Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Orthopedic
Pain management

Diagnosis: back pain
treatment: Intraosseous Basivertebral Nerve Ablation
The insurer denied Intraosseous Basivertebral Nerve Ablation. The health plan's determination is upheld. 

This patient is a female who has a chief complaint of sacroiliac pain. She has a surgical history of lumbar laminectomy and gastric sleeve. This patient had trigger point injections in the back. The provider documented axial back pain of more than 18 months and prior conservative treatments including physical therapy (PT), home exercise and non-steroidal anti-inflammatory drugs (NSAIDs) with mild pain relief. Magnetic resonance imaging (MRI)showed a broad based right foraminal disc protrusion at L (lumbar)5-S (sacral)1, fact arthrosis at L4/5 and Modic type 1 changes at inferior endplate of L5.

Intraosseous basivertebral nerve ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The Intracept system was designed to treat low back pain from vertebral body by ablating Basivertebral nerves. This patient has a chief compliant of sacroiliac joint pain. MRI showed a broad based right foraminal disc protrusion at L5/S1 and fact arthrosis at L4/5. Truumees's study supported the efficacy of Intracept procedure. However, the patients with radiographic evidence of other pain etiologies including disc bulge and facet arthrosis were excluded.
Given this patient's medical history including a chief complaint of sacroiliac pain, MRI findings of L5/S1 disc protrusion with facet arthrosis, and the current clinical evidence, it is unlikely that Intracept is more beneficial than any standard treatment or treatments.
Appeal type: Medical necessity
Decision: Overturned

Digestive System/ Gastrointestinal/Pancreatitis
Inpatient Hospital/full hospital admission
The health plan has denied the requested treatment, full hospital admission, as not medically necessary. The health plan's determination is overturned.

The patient is a male with a medical history of depression, factor II disorder complicated by multiple thromboses including deep venous thrombosis and pulmonary embolism, cerebral sinus venous thrombosis, and alcohol abuse. He presented to the emergency department with a suicide attempt, diarrhea, and abdominal pain. There was a reported suicide attempt in the emergency department. His vital signs were unremarkable. The physical examination was notable for auditory hallucinations, depressed mood, blunted and tearful affect, delayed speech, impulsive judgment, and suicidal ideation with a plan. A computed tomography (CT) scan of the neck with angiogram showed no high-grade arterial stenosis, occlusion, or dissection. Laboratory studies showed an elevated white blood cell count of 17.0KUL, an elevated aspartate aminotransferase of 42, and an elevated lipase of 412. An Emergency Medicine consultation noted the patient's laboratory studies were concerning for pancreatitis possibly with necrosis, diarrhea secondary to alcohol use, and worsening by dehydration in the setting of decreased oral intake; the recommendation was intravenous (IV) placement for fluids, a computed tomography scan of the abdomen and pelvis with intravenous and oral contrast, intravenous fluids, admission to Medicine, Zofran as needed, and Imodium if stool testing was negative for pathogens. He was made nil per os.

At issue is the medical necessity of a full hospital admission.
I overturn, in whole, the health plan's determination.

The inpatient level of care is supported and was medically necessary due to the severity of the patient's conditions.

The patient presented with pain and an elevated lipase consistent with acute pancreatitis. This supports the inpatient level of care given the risk for complications such as pancreatic necrosis [1-6]. The patient's pain persisted. Additionally, he had a need for 1:1 sitter and inpatient psychiatric care given his recent suicidal ideation; he was not cleared for discharge home during this time [7,8]. For these reasons, the inpatient level of care is supported in this case.
Per the Milliman Care Guidelines for Major Depressive Disorder, Adult: Inpatient Care, the inpatient level of care is supported due to the patient's eminent risk for recurrence of suicide attempt, as there had been a recent suicide attempt, sufficient relief factors that precipitated need, and an anterior behavioral health disorder characterized by depressive symptoms and dysfunction in daily living.
Per the Milliman Care Guidelines for Pancreatitis, the inpatient level of care is supported due to acute pancreatitis with persistent pain.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a girl who was brought to the emergency department by emergency medical services after she was found in the shower unresponsive.
Her younger sister had heard a noise in the shower and walked into the bathroom to find the patient on the floor of the bathtub "wiggling". She called her mother who came in and took her out of the bathtub. She was unresponsive at that time but was no longer shaking. Her mother called 911 at that time. She was unconscious for approximately 7 minutes. She did not have any loss of incontinence at that time and she was alert in the ambulance. She had had no similar episodes in the past.

