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

Diagnosis: Seizure.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.
 

The patient arrived via Emergency Medical Services (EMS) after a witnessed seizure and a motor vehicle collision. The passenger noted the patient started having what looked to be a seizure, foaming from the mouth, and hit a fire hydrant and then a pole. She reportedly had generalized tonic-clonic shaking movements for approximately 2 minutes after the accident. When EMS arrived at the scene, she was agitated and postictal. Since then, her mental status has improved, and she does not recall what happened. Computed tomography angiography (CTA) scan and computed tomography (CT) are unremarkable. The patient was admitted to the pediatric floor. Magnetic Resonance Imaging (MRI) is unremarkable. Electroencephalogram (EEG) is unremarkable. She was discharged and told not to drive until cleared by a neurologist. She is to follow up with her provider in 2-3 days. 

Milliman Care Guidelines (MCG) recommends observation care for the first seizure in a patient who has not previously been diagnosed with a seizure disorder. Inpatient admission is recommended if the patient has a recurrent seizure without a history of a seizure disorder. 

Evidence-based literature notes that almost 10% (percent) of people will experience at least one seizure over a lifetime. Although common, first seizures are serious events and warrant careful assessment and management. First seizures may be provoked by acute or remote symptomatic factors including life-threatening metabolic derangements, drug toxicity, or structural brain lesions. A detailed history and an eyewitness account are important in diagnosing a seizure. Antiseizure medication is generally not prescribed after a single seizure, except for patients with a high risk of recurrence. 

The level of care should have been observed.

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

Diagnosis: Cholelithiasis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is the case of a patient who presented to the emergency department (ED) with symptomatic cholelithiasis. As per the triage note the patient woke up with abdominal pain and vomited once. The patient was afebrile with stable vital signs.

As per the ED provider note, the patient complained of right upper quadrant (RUQ) pain and did vomit. The exam revealed RUQ pain, tender to palpation without guarding or rebound. The patient's white blood cell (WBC) count was 9.37. Aspartate aminotransferase (AST) was 34 and alanine aminotransferase (ALT) was 22.  Re-evaluation by the ED provider indicted the patient stated their pain was improved after the morphine. The plan was sonogram and computed tomography (CT) of the abdomen. The plan was also to give the patient a dose of Zosyn and likely operating room (OR) later that day. The principal diagnosis was cholelithiasis.

As per the history and physical, the patient woke up around 1 in the morning with pain. The patient had no history of this pain in the past. The patient vomited at home. The pain persisted so the patient came to the ED. Labs were reviewed. Total bilirubin was normal. Sonogram showed cholelithiasis.  CT of the abdomen showed cholelithiasis with gall bladder wall thickening.

A progress note from the following day indicated the patient was preoperative for a laparoscopic (lap) cholecystectomy.  The patient underwent a lap cholecystectomy on the second day of admission. The procedure was uneventful. The patient tolerated the procedure well and progressed appropriately. The patient was tolerating diet, voiding independently and was discharged the following day.

Based upon the records it is not felt that the acute inpatient admission was justified as this patient should have been managed as noted by the insurer in an ambulatory/observation setting as they had an uneventful lap cholecystectomy. It appears that the patient did not have acute cholecystitis but rather biliary colic. The patient did not have a significantly elevated WBC and did not have a fever. The patient did not have abnormal liver function tests. The patient presented with pain and was taken for the lap cholecystectomy and was discharged afterwards.  But this should have been done in an ambulatory/observation 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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient, an adult female presented to the Emergency Department (ED) with complains of nausea, dizziness and vomiting. The patient had a history of dental work 2 days prior to the ED admission. She began feeling nauseous with upset stomach a few hours later. The nausea worsened and she was found lying on the floor due to dizziness. The patient has a history of hypertension and in the ED the Blood Pressure (BP) was 205/97. On admission, BP was 175/91, she was alert and oriented X3, neurological exam  showed difficulty with finger to nose and unsteady gait. Normal speech. The patient had a head computed tomography (CT) and CT angiography which ruled out aneurysm and other emergencies such as cerebrovascular disease that would support central etiology of the vertigo. Neurology felt most likely vestibular neuritis and recommended rehabilitation and meclizine. 

Imaging did not show any acute intracerebral pathology. This patient required a period of observation. However, in absence of any acute findings an acute inpatient admission was not required. 

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

Diagnosis: Dental malocclusion

Treatment: D8080 braces and D8670 monthly visits (x12)

The insurer denied coverage for D8080 braces and D8670 monthly visits (x12)

The denial is overturned
 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images) dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified mandibular protrusion and open bite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 28 total points. 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 only 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 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 Labio - Lingual 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 completes the second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 
Regarding the validity of the Handicapping Labio - Lingual 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. 

Reverse denial as the clinical circumstance  as presented does meet and substantiate the medical/dental necessity of orthodontics  care as it meets the accepted standards.

D8080 braces and D8670 monthly visits (x12) is considered medically necessary for this patient.

