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

Diagnosis: Incorrect position of teeth
Treatment: Braces and monthly visit x4
The braces and monthly visits are medically necessary. 

The patient's upper canines (especially the upper right) are not in their correct positions. Upper canines are very crucial teeth that help guide the jaw and other teeth during the chewing cycle. Without the canines in their correct positions guiding the lower jaw and teeth, the teeth will bang into each other in a random fashion which will cause trauma to them over time. Chipping, cracking and fracturing is to be expected to multiple teeth over time. The canines need to be positioned properly with orthodontic treatment to correct this problem. The monthly visits are needed to monitor the treatment and adjust brackets and wires as needed. Both the orthodontic treatment and the monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse
Issue under review:  Continued inpatient admission

Determination:
The Continued inpatient admission was medically necessary.

The requested benefit of the Continued inpatient admission and associated services could not have been safely or effectively provided at a lower level of care in this case scenario.  The patient in this case was using large quantities of opioids and Cannabis on a daily continuous basis, as well as intermittent use of Xanax that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring.  Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient struggled with mild withdrawal symptoms in the context of associated clinical features that included limited insight, impaired judgment and poor control of impulses, and psychosocial stressors with limited sober supports.

Thus, the adult inpatient stay and detoxification treatment of this patient's substance use disorders did necessitate the continued structure of an inpatient level setting with 24-hour monitoring and withdrawal management.  The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors that included the social environment and occupational and primary support domains and functional impairments do reflect the seriousness of the substance use disorder.  The patient did require a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure or general medical complications if detoxification and withdrawal management were to have been attempted at a lower level of care.  Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the appropriate application of NY OASAS LOCADTR 3.0 Criteria-referenced below.

The requested benefit of Continued inpatient admission is clinically appropriate, medically necessary and warranted; therefore, it should be covered in this case scenario.  The continued inpatient level detoxification treatment through discharge could not have been effectively provided with lower level services.  Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Patient Placement Criteria and NY State OASAS LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bipolar Disorder
Treatment: Cariprazine (Vraylar) 

Summary:
The patient is a female with a history of mental illness and substance abuse who was treated with Vraylar for Bipolar Disorder.

The patient has been diagnosed with Bipolar Disorder.  TheRe is a history of depressive and hypomanic episodes.  It is unclear that she has ever seen a psychiatrist.  She received treatment from a family medicine resident physician who is under the supervision of other family medicine physicians.  It is noted that the patient has been treating her symptoms with Celexa, which was ineffective.  She took other previous medications, including Prozac, Wellbutrin, Zoloft, Tegretol, Abilify, and Seroquel.  It is noted, "these medications did not provide sufficient control of symptoms," and, "were not well tolerated."

The treatment with Cariprazine (Vraylar) is not medically necessary.
The patient is taking a medication for a diagnosis of Bipolar Disorder.  Vraylar has not been shown to be superior to other alternative medications for bipolar disorder, including but not limited to other first-line treatments, such as Ziprasidone.  Treatment with a mood-stabilizer may be medically necessary, but not more so with Vraylar as opposed to any of the other standard-of-care medications available.  Furthermore, there is no formal evaluation that has been done by a psychiatrist that suggests that this specific medication is any better or more necessary for this specific patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plantar Fasciitis
 
Treatment: Durable Medical Equipment -Custom Shoe Inserts (L3000 x2)

The insurer denied the Durable Medical Equipment -Custom Shoe Inserts (L3000 x2). The denial was upheld.     

This is a young male patient who presented to his doctor for an evaluation for orthotics. The patient was diagnosed with Planter Fasciitis. The patients had a history of an ankle sprain three weeks prior to presentation. On exam it was noted that the patient had tenderness over the anterolateral aspect of the ankle. The patient was guarded with plantar flexion, inversion bilaterally and restricted subtalar joint range of motion. The patient had mild increased soft tissue density and joint space narrowing to the posterior ankle. It was advised that if the patient did not have improvement, he would require physical therapy. The patient had a history of custom orthotic use due to the patient's foot structure, size and athletic activities. It was reported that the patient experienced a better result with the custom verses the over the counter.  

