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

Diagnosis: Neck Pain. 
Treatment: Epidural Steroid Injection. 
The insurer denied: Epidural Steroid Injection. 
The denial is: Upheld. 

The patient is a male. Magnetic resonance imaging (MRI) of the cervical spine demonstrated multilevel degenerative changes. The patient presented for an office visit with complaints of neck pain radiating to bilateral upper extremity. The pain is rated 8 out of 10, it is sharp and shooting with numbness and tingling. The patient is status post cervical epidural steroid injection with 80% improvement in neck pain. Medications include gabapentin. Physical exam demonstrated cervical spine range of motion restricted. Spurling's maneuver was positive bilaterally. It is noted that the patient had prior physical therapy with minimal relief. 
The subject under review is the medical necessity for an epidural steroid injection.

The health plan's determination is upheld. 

The requested epidural steroid injection is not medically necessary for this patient. In this particular case, the provider is requesting repeat cervical epidural steroid injection for the patient's continued pain. However, the documentation does not substantiate that the prior cervical epidural injection resulted in at least 50% pain relief for a period of at least 10 weeks. Therefore, the request is not supported as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep impinging overbite.
Treatment is D8080 braces.
The insurer denied coverage for D8080 braces.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the HLD (Handicapping Labia-Lingual Deviation) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 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 14 points on review by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), 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, New York State requires, as of September 1, 2012, 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 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 as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic using this criterion. In this case, the clinical circumstances do not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index with a total of 14 points (3 points overjet, 4 points overbite, 5 points anterior crowding, 2 points labiolingual spread).

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. 

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

The insurer's denial of coverage for D8080 braces is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult male patient was hospitalized for chest pain. He presented to the hospital emergency department for evaluation of chest pain and palpitation. His past medical history is pertinent for hyperlipidemia (HLP). The patient's vital signs were stable. His electrocardiogram (EKG) showed sinus rhythm (SR) and no acute changes. There were no arrhythmias or elevated troponin documented. The patient's chest x-ray was negative. Echocardiogram with doppler showed the patient's left ventricular ejection fraction (LVEF) was 50-55% and inferior akinesis. The patient's stress test was unremarkable. 
This claim was denied by the health plan; this is an appeal that the requested acute inpatient hospital stay was medically necessary for this patient.

The proposed inpatient hospital admission was not medically necessary.
Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, acute myocardial infarction, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which emergency and observation care have failed or are not considered appropriate. The care the patient received, including an unremarkable stress test like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma (flare up)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is an adult female with a history of asthma. She has had acute respiratory failure requiring intubation and mechanical ventilation in the past, the last one having occurred in last year. She presented to the ER (emergency room) with worsening SOB (shortness of breath) and wheezing.
The patient was found to have asthma exacerbation and was started on DuoNebs, oxygen, IV (intravenous) steroids and IV antibiotics. The patient was admitted to acute inpatient level of care. This hospitalization was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The inpatient admission was not medically necessary.
The patient was admitted for asthma exacerbation. The patient's symptoms improved within 24 hours of hospitalization. The patient was not in any distress. The patient was tolerating oral diet. The patient was not on any invasive drips or high amounts of supplemental oxygen.

Given the patient's signs and symptoms, it would have been reasonable to expect significant improvement within 24 to 48 hours, as is what happened with the patient. The patient's treatment course would not have been expected to require treatments or interventions that could not have been provided at a lower level of care. No treatment was provided or was reasonably expected to be provided that required an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right hip pain, Osteoarthritis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of right hip pain and known osteoarthritis. The patient failed conservative treatment and opted to undergo elective right total hip replacement surgery. The surgery was successful with no documented complications. The patient recovered well after the operation and participated in supervised physical therapy. The patient's health plan denied the inpatient hospital admission as not medically necessary. At issue is the medical necessity of the inpatient hospital admission.