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

The medical necessity for D8080 braces and D8670 monthly visits (x12) is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: autism
Treatment: Additional 35 Hours of Direct Applied Behavior Analysis (ABA) Therapy and 7 Hours of Supervision 
The insurer denied Additional 35 Hours of Direct Applied Behavior Analysis (ABA) Therapy and 7 Hours of Supervision 
The health plan's determination is overturned in part. 

The patient is a male who has been diagnosed with autism spectrum disorder. According to the documentation provided, he has been receiving applied behavioral analysis (ABA) therapy for over 9 years. At present he receives 12 hours per week of direct ABA therapy and attends an ABA-based school. His ABA therapist is requesting an additional 35 hours of direct ABA and 7 hours of supervision to address an increase in aggressive behavior and elopement.

Five (5) hours of direct ABA per week and for the next 6 months, with an additional 4 hours per authorization period for supervision are medically necessary.
Documentation by the ABA therapist, of the frequency and severity of elopement and aggressive behaviors is incomplete. The mother's description of the patient's behaviors is concerning, however, particularly as injury to other family members is reported. The Mother reports that his neurologist has recommended a minimum of 15 hours' direct ABA per week. The 15 hours of direct ABA per week and for the next 6 months, with an additional 4 hours per authorization period for supervision are indicated. Documentation of behavior frequency and severity by the ABA therapist must be improved and completed. Re-evaluation of the response to therapy intervention should be performed at the end of 6 months.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: vomiting
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

This is the case of a young male who presented to the emergency department (ED) due to vomiting. Symptoms have been present for 2 days with 3 episodes of vomiting the day of presentation. There was cough and runny nose for 1 week, no fevers or diarrhea. There was decreased urine output.

The inpatient hospital admission was medically necessary for this patient. This patient presented with acute gastroenteritis and moderate dehydration. Vomiting continued despite ED interventions and lab work showed low bicarbonate of 13. She also had low blood sugars. She required additional monitoring and treatment for resolution of laboratory abnormalities and clinical improvement to be able to maintain oral hydration at home. An inpatient admission was indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abscess
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a young male who presented to the emergency department (ED) with three-day history of neck pain. He initially noted a pimple on the back of his neck that increased significantly in size overnight. The pain was radiating to his left ear and left shoulder. He attempted to "pop" the pimple without success. He subsequently noted that an apparent abscess had formed, was hard, and warm to touch. He had no fevers or other constitutional symptoms. 

The inpatient hospital stay was not medically necessary. This male teen presented with a papular lesion that progressed to an abscess with surrounding cellulitis. He was treated with parenteral antibiotics and admitted for ongoing treatment. Surgical drainage was performed with culture positive for MRSA. While it was reasonable to monitor him in the hospital for initiation of therapy pending surgical drainage, he was overall hemodynamically stable with no significant constitutional symptoms, no significant laboratory abnormalities, and pain manageable without opiate pain medications. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: abdominal pain and vomiting

Treatment: air ambulance services (procedure codes A0431 and A0436)

The insurer denied coverage for air ambulance services (procedure codes A0431 and A0436)

The denial is upheld 


This is an adult male who had surgery at a cancer hospital. 2 weeks later he was taken to the emergency room (ER) at a different hospital where it was determined he had bowel obstruction. The patient has a history of colon cancer and is post right colectomy one week prior to admission. The patient developed acute severe abdominal pain with vomiting and computerized tomography (CT) revealed bowel obstruction/ischemia. The patient was hemodynamically stable. The ER doctor felt the patient should go back to surgical hospital. The patient was transferred via helicopter and care was given there. No hospital records were provided.

The plan clinical criteria consider this transport to be medically necessary when the care needed cannot be given where the patient is now, or at another closer hospital (within a 30-minute ground ambulance ride). The request does not show this. 

The patient was hemodynamically stable.  He was transported via air ambulance for exploratory laparotomy because a surgeon was reported as not available at the presenting hospital. The timeline showed that the time from notification to arrival at the surgical hospital took 1 hour and 58 minutes. The insurer noted that ground ambulance would have taken 1 hour and 36 minutes. The time between identification of the need for transportation until arrival at the intended destination for ground ambulance is not more than 30 minutes than air transport. It is also noted that there were other tertiary centers with colorectal surgery capabilities closer. Therefore, this does not meet approval criteria for air ambulance. 

The use of air and water ambulance services is considered medically necessary when all the following criteria are met: The ambulance must have the necessary equipment and supplies to address the needs of the individual; and the individual's condition must be such that any form of transportation other than by ambulance would be medically contraindicated; and the individual's condition is such that the time needed to transport by land poses a threat to the individual's survival or seriously endangers the individual's health; or the individual's location is such that accessibility is only feasible by air or water transportation; and there is a medical condition that is life threatening or first responders deem to be life threatening, including, but not limited to, the following: bowel obstruction. Air transportation may be appropriate if the time between identification of the need for transportation until arrival at the intended destination for ground ambulance would be 30 minutes or longer than air transport.

