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

Diagnosis: Status asthmaticus
 
Treatment: Inpatient admission

The insurer denied the inpatient admission. The denial was reversed. 

The patient is a male child with a history of moderate persistent asthma who is followed by a pediatric pulmonologist and receives daily treatment with Symbicort and montelukast. The child had been sick for 6 days with a cough and congestion. There had been a fever of 102.9 4 days prior to the admission. The child was being treated with albuterol for the coughing. He was taken to the pediatrician where he was noted to be wheezing and was treated with 3 inhalation treatments in the office and then discharged on prednisone and to continue albuterol in the home. When the child began complaining of intermittent sharp chest pain the mother decided to take him to the emergency department (ED) for additional treatment. In the ED, the child was noted to have inspiratory and expiratory wheezing with a prolonged expiratory phase noted. He was treated with albuterol and DuoNeb twice. He was also given additional prednisone and intravenous (IV) magnesium. A chest x-ray was performed which was significant for hyperinflation. When the wheezing did not improve with treatments the decision was made to admit him to the hospital with a diagnosis of status asthmaticus. The plan was to continue treatment with steroids and albuterol every 3 hours.

The patient was treated appropriately in the ED. The decision to admit him to the hospital with a diagnosis of status asthmaticus for ongoing treatment was consistent with the standard of care for a child who failed outpatient management.

According to Scarfone, patients who were moderately to severely ill on arrival and who have little improvement after initial therapy with beta agonists and systemic glucocorticoids require hospitalization. This includes patients who continue to have significant wheezing and retracting, poor aeration, or altered mental status, such as drowsiness or agitation.

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: Glioma
Issue under review: Tafinlar

Determination:
The Tafinlar is medically necessary.

Ganglioglioma is the most common epilepsy-associated neoplasm that accounts for approximately 2% of all primary brain tumors. A subset of gangliogliomas is known to harbor the activating p.V600E mutation in the BRAF oncogene. There are no FDA-approved therapies for this type of rare tumor. Dabrafenib is a drug for the treatment of cancers associated with a mutated version of the gene BRAF. Dabrafenib acts as an inhibitor of the associated enzyme B-Raf, which plays a role in the regulation of cell growth. 

One study evaluated dabrafenib in a phase I/II trial that included 32 children with relapsed or refractory low-grade gliomas. The objective response rate was 38%, including one complete response and 11 partial responses. An additional 14 patients had stable disease. The drug was found to be safe in this population of children with brain tumors. 

Based on the above data, the use of dabrafenib is medically necessary for this patient and would meet the criteria for medical necessity:

The treatment is in accordance with generally accepted standards of medical practice. The treatment is clinically appropriate, in terms of type, frequency, extent, site and duration, and is considered effective for the patient's illness, injury or disease. The treatment is not primarily for the convenience of the patient, physician, or other health care provider. The treatment is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient's illness, injury or disease.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with history of abdominal seroma, who presented to the emergency room (ER) with epigastric pain. The patient had recent abdominoplasty.
The patient was admitted for recurrent seroma. Initial vitals showed temperature of 36.8, heart rate (HR) 97, blood pressure (BP) 140/77, respiratory rate (RR) 16, and oxygen saturation 100% on room air. Labs were significant for anemia, with a hemoglobin (Hgb) of 10.8. Chest x-ray showed clear lungs. CT of the abdomen showed 10.1 x 9.0 x 1.6 centimeter (cm) supraumbilical midline anterior abdominal wall subcutaneous collection, consistent with seroma. She underwent computed tomography (CT) guided drainage of seroma, with 75 cubic centimeter (cc) of serosanguineous fluid drained and a catheter sutured in placed. The patient was discharged.
The health plan's determination is upheld.