Inpatient Hospital Admission was medically necessary for this patient. She required inpatient care for monitoring after an initial afebrile seizure with additional treatments as needed, as well as video electroencephalogram (EEG) assessment. An EEG should be obtained as soon as possible after an initial afebrile seizure, because the incidence of epileptiform discharges is highest in the first 24 hours after a seizure.
This patient presented after a seizure with unresponsiveness. She required prompt evaluation in an inpatient setting for careful evaluation and to obtain specialist consultation and video EEG monitoring. The decision making at the time of admission for this patient was consistent with her young age, the presence of a seizure event with unconsciousness that lasted several minutes, and the need for prompt video EEG evaluation, specialist consultation, and close monitoring with additional treatments as needed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myelodysplastic syndrome. 
Treatment: Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 Minutes: 84 Hours per Week. 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 84 Hours per Week. 
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for myelodysplastic syndrome, normal pressure hydrocephalus, dementia, and delusional disorder. The patient and her care team requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 84 Hours per Week. 
The patient provided a letter of support on her own behalf for this appeal. The letter states that she is unable to transfer from the bed/toilet and that she requires assistance with walking. She requests additional assistance for completing her activities of daily living. 

The requested health service of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 84 Hours per Week is medically necessary for this patient.
The patient has dementia and normal pressure hydrocephalus. She is reliant on assistance from others for all activities of daily living (ADL) and Instrumental activities of daily living (IADL). She requires help with ambulation, transfers, and toileting. She is incontinent of urine and requires assistance with incontinence products. Her care needs are expected to be continuous and unscheduled throughout the day. She cannot be expected to coordinate all of her personal care tasks into an 8 hour period each day. Her recent falls while attempting personal care tasks without an aide are evidence of unmet personal care needs. The requested increase in personal care hours is medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Confusion
Treatment: CDPAS 24 hours a day, 7 days a week live-in totaling 91 hours
The insurer denied the CDPAS 24 hours a day, 7 days a week live-in totaling 91 hours.
The determination is overturned.

This is a female patient with a medical history notable for dementia, incontinence, and arthritis. The patient was approved for 24 hours per day, 7 days per week (live-in) consumer directed personal assistance services (CDPAS) (totaling 91 hours per week). The plan decided to reduce the CDPAS hours to 70 hours per week. The patient and her care team are appealing the reduction in hours.
The patient's physician provided a letter of support for this appeal. The letter states that the patient needs assistance with all activities of daily living, "which requires the patient to have 24-hour home care services." The letter reviews the patient's list of medical conditions.
The patient's case workers provided a letter of support for this appeal. The letter states that the patient cannot use the bathroom without assistance, but due to her dementia she attempts to do so anyway. She will then be found on the floor by her aide in the morning, and will require a change of clothes due to soiling from incontinence.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives alone in her apartment. She was alert and oriented to person only. She recognizes only a few family members. She is confused and unable to direct her own care. For her Instrumental activities of daily living (IADLs), she requires total dependence or maximal assistance for all. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires extensive assistance for all others. She is frequently incontinent of urine and occasionally incontinent of stool. A task tool associated with the assessment recommended 66 hours per week to address her personal care needs. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) 24 hours a day, 7 days a week live-in totaling 91 hours.

