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

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

The patient presented to the emergency department with a two-day history of a fever and skin rash. The rash first presented on the right forearm as a big red patch, as well as all over his trunk, extremities, and face. He had been feeding well until the day of presentation. He was seen at an urgent care where he was prescribed Keflex. He vomited after the first dose. He was then taken to the pediatrician's office where a spot white blood cell count (WBC) was elevated, so he was referred to the emergency department (ED). The rash on his forearm was spreading rapidly and seemed to be painful. The examination was significant for no acute distress, well appearance, moist oral mucosa, cradle cap and overall dry skin, right forearm with redness and swelling extending to near the elbow, no fluctuance, tender to palpation, normal wrist range of motion, visible punctum in the middle of the right forearm, generalized papular rash, and non-focal neurologic exam. He was diagnosed with eczematous skin, probable viral rash, and right forearm cellulitis. Laboratory evaluation was significant for a white blood cell count (WBC) count of 18.3 thousand (K), C-reactive protein (CRP) 5.357, respiratory viral panel positive for rhinovirus-enterovirus. He was given vancomycin for suspected methicillin-resistant staphylococcus aureus (MRSA) cellulitis (positive family history) and admitted for further management.

Admission orders included marking and following the area of erythema, continued vancomycin, vancomycin level, consideration for Strep coverage, consideration for acetaminophen as needed for fever, and feeding ad lib. The erythema began to recede. After losing intravenous (IV) access, he was prescribed enteral clindamycin. He vomited after the first dose but was able to tolerate it thereafter. He continued to improve and was deemed stable for discharge. At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary.

This young male infant presented with a minor acute viral illness, generalized viral rash, and an area of rapidly spreading erythema on his right forearm. He failed outpatient management after vomiting the oral antibiotic he had been prescribed. It was not unreasonable to monitor this infant in the hospital for improvement while administering parenteral antibiotics. However, he was overall hemodynamically stable with no evidence of impending sepsis or other complications. He did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glaucoma

Treatment: Durysta implant

The insurer denied coverage for codes 66030/J7351

The denial is overturned

This is a patient with history of glaucoma. Recent visual acuities were "count fingers" for the right eye (OD) and 20/25 left eye (OS). Intraocular pressures were 36 OD and 13 OS. Exam showed lagophthalmos OD and cup-to-disc ratios were 0.95 OD and 0.9 OS. Patient was on Cosopt, Azopt, and Lumigan. Patient noted to have severe glaucoma in both eyes. Durysta was injected OD and Diamox was started. It was noted that if intraocular pressures were not controlled, surgery will be discussed.

In a letter it was stated that the patient presented with elevated intraocular pressures, and the right eye was elevated on maximum topical therapy. Thus, an intracameral injection of Bimatoprost was used.  

In another letter, the requested Durysta implant was denied because it was not established as medically necessary based on the records provided. It stated that review of peer reviewed medical literature does not identify Durysta implants as safer and more effective than topical Bimatoprost. 

The patient has severe glaucoma and uncontrolled intraocular pressure in the right eye. Her intraocular pressure was elevated at 36 in the right eye, despite being on maximal topical therapy with Cosopt, Azopt and Lumigan (bimatoprost). The patient has tried and had inadequate responses to topical ophthalmic agents with different mechanism of actions, including a topical ophthalmic prostaglandin analog (Lumigan).

Because the patient has a documented inability to manage intraocular pressures with regular glaucoma eye drops, and failure of all classes of glaucoma topical medications, including with topical bimatoprost, the Durysta implant is one of few remaining non-surgical options to help control the patient's intraocular pressure.

