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

Diagnosis: Nausea and vomiting (substance abuse).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

This is a woman with a history including alcohol abuse, seizures, and bipolar disorder who presented for evaluation of withdrawal.  ED records note tremors and vomiting.  There was no suicidal ideation (SI) / homicidal ideation (HI) or hallucinations.  Vital signs (VS) were as follows: 98.3, 96, 16, 153/106, and 100%.  Exam at admission was unremarkable.  Labs revealed the following: white blood cell (WBC) 8.63, hemoglobin/hematocrit (H/H) 11.4/35.6,and platelets (Plt) 176. Basic metabolic panel (BMP) was unremarkable.  Alcohol (EtOH) was negative.  Venous blood gas (VBG) was 7.46/42/51/30.  Electrocardiogram (EKG) was with normal sinus rhythm (NSR).  The patient was admitted for alcohol withdrawal.  Plan included Clinical Institute Withdrawal Assessment (CIWA) protocol.  The following day vital signs were stable (VSS).  The patient was feeling better.  She has mild tremors.  The patient's vomiting resolved and she was tolerating a liquid diet.  The patient was discharged.

No, the inpatient admission was not medically necessary.

This patient was admitted for alcohol withdrawal.  The patient did not have active comorbid conditions.  The patient was hemodynamically stable and afebrile.  She did not have tachycardia or arrhythmia.  At time of admission, there is no documentation of persistent vomiting, delirium, seizures, or gross tremor.  Labs were unremarkable.  The patient remained hemodynamically stable.  Her symptoms were resolving.  She was tolerating by mouth (PO).  The patient was clinically stable and did not have findings of severe alcohol withdrawal that required an acute inpatient level of care.  She had not failed management in a lesser level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's Disease, Parkinson's Disease
Treatment: Personal Care Services to 24 hours, 7 days per week (live-in)
The insurer denied coverage for Personal Care Services to 24 hours, 7 days per week (live-in).
The denial is overturned.
This is a female patient with an extensive medical history that include Alzheimer's disease, Parkinson's disease, lightheadedness, syncopal episodes, chronically low blood pressure, low back pain, chronic urinary tract infection (UTI) with substantial functional impairment. She lives with her husband who can offer limited assistance due to his own health problems. The patient's sons work and cannot provide routine care. The patient was approved for personal care services 23 hours per week. The patient requested (via designee) increase of PCS to 24 hours live-in; which was denied by the insurer but approved increase of PCS to 49 hours per week. 

The UAS functional assessment indicates patient is totally dependent on caregivers for most IADLs, except maximal assistance for medications and phone use. The patient needs extensive or limited assistance for ADLs. The patient has several medical conditions that contribute to her functional decline, but it appears that Parkinson's disease and dementia have had the most significant effect.

The request for 24 hour PCS is for live-in services. As per NYS regulations for personal care services, in order to qualify for 24 hour live-in aide, the patient's care needs must be sufficiently infrequent so that the aide can expect to have at least 5 uninterrupted hours of sleep within an 8 hour sleep period each day. If the patient's care needs are of such frequency that the aide cannot obtain this amount of sleep on a regular basis, then continuous services are indicated, i.e. split shift. The UAS indicates the patient gets up to use the bathroom once at night (per husband), but some notes in the functional log appear to indicate some nights when the patient was out of bed more frequently. The patient's behavior is not predictable due to dementia, and the timing of her ADL care needs at night vary due to her need to use the toilet or for other reasons to get out of bed. It is not clear whether a live-in aide will be able to have 5 uninterrupted hours of sleep most nights. The maximum amount of services that can be approved from this review is limited by the amount requested, i.e. live-in services.

Personal Care Services (PCS), 24 hours per day, 7 days per week (live-in) services are medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for an increase Personal Care Services to 24 hours, 7 days per week (live-in) is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System.
Treatment: Inpatient stay.
The insurer denied the inpatient stay as not medically necessary. The denial is overturned in whole.

