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

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Reviewer Findings:

The patient is an adult male who presented to the emergency department (ED) for syncope. He was admitted for syncope. The patient has experienced four episodes. The physical exam was with no abnormalities. The patient has undergone two work ups for syncope in the past with no cause identified. He underwent neurology and cardiology consult. The computed tomography (CT) of the head showed no abnormality. The patient left against medical advice. 

"Syncope is an abrupt and transient loss of consciousness caused by cerebral hypoperfusion. It accounts for 1% (percent) to 1.5% of emergency department visits, resulting in high hospital admission rates and significant medical costs. Syncope is classified as neurally mediated, cardiac, and orthostatic hypotension. Neurally mediated syncope is the most common type and has a benign course, whereas cardiac syncope is associated with increased morbidity and mortality. Patients with presyncope have similar prognoses to those with syncope and should undergo a similar evaluation. A standardized approach to syncope evaluation reduces hospital admissions and medical costs and increases diagnostic accuracy. The initial assessment for all patients presenting with syncope includes a detailed history, physical examination, and electrocardiography. The initial evaluation may diagnose up to 50% of patients and allows immediate short-term risk stratification. Laboratory testing and neuroimaging have a low diagnostic yield and should be ordered only if clinically indicated. Several comparable clinical decision rules can be used to assess the short-term risk of death and the need for hospital admission. Low-risk patients with a single episode of syncope can often be reassured with no further investigation. High-risk patients with cardiovascular or structural heart disease, history concerning for arrhythmia, abnormal electrocardiographic findings, or severe comorbidities should be admitted to the hospital for further evaluation. In cases of unexplained syncope, provocative testing and prolonged electrocardiographic monitoring strategies can be diagnostic. The treatment of neurally mediated and orthostatic hypotension syncope is largely supportive, although severe cases may require pharmacotherapy. Cardiac syncope may require cardiac device placement or ablation." (Runser, L. A., Gauer, R. L., & Houser, A. 2017).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Nerve treatment in spine. 
The insurer denied Nerve treatment in spine. 
The determination is upheld. 

This is a female patient diagnosed with low back pain. The records provided note that the patient was recommended to undergo the Intracept procedure, which was denied.
Letters of appeal submitted state that the provider disagrees that this treatment is experimental and investigational. It was noted that the patient has a history of low back pain that began several years ago. She has tried multiple treatments including activity modification, back surgery, heat, ice, home exercise, medial branch blocks, medications, physical therapy and trigger point injections. Medications have included diazepam, non-steroidal anti-inflammatory drugs (NSAIDs), and Tizanidine. The pain is impacting activity levels and ranges from 4-6/10. Nothing has provided sustained relief. The provider states she had magnetic resonance imaging (MRI) demonstrating Modic type II changes at disc spaces lumbar (L) 4 - L5 and L5 - sacral (S) 1 and the provider believes this is the source of the patient's chronic back pain. At issue is the medical necessity of nerve treatment in the spine. 
The requested health service/treatment of nerve treatment in the spine is not medically necessary for this patient. The patient is noted to have a history of chronic back pain that has not responded to conventional conservative treatment. The provider feels that the patient's pain is coming from Modic changes and was recommended to undergo the Intracept System (intra-osseous basivertebral nerve [BVN] ablation). There is a lack of high quality studies evaluating the long-term risks and benefits of this procedure. Although some results have been promising, additional studies are needed to establish the safety and efficacy. This treatment is not currently considered standard of care in the general medical community. There is insufficient evidence in large, long-term studies found in the peer-reviewed medical literature demonstrating this treatment to be either safe or effective or resulting in superior benefits over that of other standard means of treatment. Additional studies are needed to evaluate long-term risks and benefits of this procedure. The requested procedure is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lung nodule
Treatment: Computed tomography
The insurer denied Computed Tomography, Thorax, Diagnostic 
The health plan's determination is upheld. 

This is the case of a female patient who had computed tomography (CT) chest that showed pulmonary embolism and 1 centimeter (cm) right middle lobe lung nodule. The patient was started on heparin then transitioned to Xarelto. The patient had a follow up CT chest that was within normal limits. This is under review.

