wave abnormalities and premature contractions. Inflammatory markers are typically elevated. Troponin is a particularly useful marker to trend the disease. The most common echocardiographic finding is dilated cardiomyopathy with left ventricular dilation and reduced ejection fraction, but other phenotypes may be present. Cardiac MRI is particularly useful, because it can be used to assess left ventricular ejection, chamber size, wall thickness, and local areas of edema and fibrosis. Specific MRI diagnostic criteria are available for suspected myocarditis. 

Complications of myocarditis include arrhythmias, chest pain, myocardial infarction, acute heart failure, and sudden death. Treatment includes limitation of aerobic activities and management of the primary medical manifestations (e.g., treatment of arrhythmias, heart block, decreased left ventricular function). Research has suggested a role for immunosuppressive therapies and antiviral therapies.

This patient presented to the ED with signs and symptoms consistent with viral infection. Because of persistent tachycardia despite fluid resuscitation and antipyretics, additional studies were obtained that were indicative of myocarditis. She was initially admitted to the PICU for cardiorespiratory monitoring. She remained stable overnight, so was able to transfer to the pediatric floor. Once her symptoms resolved (afebrile, able to tolerate a regular diet, decreased fatigue) she was considered at decreased risk for complications and stable to go home. Myocarditis is a serious disease, with potential for significant morbidity and even mortality. Appropriate medical management in this situation included ICU monitoring, Cardiology and ID (infectious diseases) consultations, and comprehensive diagnostic studies. Additionally, she was treated with broad-spectrum antibiotics pending culture results. Acute inpatient management was medically necessary and appropriate. She could not have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the Emergency Department with complaints of fever, chills, and dysuria. She has a past medical history of diabetes mellitus, hyperlipidemia, and parotid gland drainage. The patient was empirically started on intravenous antibiotics for treatment of her urinary tract infection (UTI). The chest x-ray was negative. A renal ultrasound was negative for hydronephrosis. The urine culture was positive for E. coli.  The patient remained hemodynamically stable and clinically improved. She was discharged to continue antibiotics as an outpatient management.

According to the medical records, the patient was treated by her primary physician for a UTI as an outpatient with antibiotics for three days without improvement. She presented with high fevers (39.3 C) and tachycardia (heart rate-132). Urinalysis and cultures confirmed an E. coli UTI. The patient had multiple co-morbid conditions including diabetes that placed her at high-risk for complications.

Based on the above, the medical necessity for the inpatient hospital services at the inpatient level of care is substantiated. The insurer's denial is reversed.