The medical literature indicates that custom foot orthotics are indicated for patients with arch, heel or other foot pain, as well as a foot condition as indicated by diplegic cerebral palsy; juvenile idiopathic arthritis; pes cavus; plantar fasciitis with adjustment of activities failing to improve symptoms and anti-inflammatory medications failing to improve symptoms; prefabricated orthotics failing to improve symptoms; stretching of the calf muscles and plantar surfaces failing to improve symptoms and symptoms present for three months or more. The documentation indicated that the patient did have arch pain and plantar fasciitis. The patient recently sprained his ankle. The patient had been utilizing the custom foot orthotics.  However, the documentation did not indicate that adjustment of activities failed to improve symptoms and that anti-inflammatories failed to improve symptoms. The patient previously had custom orthotics. It is unclear why the patient would require a new pair.

Based on the above, the medical necessity for Durable Medical Equipment-Custom Shoe Inserts (L3000 x2) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  UTI, Pyelonephritis
 
Treatment:  Inpatient Admission

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

This is a young female patient who presented to the emergency department with a fever secondary to a urinary tract infection (UTI) that was diagnosed 2 days earlier from a previous emergency department visit.  She had been discharged on oral antibiotics.  A renal ultrasound was performed which revealed fullness in the right renal pelvis. She was placed on intravenous (IV) ceftriaxone for treatment.  She tested positive for rhino/entero virus, which suggested that there was a possible viral infection present in conjunction with the current bacterial infection. 

The patient's respiratory viral panel was noted to be positive for rhino/entero virus.  The issue at hand is how much that was contributing to her current fever versus her being colonized, and it was an incidental finding.  There are two different studies that must be considered.  The first is that many children with rhino/entero virus carry positive nasal swabs for weeks after illness (1), suggesting that this pathogen may not play a role in her current fever event.  In contrast to that hypothesis is the recent/new history of cough and upper respiratory infection (URI) symptoms that were present.  These, along with her white blood cell (WBC) count of 6.4 and her differential showing elevated monocytes suggest that, in fact, there was an acute viral component that was active. However, the presence of a viral URI does not negate the presence of a UTI/Pyelonephritis, as data from at least two different studies has demonstrated (2, 3).  Thus, it must be considered that the cefdinir (in the face of a proteus infection) was insufficient to treat the patient, and that IV ceftriaxone was needed, at least until the repeat cultures were back at 48 hours.

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Dysphoria, Hirsutism
 
Treatment: Facial Electrolysis Pre-Service

The insurer denied the Facial Electrolysis Pre-Service. The denial was reversed. 

This is a transgender patient, male to female, who presented to a clinic for her ongoing hormone replacement therapy. She has a history of major depressive disorder, recurrent, moderate, and attention-deficit hyperactivity disorder, predominantly inattentive type. It was noted that the patient was receiving electrolysis therapy for hair removal and was interested in pursuing bottom surgery. 

According to the World Professional Association for Transgender Health, the nationally accepted medical society guidelines regarding transgender care, electrolysis is an important and medically necessary component of transgender care.  Per the 7/15/16 policy statement: "It has come to our attention that some insurers are assuming that facial hair removal is not a medically necessary procedure due to a lack of parallel structure in language between our 2008 Medical Necessity Statement and our 2012 Standards of Care, Version 7.  In the former, we stated 'Medically necessary sex reassignment procedures also include ... facial hair removal, and certain facial plastic reconstruction as appropriate to the patient.' In the latter, we state that 'hair removal through electrolysis, laser treatment, or waxing ... can be considered to help alleviate gender dysphoria.' The problem appears to be that this later language is not specific to the medical necessity of such procedures, and therefore some analysts take this as an opportunity to reject claims for hair removal treatments.  To clarify, there has been no change in our position that electrolysis is medically necessary for those whose gender dysphoria can be alleviated using this treatment modality.  In fact, throughout Version 7 of the SOC, we state that treatment must be individualized.  It remains our position that electrolysis 'can be considered to help alleviate gender dysphoria,' and its medical necessity should be determined according to the judgment of the referring physician.  As with every medical problem, the objective of treatment for gender dysphoria is to alleviate the condition, and patients with the same condition do not always respond to-or thrive following-the application of identical treatments. The withholding of a particular treatment from any patient because it is thought to be unnecessary for other patients, especially when the treatment is known to be effective, does not justify a decision against the medical necessity of the treatment in every case."  