This is the case of a toddler who presented to the emergency department with a chief complaint of fever for 2 days. Additional symptoms included cough and vomiting, plus one episode of diarrhea.
ED vitals included Temperature 105.2F, heart rate (HR) 183, respiratory rate (RR) 36, O2 sat 99% on room air. Examination noted an inconsolable child with labored breathing. Influenza testing was positive for Influenza A. Labs showed bicarb=20, otherwise normal.
The patient received intravenous fluids (IVF) and Zofran, the patient continued to have vomiting after medications and oral challenge. The patient was admitted to the inpatient ward with continued IVF, Tamiflu, and supportive care. The condition improved and the patient was discharged home the next day.
The requested inpatient admission is considered medically necessary for this patient.
This toddler presented to the ED with high fever, tachycardia, tachypnea, and vomiting and was diagnosed with influenza, received IVF and antiemetic medications in the ED and was unable to tolerate oral challenge, and continued to have vomiting. Thus, due to the failure of symptoms to improve with ED care, this child required inpatient admission for continued treatment.
Given this patient's vital sign abnormalities as well as clinical condition, there was the probability of clinical deterioration without continued monitoring and treatment.  According to published guidelines for influenza, this child is also at higher risk for adverse consequences due to  age and clinical condition and required inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

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 a fever for several days. It was reported that the patient's primary care physician (PMD) had prescribed amoxicillin for him the previous day for a sore throat.  Upon presentation he had fever 105F, and he remained febrile up to 103.5F before admission.  His oxygen saturations remained 98-99% though, and his tachycardia was concordant with his fever. He was admitted to the hospital for treatment for pneumonia; he received intravenous (IV) fluids and IV antibiotics. The patient was medically stable and discharged home.

He was admitted with a diagnosis of pneumonia but the medical decision making is non-persuasive, citing failure of outpatient treatment, whereas 1-2 days of antibiotic therapy is not enough to count as an adequate trial of oral antibiotic therapy.  The slightly elevated white blood cell (WBC) count of 16,000 (pediatric normal range is 5-15,000) may have factored into the decision, but leukocytosis only signifies an inflammatory response  and generally should not be used as a factor in deciding parenteral versus oral therapy. 

The diagnosis of pneumonia was made correctly, based upon finding of crackles at the left lower base and the radiographic finding of left lower lobe infiltrates.  However, he is described on examination as well-appearing, in no distress and well hydrated.  There was no suggestion of lobar pneumonia on the Chest X-ray report, which suggests he had viral pneumonia.  The appropriate course of action would be to start him on amoxicillin at 80-90 mg/kg/day for the small possibility of pneumococcal infection.  Intravenous (IV) ceftriaxone, IV fluids and hospital admission were not indicated based upon his condition.  Also, fever can be expected to continue for a few days even on therapy. 

The patient did not meet criteria for admission for pneumonia (UpToDate, Barson et al), which include:

1)	Hypoxemia (peripheral capillary oxygen saturation [SpO2] <90 percent)
2)	Dehydration 
3)	Moderate to severe respiratory distress: Respiratory rate >50 breaths per minute for older children; retractions; nasal flaring; difficulty breathing; apnea; grunting
4)	Toxic appearance
5)	Underlying conditions that may predispose to a more serious course of pneumonia (eg, cardiopulmonary disease, genetic syndromes, neurocognitive disorders, (eg, immunocompromised host)
6)	Complications (eg, effusion/empyema, necrotizing process, abscess)
7)	Suspicion or confirmation that the pneumonia is due to a pathogen with increased virulence, such as Staphylococcus aureus or group A Streptococcus (GAS)
8)	Failure of outpatient therapy (worsening or no response in 48 to 72 hours)
	Recurrence of pneumonia 
9)	Age younger than 8 weeks. 

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

The carrier's denial of coverage for Inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstruction of vision
Treatment: Blepharoplasty
The insurer denied the Blepharoplasty. 
The denial is overturned. 

The patient is a female for whom coverage of blepharoplasty (15823) is requested. Coverage was previously denied for lack of photos to support policy criteria. 

According to the provider, the patient had been complaining of obstruction of her vision for some time and had noticed that when physically holding up her forehead, she could see better, experiencing less fatigue and improved field of vision.  Marginal reflex distances were reported as 0.5 millimeters (mm) both eyes (OU).  Visual fields also reportedly improve by more than 30% with taping of the eyelids. An exam documents vision corrected to 20/25 OU. Dermatochalasis was characterized as three-plus (3+) OU with 3+ tenting temporally. One-plus (1+) cortical and nuclear sclerotic cataracts were noted OU.  

