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

Diagnosis: Crowding and posterior crossbite.
Treatment: D8030 - Braces.

The insurer denied the D8030 - Braces.  The denial is upheld.

The patient is a female. The request is for dental benefits for braces.

Per the Provider's dental clinical summary, the patient presents with mixed dentition, causing crowding and posterior crossbite.

The health plan is denying the service because the conditions do not meet the severely handicapping criteria, meaning that the malocclusion is not severe enough to warrant braces.

The Provider is appealing the denial based on the diagnoses presented in the dental clinical summary.

No, the requested braces are not medically necessary.

The information submitted does not support the existence of a posterior crossbite. It is not supported in the photos that were submitted for review.

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

The diagnoses of posterior crossbite was not supported in the information submitted, and, therefore, braces treatment is not warranted.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post right knee revision

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld.

This is a patient with a history of obesity. Body mass index (BMI) 45. She presented to the hospital for an elective right knee revision arthroplasty. The patient tolerated the procedure well. She was initially placed in the post anesthesia care unit (PACU) and was later transferred to the floor. Her home medications were resumed, and pain was well controlled. She worked with physical therapy and occupational therapy (PT & OT). The patient was later discharged.

The medical records show an underlying medical condition of morbid obesity (ie. BMI 45). The surgery was complex and extensive of over 6 hours anesthesia time. These findings would substantiate necessity of an admission. The records then show a non-complicated course. Her vital signs were stable, the wound was clean, there was no evidence of infection, and she was able to tolerate oral medications. There were no delays in physical therapy nor necessity for evaluation for other medical problems. Physician records show recommendations for DC (discharge) placement daily. The records also show "the patient is ready to go to rehab," (POD (post operative day #3). There would be no medical reason why acute length of stay was required.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Injured back and right leg.
Treatment:  Increase Consumer Direct to 84 Hours per Week, One Client.

The insurer denied the Increase Consumer Direct to 84 Hours per Week, One Client
The denial is upheld

The patient is a male with a history of a fall on the staircase. He injured his back and right hip. He has chronic right knee pain, lower back pain, and stiffness in the neck. He receives epidural injections approximately every six months. He has a diagnosis of sciatica nerve pain.

No, the proposed treatment is not medically necessary.

The patient ambulates using a walker indoor and motorized scooter for outdoors; his gait is slow and unsteady, and he needs help with dressing and showering.  His functional status is as follows: ordinary housework total dependence, stairs maximal assistance, transportation and shopping maximal assistance, activities of daily living maximal and extensive assistance.  The patient states he transfers to the toilet by holding his walker and girlfriend's hand.  He needs help cleaning and wiping after toilet use.

The patient's status, post-fall with injury to the back and right hip, chronic knee pain, and lower back pain requires maximal to extensive assistance with activities of daily living.  The approved 63 hours is sufficient for the patient's condition.

The patient does requires assistance with his activities of daily living  (ADLs), but the hours approved by the health plan are sufficient for care for this patient.  He does not require additional hours of help. The patient is mobile, and he requires assistance but is not completely dependent.

Yes , the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.  Based on the records, management was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pelvic Inflammatory Disease (PID)
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

This patient with a history of pelvic inflammatory disease (PID) presented to the emergency room (ER) with complaints of abdominal pain. She was recently hospitalized with PID and left against medical advice (AMA). She was afebrile and vital signs were stable. Pelvic examination showed cervical motion tenderness. In the ER, she was given Ceftriaxone, Doxycycline, and Flagyl. She was admitted with PID. She was continued on intravenous (IV) antibiotics and then transitioned to oral (PO) antibiotics after 24 hours. She tolerated the new regimen without issue. The patient was discharged after a period of medical stability.

Most females with PID can be safely treated in outpatient settings. Indications for hospitalization and parenteral antibiotics include: severe clinical illness (e.g., fever >=38.5C (Celsius) [101F (Fahrenheit)], nausea and vomiting), complicated PID with pelvic abscess (including tubo-ovarian abscess), possible need for invasive diagnostic evaluation for alternate etiology (e.g., appendicitis or ovarian torsion), or surgical intervention for suspected ruptured tubo-ovarian abscess, inability to take oral medications, pregnancy, lack of response or tolerance to oral medications, concern for nonadherence to therapy.

This patient has nausea and vomiting with concern about her ability to take oral medications. In addition, there was concern for nonadherence to therapy as she has been seen 3 times for the same condition.

Based on the above, admission was medically necessary for treatment. Once the patient was able to tolerate oral medications, she was transitioned to PO antibiotics and discharged home.