This patient's hospitalization was not medically necessary at an inpatient level of care. The patient presented with a post-operative seroma after abdominoplasty, the most common complication after this kind of surgery. "Seroma formation after combined abdominoplasty-suction lipectomy procedures is usually a self-limiting condition."
Management of the seroma generally includes: "If the seroma formation persists beyond a few weeks, take a culture to make sure there is no infection. If these conservative measures do not produce good results, then proceed with diagnostic measures including CT scans, sonography, or injection of radiopaque material to outline the size of the cavity. Eventually, surgical intervention may be necessary."
This patient had no evidence of infection. She was successfully treated with CT guided drainage. There were no complications. She did not require inpatient management of pain, as she did not require a continuous IV pain medication. She did not have a large amount of blood loss from her procedure.
The patient doesn't meet acute inpatient criteria using 2019 InterQual Level of Care Criteria under the General Surgical subset.
She did not have a designated inpatient surgery, and she did not have high risk for thromboembolism.
The patient's treatment could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical and cervicothoracic radiculopathy
 
Treatment: Chiropractic treatment

The insurer denied continued chiropractic treatment after 1 month of treatment. The denial was upheld.

The patient is a female with neck pain and radiculopathy. She initially presented for chiropractic treatment of the neck and mid-back pain and left arm intermittent tingling at the beginning of this year. Her diagnoses included cervical and cervicothoracic region radiculopathy. She received chiropractic treatment for several months, including manipulation, ultrasound and traction. After 1 month of treatment the patient's reported pain levels did not demonstrate further clinically significant improvement. The treatment and progress had become stagnant and did not produce any further improvements.

For cervical radiculopathy, the Official Disability Guidelines (ODG) recommend up to 18 visits if objective improvement is shown. Since progress had not been reported after month #1 of treatment, further treatment was not medically necessary. Progress reports show minimal improvements past the first month of treatment. The treatment rendered appeared redundant and repetitive without gains in subjective and objective findings. The records do not provide functional improvements past the first month of treatment. 

There is little clinical evidence to support the use of many physical medicine modalities for mechanical neck pain, and these treatments are often employed based on anecdotal evidence or case reports alone. In general, it would not be advisable to use these modalities beyond 2-3 weeks if signs of objective progress towards functional restoration are not demonstrated. (Gross, 2000) (Aker, 1996) (Philadelphia, 2001)."                                                         

Based on the above, the medical necessity on specific dates for the CPT codes: 97035: Application of a modality to 1 or more areas; Ultrasound, each 15 minutes; 98940: Chiropractic Manipulative treatment (CMT); Spinal 1-2 regions; 97012: Application of a modality to 1 or more areas; traction, mechanical; 99212-25: Office or other outpatient visit for the evaluation and management of an established patient, billed at the end of treatment, is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

The patient is a single female with a diagnosis of major depressive disorder, recurrent, severe, without psychosis (MDDR), and generalized anxiety disorder (GAD) with panic disorder (PD). Records document that for about two or more weeks prior to admission the patient was decompensating with worsening depressive symptoms. She experienced suicidal ideation with a plan to hang herself. Her depressive symptoms worsened to the point of functional impairment: she was not able to work, often calling in sick. Her symptoms included increased crying, anxiety, panic with shortness of breath, helplessness, hopelessness, decreased concentration and insomnia. She lost 20 lbs. She has a positive family history for substance use disorder. She was being cared for by an outpatient provider for six years and was taking her medications but had not experienced improvement despite a long list of medications tried, including Prozac, Abilify, Latuda, Paxil, Wellbutrin, Lexapro, Celexa, Effexor, Zoloft, and Cymbalta which were all found to be ineffective. She has a long history of substance use, and at the time of this admission, was on Suboxone for opiate use disorder (OUD). In the past she suffered from alcohol use disorder and cannabis use disorder. She is more vulnerable because of a history of two rapes. In the past she required two prior psychiatric admissions for her depressive disorder. Her inpatient hospital treatment included medication , supportive therapy, and an urgent assessment for electroconvulsive therapy (ECT) which was deemed of probable help and scheduled to be received on an outpatient basis. Her inpatient medications included Suboxone, Lexapro, trazodone, and Wellbutrin.

The health plan's determination is overturned. 