The carrier's denial of coverage for Current Procedural Terminology (CPT) code 17380 for facial electrolysis is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Dysphoria, Hirsutism.  
 
Treatment: Facial Electrolysis

The insurer denied the Facial Electrolysis. The denial was reversed.  

This is a transgender patient who presented to a clinic for continued hormone replacement therapy. It was reported that the patient was taking estrogen replacement with no ill effects. The patient had a past history of major depressive disorder, recurrent, moderate, and attention-deficit hyperactivity disorder, predominantly inattentive type. It was reported by the patient that she was continuing to receive electrolysis for hair removal and expressed an interest in pursuing bottom surgery.

According to the World Professional Association for Transgender Health, the nationally accepted medical society guidelines regarding transgender care, electrolysis is an important and medically necessary component of transgender care.  Per the 7/15/16 policy statement: "It has come to our attention that some insurers are assuming that facial hair removal is not a medically necessary procedure due to a lack of parallel structure in language between our 2008 Medical Necessity Statement and our 2012 Standards of Care, Version 7.  In the former, we stated 'Medically necessary sex reassignment procedures also include ... facial hair removal, and certain facial plastic reconstruction as appropriate to the patient.' In the latter, we state that 'hair removal through electrolysis, laser treatment, or waxing ... can be considered to help alleviate gender dysphoria.' The problem appears to be that this later language is not specific to the medical necessity of such procedures, and therefore some analysts take this as an opportunity to reject claims for hair removal treatments.  To clarify, there has been no change in our position that electrolysis is medically necessary for those whose gender dysphoria can be alleviated using this treatment modality.  In fact, throughout Version 7 of the SOC, we state that treatment must be individualized.  It remains our position that electrolysis 'can be considered to help alleviate gender dysphoria,' and its medical necessity should be determined according to the judgment of the referring physician.  As with every medical problem, the objective of treatment for gender dysphoria is to alleviate the condition, and patients with the same condition do not always respond to-or thrive following-the application of identical treatments. The withholding of a particular treatment from any patient because it is thought to be unnecessary for other patients, especially when the treatment is known to be effective, does not justify a decision against the medical necessity of the treatment in every case."  

The carrier's denial of coverage for Current Procedural Terminology (CPT) code 17380 for facial electrolysis on dates of service is reversed.  The medical necessity is substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Fever
Issue under review:  Inpatient admission

Determination:
The Inpatient admission was not medically necessary.
The patient had fever with cellulitis but remained hemodynamically stable.  There was no failure of outpatient treatment and no bacteremia, necrotizing fasciitis, or osteomyelitis.  Glycemic control is acceptable; the patient was not significantly immunocompromised.  There was no evidence of abscess, confusion, or acute kidney injury.  There were no decompensated medical comorbidities.  The fever resolved with conservative treatment.  
In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
 
Treatment: Inpatient Admission

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

This is a male patient who presented to the emergency department with complaints of non-radiating chest pain. He had a history of tobacco abuse, cocaine abuse, alcohol abuse, hypertension, hyperlipidemia, coronary artery disease, and myocardial infarction. On presentation, his physical exam and vital signs were reported to be normal. Cardiology was consulted. He had an electrocardiogram which showed normal sinus rhythm. A nuclear stress test showed a large infarction in the left anterior descending (LAD) artery with an ejection fraction was 31%. His Troponin results were negative. He was medically stabilized and discharged home.