The requested Computed Tomography, Thorax, Diagnostic was not medically necessary for this patient. Based on the Fleishner Society, this patient would be considered a low-risk patient. 
This patient had CT chest that showed a 1 cm lung nodule. The patient is considered low risk as she is a non-smoker. The requested CT chest was therefore not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Allergies

Treatment: Dulera (mometasone furoate-formoterol fumarate)

The insurer denied coverage for Dulera (mometasone furoate-formoterol fumarate).

The denial is upheld. 

The patient is an adult male who has been treated for allergies, whose first progress note reviewed is noted to have peanut allergies but not milk allergies. Medications at that visit listed Proair hydrofluoroalkane (HFA), Xopenex HFA, and Qvar. Allergy immunology notes that the patient has asthma, peanut allergies and a history of nasal polyps. The patient claims milk allergy and was prescribed Dulera instead of Advair/Symbicort which the patient prefers not to take due to alleged milk exposure with these 2 medications. The assessment on that visit note did not list milk allergy. An appeal letter for Dulera states that Dulera is the only prophylactic inhaler for the patient. No test results were included in the progress note. There is no indication that the patient has tried Symbicort. An addendum was also reviewed which is a form that relates to Dulera authorization if alternatives have failed. 

There is inadequate evidence that this patient has milk allergy(generally) or has tried the formulary alternative. Milk allergy is generally a childhood disorder and is generally relevant only to dried powder inhalers rather than standard metered dose inhalers not employing dried powder. 

There is inadequate evidence to accurately assess that the patient would have an adverse reaction to the formulary drug. 

From the documentation provided there is no history of the formulary drug having been ever used and thus the formulary drug has not been shown to be ineffective. 

There is no evidence that the requested drug would be more effective than the formulary drug.

The carrier's denial of a request for a Formulary Exception for Dulera (mometasone furoate-formoterol fumarate) is upheld.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman who presented with complaint of abdominal pain of 1-day duration. Past medical history includes prior sleeve gastrectomy. She was admitted to the hospital. Vital signs were normal at the time of presentation. She was tender in the right upper quadrant. The white blood cell (WBC) count was slightly elevated at 11.9. Liver enzymes were elevated with a normal bilirubin. A computed tomography (CT) scan showed a gallbladder with stones and a thickened wall. The surgical history and physical (H&P) states that the patient had cholecystitis for which laparoscopic cholecystectomy was planned.

An inpatient level of care was not medically necessary in this case. This patient presented to the hospital with complaint of abdominal pain. Imaging and surgical consultation was performed and established the diagnosis of cholelithiasis/cholecystitis. At the time of presentation and at the time of surgical assessment, the patient had normal vital signs and was without fever. Lab data identified elevated serum transaminases. Surgery (cholecystectomy) was performed. The perioperative and early post-surgical recovery were uncomplicated and the patient had normal vital signs and tolerated a diet on the first post-surgical day. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered with a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: Orthodontic care: D8080 braces and D8670 monthly visits x 12.
The insurer denied coverage for: Orthodontic care: D8080 braces and D8670 monthly visits x 12.
The denial is: Upheld .
 
Based on the submitted documentation it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, among other findings and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 20 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 11 points by internal reviewers. Melanie Salgado is appealing the decision on behalf of the patient.

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess severity of the malocclusion and therefore medical/dental necessity for orthodontic care a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 20 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 20 points on the HLD index (6 overjet, 8 overbite, 6 labiolingual spread) which is below 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 the peer reviewed articles cited 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 is 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 D8080 braces and D8670 monthly visits x 12 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman with a history of anxiety, schizophrenia, vertigo, Migraine, traumatic brain injury and possible seizures. She presented to the emergency room with a large number of complaints including abdominal pain, shortness of breath, and lip tingling. The vital signs were unremarkable. She was alert and appeared anxious. The mental status exam was notable for rapid tangential speech. Labs were remarkable for a potassium of 2.8. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The patient was admitted for further treatment and evaluation.

The inpatient hospital admission was not medically necessary for this patient.
Upon presentation, there was no objective evidence on physical exam, labs, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, persistent hypoxia, or severe metabolic disarray. The hypokalemia responded quickly to straightforward treatment. The services provided - intravenous fluids, potassium supplements - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental malocclusion

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 overturned


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 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 29 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.