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 air ambulance services (procedure codes A0431 and A0436) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral atherosclerosis
Treatment: Duplex scan of extracranial arteries; complete 
bilateral study
The insurer denied: Duplex scan of extracranial arteries; complete bilateral study
The denial is upheld.

The patient is an adult female with a history of cerebral atherosclerosis who had a carotid ultrasound. The test was denied coverage as there was no documentation that the 
patient has signs or symptoms of carotid stenosis.

The requested health service was not medically necessary.

There is no documentation provided to support that the carotid ultrasound was necessary. There is no documentation of previous stroke, transient ischemic attack, or known carotid artery stenosis to warrant the requested test (2). The use of carotid ultrasound as a screening tool for persons with cerebral atherosclerosis has not been demonstrated to change management or improve outcomes for patients. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suspected herpetic uveitis
Treatment: polymerase chain reaction (PCR) testing
The insurer denied polymerase chain reaction (PCR) testing
The determination is overturned.

This is a male patient with suspected herpetic uveitis for whom coverage of polymerase chain reaction (PCR) testing is the subject of review. Coverage was previously denied. Upon appeal, the provider reports literature as evidence supporting the use of PCR for deoxyribonucleic acid (DNA) / ribonucleic acid (RNA) detection of viruses from ocular fluids and its quantification. The patient's inflammation is considered vision threatening. The provider states that anterior chamber paracentesis was performed to perform PCR testing for herpetic viruses which is considered standard of care.

According to the American Academy of Ophthalmology, herpes simplex virus (HSV) associated uveitis is a common cause of unilateral hypertensive anterior uveitis. Because of the high prevalence of positive HSV antibodies in most populations, serology is only helpful in the diagnosis in that a negative HSV antibody titer will rule out the possibility that iritis is due to HSV. According to Sugita et al, polymerase chain reaction for HSV DNA from an anterior chamber tap may be helpful in diagnosis with a high sensitivity (91.3 percent [%]) and specificity (98.8). According to Wensing et al, the clinical characteristics of HSV anterior uveitis can mimic other viral and non-infectious anterior uveitis entities especially at onset. Aqueous humor analysis for PCR and Goldmann Whitman Coefficient (GWC) can be useful in case of suspected viral uveitis. Choi et al agrees that aqueous humor PCR can be a valuable diagnostic tool for confirming the infectious etiology in patients clinically diagnosed with uveitis and finds that PCR had good predictive and diagnostic value for anterior uveitis and panuveitis. de-la-Torre et al concluded that early diagnosis and treatment of virus induced uveitis (VIAU) in immunocompromised patients can be achieved with high suspicion, recognizing clinical features, and obtaining specimens for molecular diagnostic testing in order to avoid usually severe ocular morbidity. Terada et al have also used polymerase chain reaction (PCR) to distinguish between anterior uveitis (AU) caused by herpes simplex virus (HSV), varicella-zoster virus (VZV), and cytomegalovirus (CMV).
Therefore, as this patient was suspected of herpes uveitis where the requested PCR testing is identified as both effective in establishing a diagnosis and where utility of such testing has been established, and as such testing is identified as among standard of care by the American Academy of Ophthalmology, the requested is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male with a painful left hip. He was admitted to the hospital for an elective left total hip replacement. He was reported to have problems with pain after his surgery and required medications. He also had problems with mobility. He was discharged.

The requested health service is not medically necessary.

The medical records demonstrate a non-complicated post-surgical course. There were no underlying comorbidities. The vital signs were satisfactory. The pain level reported was tolerable. The wound was satisfactory. There was no bleeding to require additional care. There was no need for subspecialty consultation nor imaging. There were no delays to ambulation. The patient was reported to be able to walk 150 feet after his operation (same day). Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: pulmonary embolism
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

This is a case of a male admitted for diagnosis of pulmonary embolism. The patient presented with chest pain that started the day of admission and had resolved at the time of admission. Vital signs demonstrated temperature 36.3C, pulse 72, blood pressure 131/76, respiratory rate 18 and O2 (oxygen) saturation 97%. Physical exam showed no acute distress or altered mental status. Sodium was 139 with creatinine 1.3. Troponin was negative. White blood cell count was 5.4 with hemoglobin 13.3. A computed tomography (CT) of the head showed no acute pathology. An electrocardiogram (EKG) showed no acute ischemic changes. CT angiogram showed no dissection or hematoma. The patient was noted to have a recent negative stress test. A computed tomography angiography (CTA) showed right lower lobe pulmonary embolism.

The inpatient hospital admission was medically necessary.
The patient was admitted for symptoms of chest pain and was found to have a pulmonary embolism. He required further evaluation for deep vein thrombosis and echocardiogram for evaluation of heart strain. He remained hemodynamically stable but given the potentially life-threatening nature of pulmonary embolism he would usually require admission to ensure stability and further evaluation for cause. He also required anticoagulation and would need to be admitted ensuring he tolerated anticoagulation without complication.