Yes, the blepharoplasty performed 06/10/2019 was medically necessary.

No, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  However, it should be noted that the health plan reportedly did not have the external photos that were provided for this current review.

According to general standards of practice supported in the peer reviewed literature, blepharoplasty procedures and repair of blepharoptosis are considered medically necessary when performed as functional/reconstructive surgery to correct impairment of near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis and/or symptomatic redundant skin weighing down on upper lashes. Typically, patient complaints which justify functional surgery include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin. Photos should correlate with visual field testing.

A task force from the American Academy of Ophthalmology reviewed the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results.  Ptosis and upper eyelid blepharoplasty surgery were found to be functionally beneficial for each of these quantitative findings:

1) Marginal reflex distance one (MRD1) of two mm measured in primary gaze (MET)
2) Superior visual field loss of 12 degrees or 24% (MET)
3) Down-gaze ptosis impairing reading documented by MRD1 of two mm measured in down gaze.

In this case, visual field testing performed within 30 degrees found superior visual fields restricted to near zero degrees OU, increasing to at least 30 degrees OU with taping of the eyelids. Black and white copies of external photos confirmed dermatochalasis with excess upper eyelid skin resting on the base of the lashes temporally and weighing down eyelids.  Marginal reflex distances are estimated as one mm OU. Photos correlate with the required superior visual field loss.  Therefore, medical necessity of bilateral upper eyelid blepharoplasty is established per standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac / Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial was overturned in whole. 

The patient is a male with a history of significant multivessel coronary artery disease, coronary stents to the right coronary artery (RCA), left anterior descending (LAD), and first obtuse marginal (OM1), hypertension, type 2 diabetes mellitus, hyperlipidemia who presented to the emergency room (ER) with progressive exertional chest pain consistent with unstable angina. The patient underwent urgent coronary angiography demonstrating severe stenosis of the right patent ductus arteriosus (PDA) requiring drug-eluting stent (DES) placement. The patient was discharged the following day in stable condition.

The health plan's determination is overturned in whole. 

An inpatient stay was medically necessary for this patient.
This patient with known significant multivessel coronary disease requiring stents in the past and multiple risk factors for CAD presented with unstable angina in the setting of severe hypertension requiring urgent coronary angiography under the inpatient level of care. Urgent coronary angiography was medically appropriate with the goal of treating ischemic symptoms and reducing the risk of myocardial infarction. The patient presented with an elevated thrombolysis in myocardial infarction (TIMI) risk score (4) with an approximate 20% risk of future adverse cardiac events (all-cause mortality, new or recurrent myocardial infarction [MI], or recurrent ischemia requiring urgent revascularization) favoring benefit with urgent coronary angiography (1). Furthermore, according to the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) guideline for the management of patients with non-ST-elevation acute coronary syndromes, the standard of care for patients with unstable angina, as in this case, is admission for inpatient management to reduce ischemic symptoms and prevent myocardial infarction and death (2). For these reasons, inpatient level of care was medically appropriate and necessary in the best interest of this patient's safety.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Hyperkalemia, Pneumonia.
Treatment:  Inpatient admission.

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

This is a female patient with a history of depression, end stage renal disease (ESRD) on dialysis who presented to emergency department (ED) with complaints of shortness of breath (SOB), weakness, dizziness, light headedness and nonproductive cough for one day.  As per patient, she is on maintenance dialysis 3 x week; her last dialysis session was cut short due to hypotension.  The patient had received some fluids to correct that.  Vital signs (V/S) at presentation to ED revealed temperature 98.4 F, heart rate 89, respiratory rate 18, blood pressure 112/62 mm Hg, oxygen (O2) saturations 96% on room air (RA).  The patient was in no acute distress was alert and oriented (A x O) x 3, her lungs were clear.  Cardiovascular (CVS) was normal; abdomen was soft, and non-tender.  Initial Labs revealed that K+ was 9.8, EKG revealed normal sinus rhythm (NSR) and non-specific ST-T changes.  White blood cell count (WBC) was 6.3K; Hb was 10.6; BNP was 129; Troponin was negative; BUN/Creatinine was 52/8.1.  A chest x-ray revealed (CXR) some increased density possible atelectasis/possible early infiltrate.  Hyperkalemia was treated with Calcium and Kayexalate.  Nephrology was consulted; she underwent dialysis.  Infectious Diseases was consulted for possible pneumonia. Intravenous (IV) antibiotics were started empirically.  The patient remained stable after admission, was afebrile and hemodynamically stable.  She was tolerating oral intake.  A computed tomography (CT) chest was done, which did not reveal any acute infiltrate; antibiotics were discontinued.

