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

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

The patient has a Class I malocclusion and anterior crossbite of tooth number (#) 7. Tooth #27 is showing some recession and is completely blocking #26 out of the arch. Several primary teeth are impeding the eruption of the permanent teeth. She is treatment planned for 24-30 months of orthodontics with extraction of teeth numbers 5, 12, 21 and 28 to correct her malocclusion. At issue is the medical necessity of braces.

The patient has severe maxillary and mandibular crowding with #7 in crossbite. This tooth has a high risk for restorative problems in the future due to its traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #27 already has slight recession, and further movement of #27 is likely due to its position relative to #26 and will lead to the need for future periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, the requested orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major Depressive Disorder
Treament: Pharmacy/Prescription Drugs (Spravato)
The health plan denied the request for Spravato. 
The health plan's determination is overturned.

The patient is an adult female diagnosed with recurrent and severe major depressive disorder and a history of treatment refractory depression that has included treatment failure with multiple antidepressant medication trials. The patient does not have psychiatric co-morbidity but is treated for co-morbid general medical conditions that include type II diabetes mellitus, hypertension and allergies with associated medications.
The patient has a documented history of treatment failure with multiple antidepressants which were ineffective in producing a sustained clinical response or remission of symptoms. The antidepressant medications have included several selective serotonin reuptake inhibitors (SSRIs) s, two serotonin norepinephrine reuptake inhibitors (SNRIs) and Wellbutrin. Most recently, the patient is prescribed Pristiq together with Lexapro, Seroquel and Modafinil all of which are the patient's current medications.
The clinician recommended that the patient undergo a trial of Spravato (intranasal Esketamine) with the usual protocol with twice weekly dosing for four weeks (induction phase), then continuation treatment once weekly dosing for four weeks as clinically appropriate in combination with the currently prescribed psychotropic regimen as noted. The use of Spravato (intranasal Esketamine) is to address treatment refractory depression and augment the patient's current antidepressant regimen with the goal of achieving and maintaining mood stability in a patient with disabling treatment refractory depression.

The health plan's determination of medical necessity is overturned, in whole.

Yes, the requested health service/treatment of Spravato 84 mg solution for treatment refractory, major depressive disorder, is medically necessary for this patient.
The requested service of Spravato is in keeping with prevailing standards of medical practice for the condition under treatment in this case with an evidence-base treatment; and, the requested services/treatment being provided in this case are clinically appropriate, and are backed by credible scientific evidence known to benefit patients with the condition diagnosed in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Stay
The health plan denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a male who presented with worsening right lower quadrant pain of 1-day duration. He had an elevated white blood cell count (WBC) and an ultrasound (US) positive for acute appendicitis. He was given intravenous (IV) antibiotics and had an emergent laparoscopic appendectomy. He was admitted, went to the operating room (OR) and was discharged.

There is not a detailed operative report that I can find within the files, however, the brief operative report and progress notes indicate it was a straightforward procedure without complications. He went home soon after the OR.

At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No, this case could have been treated at an alternative level of care.

A study in 2016 found that adult patients with acute, non-perforated appendicitis can be discharged safely on the day of surgery without higher rates of postoperative complication or readmission rates compared with those hospitalized after surgery. In addition, same-day discharge in this patient group is cost-effective.

Additionally, in 2019, a study found same day discharge after laparoscopic appendectomy in pediatric patients was not associated with an increased risk of 30-day hospital admission or complication rate. Protocols to expedite perioperative care, including standardization of intraoperative care, may facilitate same-day hospital discharge, resulting in a decrease in health care costs.
Appeal type: Medical necessity
Decision: Upheld

Ear/Nose/Throat
Surgical Services (All)

Diagnosis: Nasal Obstruction
Treatment: Rhinoplasty
The insurer denied the Rhinoplasty. The health plan's determination is upheld. 

The patient is a female with a nasal obstruction. There is no medical therapy documented. An exam revealed a deviated septum, inferior turbinate hypertrophy and nasal valve collapse. The patient underwent a closed rhinoplasty without any complications noted.