The requested health service/treatment of an inpatient hospital stay was not medically necessary for this patient based upon the documentation in the provided records and the recommendations of the current, peer-reviewed literature.
The records document that the patient opted to undergo elective right total hip replacement surgery. The surgery was completed successfully with no documented complications. The patient did have a hypotensive episode in the immediate post-operative period that resolved with a fluid bolus and the administration of intravenous (IV) ephedrine and atropine. The patient was kept on bedrest the following day, per the surgeon's protocol. The patient ambulated 50 feet with supervised physical therapy and was deemed stable for discharge home with home health. Based on the documentation provided, the care rendered for this patient could have been completed at a lower level of care. A recent pee-reviewed article published by Sutton and colleagues in the Journal of Bone and Joint Surgery concluded that "Early discharge was not an independent risk factor for 30-day major complications or readmissions following total hip arthroplasty (THA) or total knee arthroplasty (TKA). Rather, increased major complications and readmissions were attributed to patient comorbidities and perioperative variables. Early discharge within the first 2 days postoperatively for risk-stratified patients appears feasible without compromising patient care." A second article published by Leroux and associates in the Journal of Bone and Joint Surgery in 2020 concluded that "When comparing matched cohorts of patients who underwent short-stay and longer-stay THA or TKA, we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA." These articles have documented the safety and efficacy of short stay hospital admission for elective total joint replacement surgery. The bedrest on post-operative day number (#) 1 for this patient following total hip replacement surgery is not supported in the peer-reviewed literature. The care rendered in this case could have been completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Foot Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male who presented to the hospital with complaints of right foot pain after falling off the table 3 days before this presentation. The patient was painting a ceiling and, upon falling, twisted his right ankle and developed swelling and bruising. He was unable to walk secondary to pain. Vital signs on arrival include tachycardia of 153, with a blood pressure of 156/97 and normal temperature. The patient expressed nervousness whenever he sees a physician. There were no reports of chest pain, shortness of breath, nausea, or vomiting.

The patient was admitted for sinus tachycardia. Cardiac troponins were negative. The secondary documented problem is blood glucose of 238; the medical team ordered glycated hemoglobin (A1c) and lipid panel. The next day, the patient was reassessed and noted no tachycardia while sleeping but a heart rate of 130 with exertion. The medical team noted iron deficiency anemia, ordered an echocardiogram, and started iron supplementation. The echocardiogram (ECG/EKG) revealed a preserved ejection fraction with no regional wall motion abnormalities. As a result, the patient was released from the hospital.

The subject under review is the medical necessity for an inpatient admission. The health plan's determination is upheld in whole. 

An inpatient admission was not medically necessary for this patient. The patient came into the hospital for ankle pain, and the fracture was ruled out. The rest of the workup does not require an inpatient level of care. The patient was hemodynamically stable, had no ST segment changes on EKG, and had no cardiac arrhythmia such as supraventricular tachycardia (SVT) or atrial fibrillation. The EKG showed sinus tachycardia, which was probably a combination of pain and nervousness at the hospital, as documented in the notes, and no clinical concerns for decompensated heart failure. There is no clinical reason to perform cardiac workup in the hospital setting. Laboratory studies are all unremarkable. Pulmonary embolism was ruled out in the ED (emergency department). An inpatient admission exceeds the needs of the clinical presentation. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class II malocclusion and severe crowding
Treatment: Braces and monthly visits
The health plan denied the requested braces and monthly visits as not medically necessary. 
The health plan's determination is overturned.

The patient in question is a female. She presents with a skeletal Class II malocclusion and severe crowding. Tooth 24 is blocked out of the arch to the labial and has severe gingival recession. Tooth 30 is not restorable and will be lost. She is treatment planned for 30-36 months of braces with the extraction of tooth 30 to address the crowding.
At issue is the medical necessity for the requested braces and monthly visits.

I overturn, in whole, the health plan's determination of medical necessity.

Early extraction of permanent first molars have some positive and some negative consequences. On the plus side, there is reduced decay on the adjacent teeth. On the negative side there are changes in the bite including lingual tipping of the incisors and counterclockwise rotation of the occlusal plane, [1] which will deepen the bite and potentially lead to damage of the anterior teeth. Orthodontic treatment concurrent with the extraction can prevent these negative sequelae.
Tooth 24 is already compromised due to its position. Its exposed root can lead to tooth sensitivity and abrasion of the root. Ideally it would be treated with a gingival graft, but a graft will be unsuccessful unless the tooth is put in the proper position. Orthodontic treatment is a valid tool when trying to treat patients with gingival recession. [2] Orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma Exacerbation
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

This is a female patient with a history of asthma and obesity. The presenting complaints were wheezing, coughing, and shortness of breath. She reported using an albuterol inhaler at home without relief. On arrival to the emergency department, the patient's vital signs were blood pressure 154/99, heart rate 110, respiratory rate 20, and an oxygen saturation of 97% (percent) to 91% on room air. The physical exam in the emergency department (ED) was notable for mild discomfort, normal breath sounds, and speaking in full sentences. An inpatient exam was notable for diffuse expiratory wheezing. She had a peak flow of 250 with an outpatient baseline peak flow greater than (>) 700. Lab results were notable for an elevated brain (or B-type) natriuretic peptide (BNP). A chest x-ray showed no acute abnormalities. In the ED, the patient was treated with intravenous (IV) steroids, fluids, Duonebs, and magnesium. Reevaluation in the ED demonstrated minimal symptomatic improvement and continued dyspnea with ambulation. She was admitted to the inpatient medicine service. Steroids and nebulizers were continued, an inhaled corticosteroid was started, and the patient's symptoms improved and her peak flow improved to 525. The patient was also evaluated for heart failure while inpatient and treated with diuretics to improve her symptoms.

