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

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit (x12)

The insurer denied coverage for D8080 braces and D8670 monthly visit (x12)

The denial is upheld

Upon review of the submitted documentation, 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 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet 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 need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Based on the above, the insurer's denial must be 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 visit (x12) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Difficulty Breathing, Cough
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This is a female child with autism and a family history of asthma who presented to the emergency department (ED) with a three-day history of congestion, runny nose, cough, fever to 103 degrees Fahrenheit, one episode of vomiting, and increasing difficulty breathing. In addition, she was irritable and frequently crying. The examination was significant for acute distress, crying, tachypnea, accessory muscle usage with retractions and belly breathing, bilateral diffuse wheezing, tachycardia, rhinorrhea, benign abdomen, erythematous right tympanic membrane, and a non-focal neurologic exam. A chest x-ray revealed central peribronchial thickening with no confluent infiltrate. She was treated with DuoNebs and Decadron as well as Tylenol. With persistent retractions, she was given an albuterol treatment and a dose of magnesium. She remained tachypneic with accessory muscle use. At this point, the decision was made to admit the patient to the pediatric floor. Admission orders included cardiopulmonary monitoring, regular diet for age, maintenance intravenous (IV) fluids, albuterol every three hours. She remained stable on room air for the duration of her hospital stay, she responded well to bronchodilator treatment, she was weaned quickly down to half-maintenance IV fluids with improved appetite. She was no longer wheezing, the oxygen saturation was consistently greater than 95 percent (%) on room air, and her intake had improved. She was deemed stable for discharge to continue albuterol every six hours as needed. At issue is the medical necessity of an inpatient stay.

Inpatient hospital stay was not medically necessary for this child.
About half of all children experience an episode of wheezing in the first six years of life, often linked with a viral respiratory infection (eg respiratory syncytial virus, rhinovirus. Human metapneumovirus, influenza). Children may even experience recurrent episodes of wheezing as triggered by viral infection.

She presented with symptoms of a viral upper respiratory illness or viral syndrome and increasing difficulty breathing. She was treated aggressively in the ED with bronchodilators, steroids, fluids, and magnesium. She responded well to the bronchodilators but because of persistent signs of respiratory distress she was admitted to the hospital. While it was reasonable and medically necessary to monitor the child for improvement versus decompensation, she was overall hemodynamically stable with no need for supplemental oxygen, no need for assisted ventilation, and no severe dehydration. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Teeth 1 and 16- removal of impacted tooth, deep sedation/general anesthesia.
The insurer denied teeth 1 and 16- removal of impacted tooth, deep sedation/general anesthesia.
The determination is overturned.

This is a male patient requesting wisdom tooth removal. The removal of impacted teeth number (#) 1 and #16 with deep sedation was denied by the health plan because there is no pathology associated with his teeth. This is under review for medical necessity.

The wisdom teeth are indicated for removal and the requested services are medically necessary. The removal of tooth #1 and #16 with deep sedation is the standard of care.
The American Association of Oral and Maxillofacial Surgeons (AAOMS) Parameters of Care states that an impacted third molar that is so positioned that it will probably not erupt by the middle of the third decade constitutes pathology with dental and medical consequences. To limit known risks and complications associated with surgery, it is medically appropriate and surgically prudent to remove impacted third molars before the middle of the third decade and prior to complete root development. An impacted tooth with completed root formation that is totally covered by bone in a patient beyond the third decade that does not meet the following indications for removal should be monitored for change in position and/or development of pathology, which may then indicate its removal. The patient meets this criteria as the patient has impacted wisdom teeth that are so positioned that they will probably not erupt by the middle of the third decade.
The decision to use sedation/general anesthesia for a particular dental procedure should only be determined by considering the needs of the patient, the requirements of the operating dentist and the effect on the quality of the dental treatment. The provider has determined that it is needed in this particular case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal bleed

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This is an adult patient with portal vein thrombosis secondary to Janus kinase 2 (JAK 2) mutation, splenomegaly post portal vein stent placement with thrombus (noncompliant with anticoagulation), and asthma who presented to Emergency Department (ED) with melena x2days and hematemesis x1day. The patient was admitted for further treatment of upper gastrointestinal (GI) bleed (concerning for esophageal varices) including intravenous (IV) proton pump hnhibitor (PPI), Octreotide and further evaluation with upper endoscopy. On the evening of admission, the patient left against medical advice. 

Acute upper GI bleed is considered a medical emergency with a mortality rate for non-variceal bleed in the range of 10% and 20% for variceal with higher rebleeding rate and hemorrhagic shock (1). Correct establishment of support measures and specific therapy is associated with decreased mortality. One study demonstrated a reduction of up 28% on in-hospital mortality with the use of accurate therapies (including high dose IV PPI, and vasoactive drugs) (2). A recent American College of Gastroenterology (ACG) Clinical Guideline for upper gastrointestinal (UGI) and Ulcer Bleeding was published in 2021 suggesting the use of a risk assessment tool to identify patients who may be discharged home from the ED with UGI should be based on Glasgow-Blatchford score (GBS) 0-1. Patients with greater than or equal to 2 GBS should be admitted to the hospital for further treatment and observation (3).

In the case of this patient, as per the indications above (UGI bleed with concern for variceal etiology), and GBS greater than 2, inpatient care for close observation and IV medications was warranted. 

The inpatient admission for IV medications and close observation was medically necessary in a patient with UGI bleed and multiple co-morbidities with high concern for a possible variceal bleed that carries a high mortality rate. Managing this patient as an outpatient is not an option. 