The medical necessity of the rhinoplasty is under review.

The Rhinoplasty is not medically necessary for this patient.

Septorhinoplasty is a well-accepted procedure by otolaryngologists to improve functional nasal breathing complaints in patients who have failed medical management. (Clinical Indicators AAO-HNS [American Academy of Otolaryngology-Head and Neck Surgery])

The patient had a nasal obstruction. There was no documentation of failed medical therapy. Medical therapy is the first line therapy for the treatment of nasal obstruction. Surgical therapy is usually considered only after medical therapy has failed. Nasal steroids, nasal anti-histamines, oral anti-histamines, and nasal saline are all reasonable medical options that are considered standard of care. There was no documentation of a failure of these first-line options. Therefore, the requested procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Flank Pain.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay. The determination is overturned in part.

The patient presented to the hospital with complaints of flank pain. Past medical history significant for sarcoidosis, lower urinary tract symptoms (LUTS), nephrolithiasis and hypertension. On presentation, he endorsed undergoing a right ureteroscopy 2 days prior to admission. During the procedure, a mid ureteral stricture was encountered and a ureteral stent was placed. There were no associated symptoms. On presentation, he was afebrile and hemodynamically stable. Lab results were grossly normal. Creatinine was 12.0 and the white blood cell count (WBC) was 17. A computed tomography (CT) scan demonstrated a migrated right ureteral stent with the distal coil at the ureterovesical junction (UVJ). A small pelvic fluid collection consistent with extravasation was noted. Extravasated urine was also seen in the right retroperitoneal cavity. He was admitted to the inpatient service and managed with intravenous antibiotics, a Foley catheter and intravenous (IV) fluids. The cultures were negative.  At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary in part. A majority of patients who present with renal colic can be discharged within 48 hours of the presentation. This patient did not present with hemodynamic instability, severe renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control.
However, the patient was noted to be febrile.  His temperature was reported to be 102.2 degrees Fahrenheit on the third day.  His white blood cell count (WBC) count was lower than at presentation.  As such, continued monitoring for another 24 hours would have been appropriate.  The patient could have been discharged earlier in the stay. He could have been treated at a lower level of care for the first 2 days and then inpatient for the next 2 days.  Discharge was appropriate when the patient was afebrile for 24 hours. He was continued on antibiotics and he had another low-grade temperature (101.4 degrees).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient admission. 
The denial is upheld. 

The patient is a female who presented to the hospital for scheduled cardiac catheterization for recurrent chest pain and an abnormal myocardial perfusion imaging study. Her medical history was remarkable for diabetes, hyperlipidemia, hypertension and coronary artery disease with two prior percutaneous coronary interventions. Coronary angiography revealed a 90% stenosis of the mid left circumflex coronary artery that was treated with balloon angioplasty. The procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. She was discharged the following day. The subject under review is the medical necessity for the inpatient admission. 

The health plan's determination is upheld in whole. 

An inpatient admission was not medically necessary. 

This patient presented for elective cardiac catheterization. She was hemodynamically stable upon presentation, without acute electrocardiographic changes. While some period of monitoring immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. In fact, in the report by Shroff et al., a literature review of randomized clinical trials, observational studies, meta-analyses, guidelines, and consensus statements showed that same day discharge after percutaneous coronary intervention (PCI), as compared to overnight hospitalization, was not associated with an increase in adverse events (bleeding, repeat coronary procedures, death, or rehospitalization). The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied continued rehab treatment. 
The denial is upheld in whole.

The patient is a male admitted to acute inpatient rehabilitation following an extended hospital stay related to pneumonia which required a stay in the intensive care unit with intubation, sedation and pressor support. Hospital course complicated by acute kidney injury and COVID-19.
The subject under review is the medical necessity for the continued rehab treatment.

The health plan's determination is upheld in whole.