After a period of medical stability the patient was discharged.

This patient did not need acute inpatient hospitalization.  She could have been placed in observation status while diagnostic testing and treatment were initiated.  The patient could have been dialyzed, and hyperkalemia could have been treated, and it did respond to treatment.  The patient was afebrile and stable and was not hypoxic.  This patient had a CT of the chest, which rule out pneumonia, so antibiotics were discontinued.

This patient was stable to have been discharged home from observation status after dialysis and medical management of Hyperkalemia.  The patient did not need antibiotics once pneumonia was ruled out.  The patient's renal failure was chronic, and she was on maintenance dialysis; K+ was 4.0.  The patient was stable to be discharged home on oral medications with outpatient follow up for her regularly scheduled dialysis.

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal Bleed, Foot Fracture.
Treatment: Inpatient admission.
The insurer is denied coverage for inpatient admission. 
The denial is overturned. 
This is a male patient with a history of hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease, and alcohol abuse. He presented to the Emergency Room (ER) with complaints of hematemesis, lightheadedness and weakness. He reportedly sustained a fall, striking the back of his head. Both proton pump inhibitor (PPI) and octreotide drips were given. The hemoglobin went from 8.7 to 7.2. The International Normalized Ratio (INR) was 1.4. The liver enzymes were elevated. The glucose was 442. The patient underwent an esophagogastroduodenoscopy (EGD) that revealed a superficial esophageal ulcer without bleeding. An x-ray of the left foot and ankle showed a dorsal dislocation of the second and third toes, acute traumatic fracture of the neck of the fourth metatarsal shaft, and an intra-articular fracture at the base of the 5th proximal phalanx. An ultrasound of the right upper quadrant showed an enlarged fatty liver with focal fatty sparing, a nodular contour consistent with cirrhosis, a small volume of perihepatic ascites, and splenomegaly. The patient was admitted for an upper gastrointestinal bleed, foot fracture, and alcoholic cirrhosis. Hi medical management included acetaminophen, blood sugar monitoring with insulin sliding scale, pantoprazole, losartan, hydrochlorothiazide, Lorazepam, Thiamine, Folic acid, and intravenous fluids. After a period of medical stability he was discharged home.

Clinical indications for admission for upper gastrointestinal (GI) bleeding (M-180) include ongoing bleeding, hemoglobin less than 12, liver disease, and a coagulopathy. The patient had all of these conditions. 

This patient was having ongoing bleeding. He had additional bleeding while in the hospital. He had liver disease and received on octreotide drip. The hemoglobin dropped as low as 7.2. He met MCG criteria for admission for upper GI bleeding. The healthcare plan did not act reasonably, or with sound medical judgement, or in the best interest of the patient. An inpatient admission was medically necessary. The denial is reversed. 

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

Diagnosis: Class I malocclusion, convex facial profile, maxillary and mandibular incisor protrusion and deep impinging overbite and maxillary and mandibular crowding.

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

This is a female patient who consulted an orthodontist for an evaluation for orthodontic care. Diagnostic imaging was performed that included lateral cephalometric radiograph, panoramic radiograph, and montage of extraoral and intraoral clinical images. Recommendations were made for comprehensive orthodontics due to Class I malocclusion, convex facial profile, maxillary and mandibular incisor protrusion and deep impinging overbite and maxillary and mandibular crowding. 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. 

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 a Handicapping Labio-Lingual 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 claims an automatic qualifying condition of deep, impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met and does 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 insurer attaining a score of 19 points on the HLD index (5 overjet, 6 overbite, 5 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to justify orthodontic care. Thus, D8080 braces are not considered medically necessary for this patient.  The health plan act reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for D8080 braces is not substantiated.  The insurer's denial should be upheld.