Yes, the requested health treatment of inpatient psychiatric hospital admission was medically necessary for this patient based on the information and reasoning above. This admission reflects good clinical judgment and is in accord with current standards of best treatment, and with the medical literature.
This patient was rapidly decompensating in her depressive and anxiety symptoms with substantial functional impairment and little social support. She has a chronic and severe illness. She had a specific suicide plan shortly before admission. She required two past hospitalizations. She is in recovery from opiate use disorder and is on Suboxone; vulnerable to return to use of opiates, alcohol, or cannabis to improve her mood and her pain. This is especially true in view of her lack of effective response to multiple medication trials. Of special import for understanding the severity of her MDDR is her 20 lb. weight loss and vegetative symptoms noted by the ECT consultant. The consultant also noted possible mixed bipolar features, often difficult to diagnose and treat. Asberg in her studies of MDD has found that substantial weight loss is a sign of serious depressive illnesses. This hospitalization was brief and strategic and served its purpose. Trying to treat this patient on an outpatient basis had a significant possibility of morbidity or mortality for outcome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back and/or neck pain
Treatment: Magnetic resonance image (MRI) of the lower back with and without contrast

The requested MRI of the lower back with and without contrast is not medically necessary.

The patient presented with acute radicular pain, without significant neurological findings on examination to warrant acute neuro-imaging. Specifically, there is no weakness, no bowel or bladder dysfunction and no "red flag" historical diagnoses, signs or symptoms to warrant imaging. 

The standard of care in this clinical context would be six to eight weeks of conservative management followed by re-evaluation.
Appeal type: Medical necessity
Decision: Upheld


The patient is a morbidly obese woman with a history of hypertension, hyperlipidemia and cigarette smoking. She presented to the emergency department and was admitted the same day complaining of chest pain and dyspnea. She described the pain as burning; it radiated to her neck, jaw, back and arm. It was worsened with exertion and relieved with nitroglycerin. Outpatient workup two weeks prior had been performed and included myocardial perfusion imaging. This showed an inferior wall defect that was possibly artifact but could have represented ischemia. In the emergency department her blood pressure was 133/65 mmHg with a heart rate of 74 beats/minute. Room air oxygen saturation was 100%. Her cardiovascular exam was unremarkable. Her electrocardiogram showed sinus rhythm with nonspecific T wave abnormality. There were no acute ischemic changes. Her serum troponin level was normal. A cardiac catheterization revealed a high-grade stenosis of the right coronary artery that was treated with a stent. 

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld.

This woman, with multiple cardiac risk factors, presented with chest pain suggestive of angina. Prior myocardial perfusion imaging suggested the possibility of inferior ischemia. Accordingly, monitoring until acute coronary syndrome could be ruled out and cardiac catheterization performed was a reasonable approach. However, the patient was hemodynamically stable, with normal cardiac biomarkers. She did not require intensive monitoring or titration of intravenous cardioactive medications. The safety of observation level care in this situation has been well demonstrated and is supported by the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

This patient underwent cardiac catheterization and implantation of a right coronary artery stent. The procedure was uncomplicated. While some period of observation immediately following percutaneous coronary intervention (PCI) is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. 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 did not have a myocardial infarction nor did she have hemodynamic instability, dynamic electrocardiographic changes or procedural complications.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Issue under review: Braces

Determination:
The braces are medically necessary.

The patient has a deep overbite with trauma to the palatal tissues (palatal impingement).This is an "automatic qualifying" condition on the handicapping scale. The patient's upper front teeth are also protruding in an extreme fashion, and over time will be subject to excessive trauma, which can cause fracturing of these teeth. Orthodontic treatment is needed to correct these problems. These two reasons lead to a decision that this case is medically necessary for the oral health of this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep Impinging Overbite with Severe Soft Tissue Damage

Treatment: D8080-Comprehensive Orthodontic Treatment

The insurer denied the D8080-Comprehensive Orthodontic 
Treatment. The denial was reversed. 

This is a young male patient who presented for an evaluation for orthodontic treatment. The orthodontist recommended comprehensive orthodontics due to skeletal Class I malocclusion, Class II canines, excessive overjet and deep impinging overbite. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 
Upon review of the submitted documentation, 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. 

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.  This is confirmed by several studies. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care.