The patient presented with chest pain, however the initial evaluation in the ER was unremarkable, including negative cardiac troponin and a non-diagnostic EKG. Inpatient admission was not medically necessary for this patient. In the absence of elevated cardiac biomarkers and a diagnostic electrocardiogram, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. Further evaluation was warranted, however inpatient admission criteria was not met.  

Although the patient had new onset symptoms, criteria were not met for any other additional extenuating circumstances. There were no other high-risk co-morbidities. 

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

Diagnosis: Vomiting, diarrhea, headache
Treatment: Inpatient admission

The inpatient admission for the management of this patient's condition was not appropriate and medically necessary. 

The patient was admitted with c/o abdominal pain, nausea, vomiting and diarrhea and black stools, but his stool Hemoccult were negative, and his Hb/HCT (hemoglobin/hematocrit) remained stable throughout the hospitalization, with no evidence of any GI bleed. His ethanol levels and lactate levels were markedly elevated on admission. He was given IV normal saline bolus 1 liter x 2, and then started on normal saline 150cc/hr. His abdominal CT revealed pan-colitis, but there was no evidence of toxic megacolon and bowel obstruction/perforation. He was empirically started on broad spectrum antibiotics for the treatment of colitis. He was also started on CIWA protocol for alcohol withdrawal. He also had hypokalemia and hypomagnesemia, which were corrected with IV K and Mg supplements. He was initially made NPO due to persistent vomiting, but then he was able to tolerate clear liquid diet. His diet was advanced to full liquid the next day and then advance to regular diet as tolerated. He was discharged home on the next day.  Given this clinical course during his hospitalization, the patient could have been safely managed at the lower level of care. Acute level of care was not appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female who presented to her dental provider's office for evaluation and treatment of tooth #19.  Provided for review are previous letters of appeal and denial, full mouth radiographic images, one page of American Dental Association (ADA) claim forms, health plan language documents, and clinical notes.
Previous denials have been on the basis that the tooth must have undergone root canal treatment or crown lengthening prior to the tooth being considered for a crown as medically necessary.  Further denials have been in the basis that there is untreated pulpal periapical pathology.  Clinical notes do not indicate that there is any failure of the current restoration as of 2015 or any decay or recurrent decay present around the existing restoration.  Radiographic documentation also does not show failure of the restoration in any way nor the presence of decay.
In question is the medical necessity of the planned treatment of crown predominantly base metal crown (2791) for tooth #19.

The health plan's determination is upheld.

No, the all metal crown for tooth 19 is not medically necessary for this patient.

As there is no decay nor failure of the restoration, there is no need for removal and replacement with a larger restoration, in this case a full coverage base metal crown.

There is no current indication nor evidence for removal of the amalgam on tooth #19 and replacement with a crown.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Costochondritis

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld

This is a female child who presented to the Emergency Room with complaints of mid- sternal chest pain. She described her pain as aching and crushing, and that it had worsened over the past week. She has a history of asthma. Cardiology consulted on the patient. She had a chest X-ray and electrocardiogram that were both normal. Serial Troponin level drawn and were within normal limits. Her vital signs remained stable. The patient was discharged home when her symptoms improved.

The following rationale is provided concluding that the denial should be upheld.
1) Chest pain in children although common is rarely of cardiac etiology and the reproducible nature of the pain on palpation and its worsening with deep breathing is clearly against an ischemic etiology.
2) The cardiac causes of chest pain which could be considered in this case of child are pericarditis and myopericarditis.  These diagnoses would be considered with an abnormal ECG.  There were no ST elevations, or low voltages to suggest these diagnoses. An echocardiogram was performed (normal), despite published Appropriate Use Criteria (ref below) indicated that an echocardiogram is rarely appropriate in this instance.  In addition the echocardiogram could have been done during an observational period.
3) Troponin levels in the pediatric age group are not needed in the face of a normal       ECG.  In addition the lab report states "Result. (Between 0.04 mg/mL to .29mg/mL) must be clinically correlated as conditions other than cardiac ischemia could yield the result".
The carrier's denial of coverage for inpatient hospital admission is upheld.