The requested health service of CDPAS 24 hours a day, 7 days a week live-in totaling 91 hours is medically necessary for this patient.
The patient has advanced dementia and incontinence. She is not able to ask for help or direct her own care. She requires hands-on assistance for all ADL's and IADL's. Her care needs are expected to be continuous throughout the day and extend into the night at times as well. Given the continuous and unscheduled nature of her needs, the patient requires around-the-clock care with a live-in personal care aide. The additional hours are not solely for the purposes of safety monitoring and supervision, but to assist with her unmet personal care needs. The documentation notes that her nighttime toileting needs are not being met, which places her at risk for adverse health outcomes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroparesis

Treatment: Interfacility transfer

The insurer denied coverage for interfacility transfer

The denial is upheld 

The patient had a history of Ehler-Danlos syndrome and gastroparesis. The patient was admitted to another hospital with intractable vomiting. The patient was treated with intravenous (IV) Erythromycin and a jejunostomy tube (J-tube) was recommended. The patient was transferred to this hospital and continued with medical therapy. An endoscopy was performed and botulinum toxin was injected into the pylorus. Afterwards, the patient's symptoms improved. The patient was transitioned to oral Azithromycin. 

Medical necessity was determined based on Milliman's Care Guidelines (MCG) MG-GAS for Gastroenterology. Gastroparesis is an indication for admission when there is severe dehydration, severe electrolyte abnormalities, acute renal failure, and vomiting that cannot be controlled and requires an inpatient level of care. This patient appears to have met these indications at the first hospital since the patient was requiring IV Erythromycin and had persistent symptoms. However, after transfer, the patient was continued on similar treatment until the endoscopy with botulinum toxin injection was done. This treatment resulted in a marked improvement in the patient's symptoms. Endoscopy with botulinum injection could have been done without an acute care admission and it resulted in improvement in the patient's symptoms. 

This patient did not respond well to IV Erythromycin and required the endoscopy with botulinum injection. This treatment could have been given at the first hospital during the initial admission. Availability of esophagogastroduodenoscopy (EGD) as well as multiple other gastroenterology (GI) procedures is noted on the first hospital's website. The hospital states that the transfer was done with the aim of continuity of medical care. However, the patient could have had the endoscopy at the first hospital and then referred for outpatient continuity of care. The health care plan acted reasonably and with sound medical judgment. The patient did not require an interfacility transfer. 

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 interfacility transfer is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

Patient has a history of asthma and hypertension. He presented to the emergency department (ED) with a history of a progressive increase in shortness of breath (SOB). The patient also complained of a mild cough and sputum production, denied fever or chest pain. The patient had seen his primary doctor earlier who had prescribed Albuterol. The patient did not improve so he came to the ED (emergency department).

Vital signs upon presentation were within normal limits, oxygen saturation was 94% (percent) on room air.  The patient was in no acute distress. Lung exam revealed bilateral wheezing. He was treated with intravenous (IV) Dexamethasone and given bronchodilators via nebulizer. He did feel better after treatment in ED (emergency department), but as he was still wheezing, he was admitted to hospital.

White Blood Cells 9.3, Hemoglobin 14.4, electrolytes within normal limits.  Chest x-ray showed no acute infiltrates, pleural effusion or pneumothorax. Electrocardiogram (EKG) showed no acute ST-T Changes. The patient was treated with oral prednisone, bronchodilators, long-acting beta-2 agonist / inhaled corticosteroids (LABA/ICS) and Doxycycline.
The patient was discharged home with close follow-up in the outpatient setting.

This patient did not need acute inpatient hospitalization for treatment of Bronchitis/Asthma exacerbation. The patient could have been placed in observation status while diagnostic testing and treatment could have been done. Observation could be for up to 48 hours if needed.
Patient had improved with treatment before that. He remained stable on oral (PO) meds, was tolerating food and fluids. Oxygen saturations were stable at rest and ambulation to 94% (percent) on room air.

This patient could have been in observation status for the time he was in the hospital. He responded well to treatment in ED (emergency department) and remained stable after admission. He could have been discharged on PO (on oral) meds after a period in observation.

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

Diagnosis: Malocclusion.

Treatment: Braces and monthly visits.

The insurer denied coverage for braces and monthly visits.