At issue is the medical necessity of an inpatient stay.

Yes, an inpatient level of care was medically necessary. The patient presented with a severe asthma exacerbation, characterized by dyspnea, wheezing, a peak flow 35% of baseline, and failed outpatient management with albuterol. Continued management in an outpatient or observation setting would not have led to a resolution in the patient's symptoms, and the diagnostic and therapeutic re-assessment to evaluate the patient for heart failure and treat with diuretics. In particular, this change in the plan of care would have been unlikely to occur in a lower-level setting. An inpatient level of care was the best site to treat the patient in the safest and most effective way possible. The patient's severely decreased peak flow reading on admission is a sign of the severity of her asthma exacerbation despite an otherwise unremarkable pulmonary exam.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

Diagnosis: hematemesis and melena
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female admitted to the hospital with hematemesis and melena. The patient was seen in the emergency room (ER), released, and then had another episode immediately after discharge and was now admitted. She is not on anticoagulation or anti-platelet agents. On admission, vitals were stable, she was not tachycardic, and the abdomen exam was benign. Admission Hemoglobin (HGB) was 10.2. The patient was started on both intravenous (IV) proton pump inhibitor (PPI) and Carafate with plans for an esophagogastroduodenoscopy (EGD) the following day. 

The inpatient hospital admission was not medically necessary. The care provided could have been provided at a lower level of care. The patient is a young, healthy individual. Despite bleeding (not well quantified in the notes), the patient had normal vital signs and a baseline hemoglobin that was only slightly below normal. The patient could have received IV fluids, anti-emetics and a PPI and been safely discharged after a period of observation and a repeat hemoglobin showing stability. The upper endoscopy did not need to be done during the admission and could have been arranged for shortly after discharge.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Full hospital admission
The insurer denied coverage for the full hospital admission.
The denial is upheld.

This is child with a history of playing outside and recent camping who developed itchiness and bullous lesions on medial and lateral aspects of his ankle, with clear fluid discharge, which could have been insect-bite related and possibly a hypersensitivity reaction. There is a notable lack of detailed physical exam in the Emergency Department (ED) notes. The Assessment/Plan is presumably the medical decision-making used to justify admission, but it only states rapidly expanding cellulitis without physical findings to back this up. 

Several clinical features in the patient's presentation indicate that there was no emergent need for intravenous (IV) antibiotic therapy. His vital signs were normal. He had no fever or chills. There appears to have been some erythema over the ankle. However, there is no documentation of delineation of a margin of cellulitis, swelling, crepitus, bullae, red streaking lines, or point tenderness. In fact, in the Attending Attestation section, it is described as non-tender. Lab parameters were within normal limits (there was no leukocytosis). 

There is no documentation of medical decision making that provides adequate clinical justification for admission to inpatient level of care. He did not fulfill systemic inflammatory response syndrome (SIRS) criteria and did not look sick or toxic. The evidence for lack of need for parenteral therapy is detailed in the skin and soft tissue infections (SSTI) review articles/guidelines referenced. Specifically, Kaplan et al. state oral antibiotic therapy for management of non-purulent cellulitis. This was non-purulent cellulitis in a hemodynamically stable child.

This patient could have been discharged from observation with an ambulatory plan of care, with an antibiotic prescribed safely as an outpatient by the oral route, following an initial parenteral dose administered in the emergency room. In fact, the doctor plan was to switch to oral Augmentin the same night, should he improve.

Additionally, in terms of antibiotic choices, clindamycin is preferred for oral therapy in hemodynamically stable children, including those at risk for community-acquired methicillin-resistant Staphylococcus aureus (MRSA) (Kaplan), and vancomycin and Unasyn were unnecessary and inappropriate choices.

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.

Treatment: full braces, periodic orthodontic treatment visit x 8, and orthodontic retention (removal of appliances, place retainers).

The insurer denied coverage for full braces, periodic orthodontic treatment visit x 8, and orthodontic retention (removal of appliances, place retainers).

The denial is overturned

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, a montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to impacted maxillary canines among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. 

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, an HLD 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 impacted permanent anterior where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet the insurer and plan criteria to justify 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 needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic needs.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for full braces, periodic orthodontic treatment visit x 8, and orthodontic retention (removal of appliances, place retainers) is overturned. Medical Necessity is substantiated.