The Durysta implant is considered medically necessary for this patient. The patient's intraocular pressure was uncontrolled despite maximal topical medications, and thus the Durysta implant was medically necessary to control intraocular pressure and prevent potential permanent vision loss in a patient with already severe glaucoma. The Durstya implant has been shown to reduce intraocular pressure in patients with open-angle glaucoma. (Bacharach 2021, Medeiros 2020) In randomized controlled studies, the Durysta implant reduced intraocular pressures by approximately 30 percent (%) from baseline and showed evidence of being able to slow glaucoma progression. (Bacharach 2021, Medeiros 2020)

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 Durysta implant (66030/J7351) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fever/Sepsis
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Overturned

The The patient is a male infant who presented with fever and upper respiratory symptoms. He was well until a week prior to presentation when he developed nasal discharge, sneezing, and a cough. His mother was using nasal suctioning and saline drops. He then developed emesis and a rectal temperature of 100.8 Fahrenheit (F). His mother was also concerned about a yellow color to his skin. His siblings also had upper respiratory symptoms. In the hospital he was continued on ceftriaxone while cultures were pending. He was found to be positive for rhinovirus/enterovirus infection.  He had improved and was feeding well, and was felt to be stable for discharge to home with follow up as an outpatient.
The subject under review is the medical necessity for the full hospital admission.

The requested health service/treatment of full hospital admission was medically necessary for this patient.
This is a patient who presented with fever, tachycardia, and tachypnea. His initial viral panel was negative, and he continued to have fever, tachycardia and tachypnea after evaluation in the emergency department. Tachycardia and tachypnea raises concern for systemic inflammatory response syndrome. He therefore required hospital admission for presumed sepsis, for parenteral antibiotic treatment and close monitoring while cultures were pending.
Febrile infants with potential sepsis are at risk of rapid decompensation and warrant full hospital admission. According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 25th Edition, Sepsis and Other Febrile Illnesses, Pediatric; hospitalization is indicated for infants 29 to 90 days of age with a temperature of 100.4 or greeter who also have tachypnea that persists or bacteremia or other abnormal findings of serious infection. This patient presented with fever, tachycardia and tachypnea. There was concern for potential sepsis, and therefore he required hospital admission with appropriate treatment and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

This is an adult that presented to the hospital complaining of palpitations for several hours. Past medical history was significant for a recent asthma exacerbation requiring treatment with oral prednisone. Upon arrival, an electrocardiogram (ECG) showed atrial fibrillation with rapid ventricular response. The ST-T waves (intervals on an ECG) were normal; the patient was tachycardic with a pulse of 145. The blood pressure (BP) was markedly elevated (202/111) with an oxygen saturation on room air of 99%(percent). Repeat BP was mildly elevated 150s/90s. The physical exam revealed no positive findings other than an irregular rapid pulse. Serum blood testing revealed an elevated white blood cell count of 17. The troponin was normal. The patient was admitted to the hospital and treated with Cardizem and anticoagulant therapy. Later she underwent a successful transesophageal echocardiogram with cardioversion X1. The Echocardiogram showed normal left ventricular function. After sinus rhythm was restored, she was released with follow up.

This patient presented with new onset atrial fibrillation and was hemodynamically stable. The initial hypertension improved within minutes and there was no evidence of an acute cardiac event or uncontrolled tachycardia. Later that day she underwent an uncomplicated electrical cardioversion. As summarized in Up to Date, such patients can be managed without the need for an acute inpatient admission.  

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

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Myoclonic jerks.
Treatment: Continued Rehab Stay.
The insurer denied: Continued Rehab Stay.
The denial is: Upheld.

The patient is a male with diabetes, hypertension, hyperlipidemia, tremor, myoclonus, polysubstance abuse: opioid abuse, cocaine abuse, and cannabis abuse, probable psychogenic nonepileptic seizure, anxiety, and chronic kidney disease. The patient was admitted to a nursing home from an acute care hospital. At issue is whether the requested Continued Rehab Stay is medically necessary for this patient.