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 overjet, overbite, ectopic eruption (mandibular premolars) and anterior crowding among other findings. The orthodontist has completed the Handicapping Labiolingual 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 19 points on the HLD index by internal reviewers. Dr. Kuncio is appealing the decision on behalf of the patient.

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 the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is 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 Labiolingual 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. 

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 D8080 braces and D8670 monthly visits x 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastrointestinal Bleeding/ Bleeding of Intestines
Treatment: Inpatient emergency admission
The health plan denied: Inpatient emergency admission 
The determination is: Upheld

The patient is a male admitted for rectal bleeding. He is a resident of a Skilled Nursing Facility (SNF). He has a history of Stage 4 colon cancer. The patient had a luminal stent placed. There was perforation of the tumor through the stent, and he underwent a left partial colectomy. Post-operatively, he had pelvic and peri-splenic abscesses which were drained percutaneously. Computed tomography (CT) imaging showed good resolution of infections, but there was the presence of a 6 centimeter (cm) rectal mass likely representing a metastasis. This was felt to be the source of bleeding, and the patient was admitted for monitoring. The initial hemoglobin (Hgb) was 11.2. The patient underwent a flex sigmoidoscopy, and a friable mass was confirmed. He was maintained on intravenous (IV) antibiotics for treatment of the infections. An application for the patient to move back to the SNF was submitted. The patient was frustrated he could not return to his SNF. His Hgb was 10.9. The patient had minimal scant rectal bleeding with wiping and no fevers. The patient was discharged.

At issue is the medical necessity of the inpatient emergency admission.

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

The requested health service/treatment of inpatient emergency admission is not medically necessary for this patient. The patient was referred for admission for rectal bleeding presumably due to a large rectal metastasis that was seen on imaging prior to admission. The volume of blood was minimal, and the patient, despite all of his problems, including cirrhosis from primary sclerosing cholangitis (PSC) and his risk factor for colon cancer parenthetically, had a near normal Hgb. The mass was very distal, only a few cm above the anal canal. The patient could have had an outpatient flex sigmoidoscopy with or without sedation to confirm the diagnosis. This can be arranged in coordination with a nursing home or SNF facility so the patient returns after the procedure. He did not require an inpatient emergency admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck injury. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

This patient is a man who presented to undergo a scheduled surgical procedure to address injuries sustained in a motor vehicle accident. The patient underwent neuroplasty of the supraclavicular plexus in the neck, C (cervical) 4 nerve root in neck, neuroma excision C5, C6, neuroplasty infraclavicular plexus, median serve in the arm, musculocutaneous nerve in the arm, axillary nerve in the arm, radial nerve in the arm, internal neurolysis lateral cord, neuroplasty medial antebrachial cutaneous nerve in the arm, medial brachial cutaneous nerve in the arm, long thoracic nerve lateral chest wall, left sural nerve, nerve grafting C6 nerve root to musculocutaneous nerve with nerve autograft, C4 nerve root to axillary nerve with sural nerve autograft, repair pectoralis major tendon, pectoralis minor tendon, and nerve transfer cranial nerve XI to suprascapular nerve. 

The inpatient hospital stay was not medically necessary for this patient. This patient presented to the hospital to undergo scheduled surgery in an effort to treat a devastating right brachial plexus injury (no motor or sensation from right elbow distally). The motorcycle accident also resulted in traumatic brain injury, right leg injury requiring right below knee amputation, jaw injury, need for tracheostomy and feeding gastrostomy tube. These other injuries had previously been treated and were not the subject of this hospitalization. 
The operation was extensive and took 9.5 hours of surgical time. He remained consistently hemodynamically stable in the perioperative period and the surgical procedure had been completed without complication. Vital signs were consistently normal following surgery and pain management was converted to oral analgesic medications. Physical therapy was initiated on the first post-surgical day and was continued daily thereafter. The patient was clinically stable and an ultrasound obtained of the left upper extremity was negative for thrombosis. He was clinically stable for discharge from the hospital with continued care able to be provided in the outpatient setting.