No, the requested health service of Continued Rehab Treatment was not medically necessary for this patient.
The physician noted that the patient had severe pain in lower extremities and developed gangrene/necrosis of his toes. Also noted, delay in discharge "because of patient had persistent high glucose, it caused a delay in discharge since it was medically unstable and needed daily monitoring from physician."
Despite this report the included documentation does not support that the patient was unstable and required daily monitoring. Inpatient progress notes did state that diabetes medication was adjusted. Review of lab work also showed that the patient was medically stable. For example, white blood cell (WBC) count was 5.8 and hemoglobin had improved from 7.5 to 8.1. Creatinine also improved from 3.7 to 1.6. Physical exam findings remained stable and there was not documentation of uncontrolled pain.
From a therapy standpoint the patient was doing very well. The patient was noted as supervision for transfers and upper/lower body dressing. The patient completed car transfer with supervision.  The patient ambulated 502 feet without assistive device variable "CSV/SupA." Patient also ambulated 7" steps 12x with supervision. The patient was modified independent with all transfers.
At time of discharge the patient was supervision for ambulation and stairs. Independent for eating and grooming and modified independent for upper and lower body dressing. Despite continued progress the patient was medically stable, and his therapy needs could have been met at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Possible May-Thurner syndrome
Treatment: Open Revascularization with Stent, Placement, Open Revascularization with Stent Placement Additional Vessel, Transluminal Balloon Angioplasty Open/Percutaneous with Imaging First Vein, Transluminal Balloon Angioplasty Open/Percutaneous with Imaging Additional Vein, Intravascular Ultrasound of Non-Coronary Vessel, Intravascular 
Ultrasound of Non-Coronary Additional Vessel

The insurer denied the Open Revascularization with Stent, Placement, Open Revascularization with Stent Placement Additional Vessel, Transluminal Balloon Angioplasty Open/Percutaneous with Imaging First Vein, Transluminal Balloon Angioplasty Open/Percutaneous with Imaging Additional Vein, Intravascular Ultrasound of Non-Coronary Vessel, Intravascular Ultrasound of Non-Coronary Additional Vessel.

The denial is overturned. 

The patient was advised to undergo left iliac venogram and intravascular ultrasound with possible angioplasty and stenting for May-Thurner syndrome.

Yes, the proposed treatment is medically necessary.

This patient presents with chronic bilateral leg swelling, left greater than right. The patient has symptoms of pain, fatigue, and tightness. Physical exam shows bilateral leg swelling, worse on the left. The left leg findings are suggestive of severe lymphedema. The provider was concerned about the possibility of May-Thurner syndrome and therefore ordered an MRV (magnetic resonance venogram).

Duplex showed no evidence of superficial thrombosis (SVT), deep venous thrombosis (DVT), or reflux. The magnetic resonance venogram showed that the left iliac vein was mildly compressed to a minimum size of 0.8 cm, compared to a baseline size of 1.3 cm (measured below the crossing point of the common iliac artery). 

The patient has history and findings suggestive of May-Thurner syndrome because he has chronic asymmetric leg swelling worse on the left. His condition cannot be explained by DVT, or reflux in the leg veins [1-3]. Lymphedema may be a contributing factor but is usually not asymmetric between the two legs.

The magnetic resonance venogram shows moderate compression (0.8/1.3 = 62%) of the left common iliac vein. This finding is not definitive for May-Thurner syndrome but is consistent with the diagnosis. In this situation, a definitive evaluation with contrast venogram and intravascular ultrasound is medically necessary to rule-in or rule-out the diagnosis [4-5]. If the diagnosis is confirmed, it is appropriate to proceed at the same setting with angioplasty and/or stenting of the iliocaval segment [1,3,5].
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endometriosis
Treatment: Lupron Depot 3.75 MG (milligrams)
The insurer denied the Lupron Depot 3.75 MG (milligrams).
The denial is overturned. 

The patient is a female. She has history of severe endometriosis status post multiple surgical procedures. Per her physician, she has failed trial of IUD (intrauterine device) and oral contraceptives. She has a normal DEXA (dual-energy x-ray absorption) scan indicating no evidence of osteoporosis.  