The requested treatment of Continued Rehab Stay is not medically necessary for this patient. The patient is a male with diabetes, hypertension, hyperlipidemia, tremor, myoclonus, polysubstance abuse: opioid abuse, cocaine abuse, and cannabis abuse, probably psychogenic non epileptic seizure, anxiety, and chronic kidney disease. The patient was admitted to a nursing home from an acute care hospital. The physical therapy (PT) note stated that transfers were maximum assistance and he was non-ambulatory. The occupational therapy (OT) note stated that he was maximum assistance for self-feeding, maximum assistance for hygiene/grooming, maximum assistance for bathing, minimum assistance for upper body dressing, and had 3/5 general strength. The OT note stated that he was totally dependent for toileting. It was stated that the patient had generalized weakness and generalized tremor on physical exam.  A physician note stated that the patient's pain level was 0/10. His strength was 3/5 in the bilateral upper and lower extremities. He had full range of motion (not stated whether active or passive) in the bilateral shoulders. His deficits in mobility and activities of daily living (ADLs) were due to generalized weakness, debility, and co-morbidities. He had gait instability and decreased strength.
There was no documentation of significant improvement in bathing, dressing, bed mobility, transfers, ambulating, grooming/hygiene, feeding, strength, range of motion, or function during the time frames in question. Milliman Care Guidelines (MCG) criteria for Continued Rehab Stay admission have not been met as there is no need for skilled nursing or skilled rehab in the setting of pain that is under control, no wound care needs, no intravenous (IV) fluid/antibiotic needs, stable vital signs, and no documentation of significant improvement in bathing, dressing, bed mobility, transfers, ambulation, grooming/hygiene, or feeding. 
For the dates under review the patient could participate in a lower level of care, such as a home exercise program to include strengthening and range of motion exercises. Ongoing nursing services, occupational therapy and physical therapy is not medically necessary as pain is under control, there are no significant wound care needs, vital signs are stable, and there was no documentation of significant improvement in bathing, dressing, bed mobility, transfers, ambulation, grooming/hygiene, or feeding.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dentofacial Deformity. 
Treatment: Jaw Surgery
The insurer denied: Jaw Surgery
The denial is: Overturned.

This is a female with difficulty with mastication due to a dentofacial deformity. Evaluation revealed an open bite, negative overjet and lip incompetence due to a vertical maxillary excess and a mandibular hyperplasia. The planned corrective procedures are a Lefort I osteotomy to impact and advance the maxilla and a mandibular osteotomy to setback the mandible to close the open bite and normalize the overjet. A genioplasty is also planned to eliminate the lip incompetence. The subject under review is the medical necessity for jaw surgery.

The requested jaw surgery is medically necessary for this patient. The denial states that the patient does not have difficulty with mastication, which is not true. This is documented in the records.

According to the American Association of Oral and Maxillofacial Surgeons Parameters of Care, the indications for surgical correction of maxillofacial deformities are any of the following:
1.	Malocclusion that cannot be corrected by non-surgical means,
2.	Speech pathology,
3.	Masticatory and swallowing abnormalities,
4.	Social and psychological impairment or
5.	Obstructive sleep apnea.
There must be either:
1.	Physical evidence of musculoskeletal, dento-osseous, and/or soft tissue deformity,
2.	Imaging evidence of musculoskeletal, dento-osseous, and/or soft tissue deformity,
Surgery is generally delayed until skeletal maturity is reached except for class II malocclusions.

The American Association of Oral and Maxillofacial Surgeons' criterion for orthognathic surgery has become an accepted assessment tool to determine if orthognathic surgery is medically necessary. This tool provides verifiable clinical measurements of maxillary and/or mandibular facial skeletal deformities associated with masticatory malocclusion and advises surgery to correct any of the following criteria:
A. Anteroposterior discrepancies
1.	Maxillary/mandibular incisor relationship: Overjet of 5 mm or more, or a 0 to negative value
2.	Maxillary/mandibular anteroposterior molar relationship discrepancy of 4 mm or more
B. Vertical discrepancies
1.	Presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks
2.	Open bite
3.	No vertical overlap of anterior teeth
4.	Unilateral or bilateral posterior open bite greater than 2 mm
5.	Deep overbite with impingement or irritation of the buccal or lingual soft tissues of the opposing arch
6.	Supra eruption of dentoalveolar segment due to lack of occlusion
C. Transverse discrepancies
1.	Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms
2.	Total bimaxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth
D. Asymmetries
1.	Anterior-posterior, transverse or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 braces
The insurer denied coverage for D8080 braces.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, 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, overbite, open bite, ectopic emption, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report, attaining 49 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 of the HLD index, attaining only 21 points. 