Based on the above, the medical necessity for the D8080-Comprehensive orthodontic treatment of adolescent dentition is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned


Treatment: Panniculectomy

The insurer denied the panniculectomy. The denial was reversed.

This patient is morbidly obese and has an edematous hanging panniculus with infections, lymphedema and an inability to ambulate. He has a diagnosis of panniculus morbidus. According to Felmerer et al, "A subgroup of grossly obese patients may develop a large hanging abdominal apron, panniculus morbidus, which can contain an element of lymphoedema. This hinders normal activities and prevents adequate hygiene." According to Koulaxouzidis, "Panniculus morbidus is characterized by an edematous, painful hanging abdominal mass, due to laxity and redundancy of the abdominal skin in morbid obesity, particularly after massive weight loss. Panniculectomy, by wedge resection, is a salvage procedure with high satisfaction rates though associated with high complication rates." Friedrich et al describes panniculus morbidus as follows: "A subset of obese people develop a pannus hanging to the floor. This panniculus morbidus prevents weight loss, as the patient cannot exercise. It prevents hygiene, leading to a profound odor and ultimately results in intertrigo, cellulitis, and/or abdominal ulceration. The only two options are to live/die with it or resect it. Some of these people are otherwise ready for a weight loss program. For this group, resection of the panniculus morbidus may be indicated." 

This patient has panniculus morbidus with a lymphedematous pannus and will benefit from resection of his pannus.

The panniculectomy is medically necessary. Based on the above, the medical necessity for the panniculectomy; 15830 Excision, excessive skin and subcutaneous tissues (Includes lipectomy); abdomen, infraumbilical panniculectomy is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department because of a facial droop. On the day of admission, the patient woke up in her usual state of health. She went to a Methadone clinic and one of the workers there noticed that she had a left facial droop. At that time, the patient had no other symptoms, specifically headache, nausea, vomiting, numbness or weakness in the extremities, gait instability, confusion, speech difficulties. The patient was admitted to the hospital with a diagnosis of facial droop. The differential diagnosis included transient ischemic attack (TIA) versus Bell's Palsy. The admitting physician indicated in the assessment and plan section of the history and physical exam note that the facial droop had resolved at the time of the exam.
Since the patient remained in stable clinical condition, she was discharged home. The health plan's determination is upheld.
The patient presented to the hospital with a single symptom of having a facial droop, which was a nonspecific sign and did not necessarily represent a stroke or TIA. The National Institute of Health Stroke Scale (NIHSS) score was calculated at 0.
When the patient was seen by the admitting physician, the facial droop completely resolved. Her symptoms, physical exam, and results of the laboratory studies and diagnostic tests were not indicative of a serious medical problem requiring admission at the acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a past medical history significant for chronic obstructive pulmonary disease (COPD), asthma, hypertension, diabetes mellitus, and tobacco use disorder who presented to the emergency department with complaints of shortness of breath and cough. The review of systems obtained by the admitting attending was positive for fever, mild runny nose, cough without sputum, shortness of breath. The rest of the review of systems was negative.

In the emergency department, patient's temperature was 99.1F, heart rate 85 beats per minute (bpm), respiratory rate 22, blood pressure 117/84, oxygen saturation 99% on room air.

At the time the patient was seen by admitting attending, her lungs were clear to auscultation bilaterally without wheezing, rales, rhonchi. There was no evidence of retractions. The rest of the physical exam was unremarkable.

Liver function tests were within normal limits. A chest x-ray was performed and demonstrated no abnormalities. The patient was admitted to the hospital with a diagnosis of COPD exacerbation.

The health plan denied the inpatient admission as not medically necessary. The health plan's determination is upheld. 

The patient had mild COPD/asthma exacerbation, which responded to treatment provided in the emergency department and also in the hospital within the first few hours of the hospitalization.

During the hospital stay, there was no evidence the patient had signs of acute respiratory failure, hemodynamic instability, pneumonia, or any other medical condition that would necessitate admission at the acute inpatient level of care. Her respiratory symptoms improved quickly, and she was discharged home.

While observation to ensure a response to treatment and clinical stability was reasonable, the severity of the patient's condition did not justify admission at the acute inpatient level of care.