The inpatient admission is 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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Upheld

The patient is a female who presented to the hospital with a history of progressively worsening abdominal pain of 5-days duration. Evaluation included physical exam, labs, and computed tomography (CT) scan. She was without fever at the time of presentation. The heart rate was 86/minute in the emergency department (ED). Lab data identified white blood cell (WBC) count of 5.6 thousand (K). CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. She was provided IV fluid and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without fever. Diet was advanced and pain management was converted to oral medications. She was discharged home. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

Inpatient stay was not medically necessary as the care and treatment provided could have appropriately rendered with a lower level of care.
This patient presented to the ED with abdominal pain. The evaluation with examination, lab data, and CT scan established the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and appendectomy performed. The early post-surgical course was uncomplicated, and the patient was clinically stable for discharge from the hospital on the first post-surgical day.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient presented with abdominal pain and underwent uncomplicated appendectomy. The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

Because of the patient being a febrile infant, with a working diagnosis of sepsis, an LP (lumbar puncture) was performed as per current febrile infant management guidelines. Ceftriaxone was administered, which requires, per guidelines, monitoring in the hospital while continuing empiric antibiotics for at least 48 hours until CSF (cerebrospinal fluid) cultures, as well as blood and urine cultures, are reported.

The assessment and plan clearly document the medical decision-making process, including rationale for empiric meningitis dosing of antibiotics to treat for the possibility of a serious bacterial infection, which can occur concurrently with a RSV (respiratory syncytial virus) infection. 

Although signs of toxicity or meningitis may not be present in young infants even in the presence of a serious bacterial infection, that is, they may be well-appearing, the patient had mottling with purplish gray extremities and a capillary refill of 4 seconds, tachycardia, and is recorded by his nurse as having occasional moaning or whimpering, which could be a sign of serious bacterial infection, specifically meningitis. Also, he was desaturating to 92% which is considered borderline on room air and given his diagnosis of RSV infection it is impossible to predict if this hypoxemia could worsen in the next 24 to 48 hours. For all the above reasons, the patient could not have been managed in the observation area and needed an admission to the hospital.
The insurer's denial of coverage for an inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever/sepsis
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is overturned

Because of the patient being a febrile infant, with a working diagnosis of sepsis, an LP (lumbar puncture) was performed as per current febrile infant management guidelines. Ceftriaxone was administered, which requires, per guidelines, monitoring in the hospital while continuing empiric antibiotics for at least 48 hours until CSF (cerebrospinal fluid) cultures, as well as blood and urine cultures, are reported.

The assessment and plan clearly document the medical decision-making process, including rationale for empiric meningitis dosing of antibiotics to treat for the possibility of a serious bacterial infection, which can occur concurrently with a RSV (respiratory syncytial virus) infection. 

Although signs of toxicity or meningitis may not be present in young infants even in the presence of a serious bacterial infection, that is, they may be well-appearing, the patient had mottling with purplish gray extremities and a capillary refill of 4 seconds, tachycardia, and is recorded by his nurse as having occasional moaning or whimpering, which could be a sign of serious bacterial infection, specifically meningitis. Also, he was desaturating to 92% which is considered borderline on room air and given his diagnosis of RSV infection it is impossible to predict if this hypoxemia could worsen in the next 24 to 48 hours. For all the above reasons, the patient could not have been managed in the observation area and needed an admission to the hospital.
The insurer's denial of coverage for an inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial cellulitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is a patient with a past medical history significant for acne who presented to the emergency room with complaints of facial cellulitis, right jaw pain, and peri orbital inflammation. 

Vitals on presentation included: Temperature 37.1 Celsius, Blood Pressure 138/78, Pulse 84, Respiratory Rate 18, oxygen (O2) saturation 98% on Room Air. Laboratory results included the following: white blood cell (WBC) count 11.5, hemoglobin 13.4, hematocrit 1.8, creatinine 0.7, glucose 120, lactic acid 0.7.
 
Patient was admitted to hospital for a facial cellulitis and empirically started on antibiotics. Maxillofacial computed tomography (CT) scan showed left preseptal soft tissue edema consistent with cellulitis. No evidence of extension into the orbit. Xray panorex was grossly unremarkable. Infectious Diseases consulted and adjusted antibiotics accordingly. Patient improved clinically, remained afebrile and hemodynamically stable. She was discharged to continue oral antibiotics as an outpatient. 

According to documentation, patient presented with a localized left pre-septal cellulitis. Patient was otherwise afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal WBC. Patient had a localized infection, and no surgical intervention was required. Based on above findings, patient did not meet criteria for acute inpatient admission. Patient met criteria for observation level of management. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection (UTI)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This case involves a patient who had a history of Beckwith Weidman syndrome and Escherichia coli (E. coli) urinary tract infection (UTI) who presented to the emergency room with reports of a 3-day history of vomiting, fever, and poor oral intake.  She had completed a course of antibiotics because of the UTI when she was last seen.  In triage, the report stated that the patient was wetting normal diapers and acting normally despite 3 episodes of vomiting.  She was tolerating oral intake intermittently.  She was seen at her clinic earlier in the day with a fever of 103.  Motrin was administered and she was referred to the emergency department.  On examination, the patient's pulse was 161 with a temperature of 102.4 (rectal).  Respirations were 39 with pulse oximetry 100% (percent).  She was documented as tachycardic, and recommendation was to rule out hyperglycemia versus dehydration versus gastroenteritis versus upper respiratory infection versus less likely pharyngitis versus less likely gastritis/gastroesophageal reflux disease.  The treatment plan included laboratory testing and intravenous fluids.  Laboratory testing revealed white blood cell count at 31.1, carbon dioxide 17, hemoglobin 9.7, hematocrit 29.1, platelet count 728, positive findings for urine nitrates, trace blood in the urine, 100 random urine protein, with red blood cell count at 3.69, and many urine bacteria noted.  The emergency department diagnosis was a urinary tract infection.  The records noted the patient's history of primary closure of omphalocele with mesh and partial glossectomy.  She had complications with wound dehiscence and underwent a revision.  