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 the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the HLD 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 49 points to justify orthodontic care. This reviewer concurs with the HLD index of the insurer, attaining 21 total points (2 overjet, 5 overbite, 6 ectopic eruption, 5 anterior crowding and 3 labiolingual spread).

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.

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval.

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

The medical necessity for D8080 braces is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pyelonephritis 
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

The patient is a young adult with a past medical history significant for anemia who presented to the emergency room with complaints of fever, dysuria, chills, and lower back pain.

Vitals on presentation included: Temperature 101 degrees F (Fahrenheit), Blood Pressure 118/66, Pulse 120, Respiratory Rate 19, and oxygen (O2) saturation 100% (percent). Laboratory results included the following: white blood cell (WBC) count 8.2, Hemoglobin (Hgb) 12.8, Hematocrit (Hct) 38.2, creatinine 0.9, glucose 96, and a urinalysis was positive for moderate leukocytes, ketones and trace proteins. 

The patient was started on intravenous (IV) fluids and empiric antibiotics (ceftriaxone). A computed tomography (CT) scan of abdomen/pelvis showed right sided pyelonephritis with significant accompanying cystitis. A chest x-ray was negative. The patient improved clinically, remained afebrile and hemodynamically stable. The patient was medically cleared for discharge home with instructions to continue oral antibiotics (cefpodoxime). 

According to medical records, the patient was admitted for a urinary tract infection. She was febrile (101 degrees F), tachycardic (heart rate 120), a urinalysis was suggestive of infection, and the CT scan confirmed pyelonephritis. Based on the above findings, criteria for an inpatient hospital admission was met. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history of hypertension, diabetes, obesity, former smoker, prior cocaine use, coronary artery disease (CAD) status/post (s/p) myocardial infarction (MI), status/post (s/p) percutaneous coronary intervention (PCI), who presented to the emergency department (ED) complaining of worsening shortness of breath for 3 days, orthopnea, paroxysmal nocturnal dyspnea (PND), associated with epigastric pain made worse with eating.

The patient's brain (or B-type) natriuretic peptide (BNP) was elevated. The electrocardiogram (ECG) showed normal sinus rhythm and chest x-ray (CXR) was clear. The patient was admitted to telemetry service for rule out acute coronary syndrome (ACS) and evaluation of heart failure and abdominal pain. The patient was treated with intravenous (IV) Lasix for diuresis. Acute coronary syndrome (ACS) was ruled out. There was no acute abdominal pathology detected on imaging. At issue is the medical necessity of the inpatient stay.

Inpatient level of care was not medically necessary given the patient remained hemodynamically stable, there was no evidence of acute coronary syndrome (ACS), or hypoxia and symptoms resolved with intravenous (IV) diuresis. A lower level of care would have been medically appropriate and safe supported by peer reviewed medical literature and expert consensus guidelines on acute heart failure management (1-3).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is upheld.

The patient has a Class I occlusion with a 4-millimeter (mm) overbite and 4-millimeter (mm) overjet. The patient has minor maxillary and mandibular crowding. The patient is in the mixed dentition with tooth 20 yet to erupt. The patient's treatment plan is for 24-30 months of orthodontics to correct his malocclusion. At issue is the medical necessity of the requested services.
There is no medical reason to correct his malocclusion with braces. While the patient has minor crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. However, this patient presents with none of those conditions. Aligning his teeth will not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. Moreover, if his teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons treatment is not medically necessary.