The health plan contends that the therapy is not medically necessary based on New York Medicaid plan criteria and only allows coverage if symptoms return and the patient has not received more than 12 months of treatment. The practitioner contends that the patient has failed all other medical treatments, has undergone multiple surgical procedures, and does respond to Lupron for relief of her symptoms.

Yes, the treatment with Lupron is medically necessary.

Lupron is an effective treatment for endometriosis. After an initial six-month period of treatment, re-treatment is appropriate if bone density is normal and it is preferred that norethindrone acetate 5 mg (milligrams) per day is combined with the Lupron therapy. Because this patient has failed other medical treatment as well as surgical procedures, treatment alternatives are limited.  

Lupron has been reported to be safe and effective for the treatment of endometriosis for up to 10 years when add-back therapy is utilized and appropriate monitoring is done for bone density.  

Therefore, given the absence of other alternatives, Lupron is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems (skeletal Class II malocclusion, maxillary spacing and diastemas, and excessive overjet and overbite).
Treatment:  D8080 braces and D8670 monthly visit x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.  The denial is upheld. 

This patient is a female child, who was evaluated for orthodontic treatment.  The orthodontist recommended comprehensive orthodontics, due to skeletal Class II malocclusion, maxillary spacing and diastemas, and excessive overjet and overbite.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying conditions of deep impinging overbite with severe soft tissue damage and overjet greater than 9 millimeters with incompetent lips or reverse overjet greater that 3.5 millimeters with reported masticatory/speech difficulties, to support orthodontic necessity.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. 

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 Handicapping Labiolingual Deviation Index.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of deep, impinging overbite with severe soft tissue damage and overjet greater than 9 millimeters with incompetent lips or reverse overjet greater than 3.5 millimeters with reported masticatory/speech difficulties.  This reviewer finds that these automatically qualifying conditions are not met and do not support comprehensive orthodontic care.  In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.  This reviewer concurs with the Handicapping Labio-Lingual Deviation (HLD) index of the insurer, attaining 14 points (5 points overjet, 6 points overbite, 3 points labiolingual spread).

The coverage for D8080 braces and D8670 monthly visits x 12 is not considered medically necessary for this patient.

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

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit x 12 is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Problems-Broken/Cracked Tooth.
Treatment:  Dental/Orthodontic Treatment-Crown.

The health plan denied the white glass with high gold content crown for tooth #3 as not medically necessary.  The reviewer has overturned in whole the health plan determination.

The patient saw her dental provider.  Two undated and unlabeled intra-oral photographs are attached.  No medical or dental history is included.  No narrative of medical necessity is included.  Images were provided from the provider upon request.  The treatment plan in question is for medical necessity for a crown on Tooth #3.

The requested health service/treatment of White Glass with High Gold Content Crown for Tooth 3 is medically necessary for this patient.  Crowns, as opposed to fillings (which are more conservative), cover the entire exposed portion of the tooth above the gum line.  They are used when the tooth is destroyed or compromised beyond the ability of a filling to restore form and function to the tooth.  The patient requires a crown because of the fracture and/or decay of the tooth.  A filling is not strong enough to properly restore form and function to the tooth.  Upon viewing the images submitted from the provider, the crown is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite
Treatment: Braces and orthodontal visits
The insurer denied the Braces and orthodontal visits.
The denial is overturned.

The patient is a male. The request is for orthodontic benefits and follow-up visits.

Yes, the Braces and orthodontal visits are medically necessary.

The patient has an anterior crossbite (tooth #7) with gingival attachment loss. This is an "automatic qualifier" according to the handicapping index scale. The patient also has an anterior open bite where his upper and lower front teeth do not touch. This will ultimately cause problems where there is improper meshing of all his teeth during the chewing cycle. Since his front teeth do not touch, this will cause his back teeth to grind together too much and cause trauma and/or fracturing. This case, with follow up visits, has medical necessity to orthodontically correct.