D8080 braces and D8670 monthly visit x 12 are considered medically necessary for this patient. 

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 visit x 12 services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is a case of a male admitted for diagnosis of alcohol abuse and transaminitis. The patient presented to the emergency room with bloody vomitus and weakness for one week prior to admission. Vital signs demonstrated temperature 99.8 F, pulse 104, respiratory rate 18, blood pressure 155/75 and O2 (oxygen) saturation 98%. Physical exam showed no acute distress or altered mental status. Clinical Institute Withdrawal Assessment (CIWA) score was five and he was treated with Librium. Chest x-ray showed no pulmonary disease. Right upper quadrant ultrasound showed hepatic steatosis with some gallbladder mural reaction and pericholecystic fluid with no cholelithiasis, biliary obstruction or lesion. He was treated with multivitamins, thiamine and folic acid. He was recommended alcohol cessation and to follow up with gastrointestinal (GI) on outpatient basis for colon cancer screening.

The inpatient hospital admission was not medically necessary.
The patient in this case was admitted for alcohol withdrawal but would be classified as mild. He did not have evidence of severe alcohol withdrawal such as withdrawal seizures, alcoholic hallucinations or delirium tremens. He had a CIWA score of 5 which is usually considered mild to even minimal severity. He had elevated liver enzymes but there was no lesion, biliary obstruction or cholelithiasis. He was simply recommended to follow up with gastroenterology on an outpatient basis.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care. Therefore, the medical necessity of admission has not been established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, osteoarthritis and dementia

Treatment: Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week, 12 hours per day, 7 days per week

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week, 12 hours per day, 7 days per week.

The denial is reversed.

 
This is an elderly female with chronic medical problems including hypertension, osteoarthritis and dementia.  She lives alone in a private residence.  The  patient's Consumer Directed Personal Assistance Services (CDPAS) aide is her son.  Her family is supportive and involved in her care; including informal care.  The insurer approved CDPAS 56 hours/week (8 hours/day, 7 days/week).  The request is for CDPAS 84 hours/week (12 hours/day, 7 days/week); leading to an external review. 

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as moderately impaired.  She is reportedly total dependent for completing much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing,  Extensive assistance is reportedly needed for personal hygiene, dressing, bed mobility, locomotion, toilet transfer/use and ambulation.  Limited assistance is reportedly needed for eating.  She is frequently incontinent of bladder and bowel.  The patient's activities of daily living (ADL) status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days.  There have been no reported falls over the prior 90 days.  

The patient's condition and functional deficits are at a level or unpredictable as to require the requested increase in CDPAS to 84 hours/week.  The treatment notes were reviewed.   

Based on the clinical records, the patient's health and safety are more appropriately provided and maintained at home by the requested  CDPAS 84 hours/week. 

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 Consumer Directed Personal Assistance Services (CDPAS) 84 hours per week, 12 hours per day, 7 days per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Kidney Stones.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is an adult with no significant past medical history, who presented to the emergency department (ED) for worsening left flank and abdominal pain. A computed tomography (CT) scan revealed a 7 millimeter (mm) left mid-ureteral stone and a 2 mm stone in the kidney. The patient was on Cipro for a urinary tract infection (UTI). The patient had a normal temperature, with pulse of 112 in the ED. The white blood cell (WBC) count was 14,600 and the urinalysis was positive (+) for red blood cells (RBCs), WBCs and bacteria. The patient was given a bolus of intravenous (IV) normal saline and IV Toradol/Rocephin/morphine. The patient was admitted and taken to the operating room (OR) by Urology later that day for a cystoscopy with insertion stent. Colic was controlled with Flomax/Oxybutynin/Pyridium. By the next day, the patient was tolerating a diet, pain was controlled, vital signs were stable, and the patient was discharged home with outpatient follow up. 

Per Milliman Care Guidelines (MCG) Health (26th) Renal Colic + Kidney Stones, the patient meets the criteria for admission to inpatient care. This pertains to the fact that the patient had a UTI (the patient was on Cipro, and urinalysis in the ED had WBCs and large amounts of bacteria) and ureteral obstruction by stone. 

The full hospital admission 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 a full hospital admission is substantiated.