The Milliman Care Guidelines confirm that inpatient stay is indicated for pediatric patients who require intravenous hydration support when they are diagnosed with a urinary tract infection.  In addition, those with bacteremia are also indicated for up to 2 days inpatient stay.  Records noted the patient had respirations at 39, which is just below the 40 breaths/min and an infant few months of age indications for admission, and in taking this information into consideration along with the patient's age and other symptoms to include abnormal laboratory values, the inpatient stay was appropriate.  As such, the request for inpatient admission was medically necessary.  The prior determination is overturned. The healthcare plan did not act reasonably or with sound medical judgment and in the best interest of the patient. 

The insurer's denial of coverage for inpatient admission overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sore Throat and Fever.
Treatment: Inpatient Hospital Admission.
The proposed inpatient hospital admission was not medically necessary.
The plan's decision is upheld.


This female patient presented with three days of weakness associated with headache, body aches, cough, fevers and sore throat. The patient's vital signs included: temperature 37.5(maximal temperature 103.5), pulse 108, respiratory rate 16, blood pressure 98/64, and oxygenation saturation 95%. The patient's exam was remarkable for pharyngeal erythema and cervical tenderness. The complete blood count and comprehensive metabolic panel were unremarkable. The patient's lactic acid was 0.69, COVID was negative, and Influenza-A was positive. The patient's chest x-ray showed no acute disease. Electrocardiogram (EKG) showed sinus tachycardia.

The patient was admitted on with sepsis due to influenza. The plan of care included intravenous antibiotics and intravenous (IV) steroids. Tamiflu was started. The patient was discharged.

This patient was admitted with Influenza-A. She did not have altered mental status. She was hemodynamically stable with a fever. She had normal oxygenation. Labs were remarkable for elevated lactic acid level. The patient did not have end organ failure or an active comorbid condition. She did not have bacteremia. She did not require intravenous antibiotics at an inpatient level of care. She had not failed an observation level of care. Inpatient hospital admission was not medically necessary.
The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Breo Ellipta.
The health plan denied the Breo Ellipta as not medically necessary.
The health plan's determination is upheld.

The patient is a female who suffers from asthma. The treating provider is recommending the use of Breo Ellipta. The patient was intolerant to Advair. The patient has normal spirometry. A computed tomography (CT) scan of the chest showed lung nodules.

At issue is the medical necessity of the requested health service/treatment Breo Ellipta.
The health plan's determination of medical necessity is upheld.

The requested health service/treatment of Breo Ellipta is not medically necessary for this patient.

The patient suffers from asthma. The patient tried and failed Advair. The request is for the Breo Ellipta. However, there is no convincing or objective evidence in the submitted documents that the patient has a contraindication to or a potential drug interaction with the formulary alternatives (Airduo, Wixela, and generic budesonide/formoterol). There is no evidence that the patient is intolerant to or has had a confirmed adverse event with the formulary alternatives. There is no evidence that the patient has demonstrated an inadequate treatment response after a trial of the formulary alternatives.

On the other hand, there are no adequate or well-conducted randomized controlled or cohort trials in the prevailing peer-reviewed published medical literature that established the long-term efficacy and safety of Breo Ellipta over the preferred formulary alternatives for the treatment of this patient's medical condition.

There is no high-quality literature showing an improvement in health outcomes with the use of Breo Ellipta over the preferred formulary alternatives for this patient's condition. There are no national guidelines that support the routine use of Breo Ellipta over Airduo, Wixela, and generic budesonide/formoterol for the treatment of asthma, as in this patient's case.

Therefore, the requested health service/treatment of Breo Ellipta is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impacted teeth.

Treatment is for D8080 braces and D8670 monthly visits.

The insurer denied coverage for D8080 braces and D8670 monthly visits.
 
The denial is upheld.


Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, a 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 impacted permanent anterior teeth maxillary spacing, mandibular crowding, excessive overjet, and deep bite. The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of 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 required medical necessity requirements on the HLD index, attaining only 16 points on review by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits 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 Labiolingual Deviation Index Report (HLD), 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 a necessity. 

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care using this criterion. This reviewer concurs with the findings of the insurer of attaining 16 points on the HLD index (5 points overjet, 6 points overbite, 3 points ectopic eruption, 2 points labiolingual spread).

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 needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic needs. 
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 and D8670 monthly visits services is not substantiated.