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 inpatient admission is substantiated
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic cancer

Treatment: stereotactic body radiation therapy (SBRT)

The insurer denied coverage for stereotactic body radiation therapy (SBRT)

The denial is upheld 

The patient is newly diagnosed with lung adenocarcinoma. The patient has a 3 centimeter (cm) pleural based right middle lobe mass. A positron emission tomography (PET) scan on 3/22 demonstrated lung disease as well as numerous bone metastasis including multiple pelvic metastasis. Currently, the patient is not particularly symptomatic from any of these diseased areas except the left hip. Patient was recommended stereotactic body radiation therapy (SBRT). 

This patient has widespread metastatic disease and can be treated with conventional palliative radiation therapy (RT) to begin with rather than SBRT. This patient has not presented as oligometastatic disease, so SBRT is not medically appropriate.

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 stereotactic body radiation therapy (code 77373) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD).
Treatment: Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split Shift - 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week).

The insurer denied Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split Shift - 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week).  The health plan's determination is overturned. 

The patient is a female with past medical history of chronic obstructive pulmonary disease (COPD) on bi-level positive airway pressure (BiPAP) therapy, atrial fibrillation on chronic anticoagulation, aortic valve stenosis, congestive heart failure (CHF), O2 (oxygen) dependence, anemia, hyperlipidemia, diabetes mellitus type 2, transient ischemic attack (TIA), dementia, depression, anxiety, glaucoma, osteoarthritis, urinary incontinence, and bowel incontinence, who had a request for increased PCA (personal care aide) services. 

Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split Shift - 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week) are medically necessary for this patient.

There is documentation from the patient's PCP (primary care provider), family, and hospice director of the patient's worsening cognitive and physical functioning. There is documentation from the patient's PCP and hospice medical director of medical necessity of increased PCA services specifically to help with overnight incontinence care as well as turning and repositioning every 2 hours. Overnight care logs indicated the patient needs activities of daily living (ADL) assistance at least every 2 hours. The patient's care needs in the overnight hours would not allow a PCA 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and Instrumental activities of daily living (IADL). The patient's care needs cannot be met with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split Shift - 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week) medically necessary for this patient are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Left below the knee amputation

Treatment: L5910, addition endoskeletal system, below knee, alignable system and L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system

The insurer denied coverage for L5910, addition endoskeletal system, below knee, alignable system and L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system

The denial is modified.

This is a patient with a left below knee amputation. The patient was seen by a certified prosthetist for a replacement left transtibial prosthesis. Under review is the medical necessity of L5910, addition endoskeletal system, below knee, alignable system and L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system.

The prosthetist provides sufficient documentation to support the medical necessity of the L5910 alignable system. A new (offset) alignment was needed due to significant weight loss and changes in the patient's residual limb with risk of skin breakdown and higher-pressure points over boney anatomy. However, the medically necessity of the L5962 flexible protective outer surface is not supported as medically necessary. There is no specific support that the patient is exposed to unusually harsh climate conditions or prior prosthetic components had evidence of "corrosion due to acidic bodily fluids, the spreads of viruses by providing a widespread surface and/or corrosion due to New York's unusually harsh winter."

The health plan did not act reasonably, with medical judgment or in the best interest of the patient in this particular case. Considerations included the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based.

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the L5910, addition endoskeletal system, below knee, alignable system is medically necessary. However, L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system is not medically necessary.

Based on the above, the insurer's denial must be modified. 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 L5910, addition endoskeletal system, below knee, alignable system is substantiated. The medical necessity for L5962, addition endoskeletal system, below knee, flexible protective outer surface covering system is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic respiratory failure on continuous supplemental oxygen, atrial fibrillation and stroke
Treatment: Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in)
The insurer denied coverage for Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in).
The denial is modified.

This is an elderly female with medical problems including chronic respiratory failure on continuous supplemental oxygen, atrial fibrillation and stroke. She was recently discharged home from a rehabilitation facility. She lives with her husband in a private residence. The insurer approved personal care services (PCS) 28 hours/week and the request is for PCS 7 days/week, 24 hours/day, live in; (91 hours/week).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent. She was noted as "alert and oriented x 3 (person, place, thing)." She was also "able to self-direct care." She is reportedly totally dependent for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. Extensive assistance is reportedly needed for bathing, personal hygiene, dressing, locomotion, ambulation (walker and contact guard assistance) and toilet transfer/use. Limited assistance is reportedly needed for bed mobility and eating. She is frequently incontinent of bladder and continent of bowel. 

The patient's activities of daily living (ADL) status has declined over the prior 90 days and she reportedly fell at home (subsequently hospitalized for stroke, transferred to a skilled nursing facility and eventually discharged home). The patient's medical condition, cognitive deficits and physical limitations are not at the level or unpredictable as to require the requested PCS 24 hours/day live-in. Given the patient's reported general weakness and debility, she may benefit from additional safety monitoring. However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. However, the patient's functional ability has significantly declined when compared to the prior UAS. Based on the records reviewed and recent clinical events over the past 6 months; attention to the patient's functional needs are more appropriately provided and maintained by increasing PCS 12 hours/day, 7 days/week, shared household responsibility of other adult living in the home and informal care from family. 

Based on the above, the insurer's denial must be modified. 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 Level 2 personal care services, per 15 minutes increase to 24 hours per day (live-in) services is not substantiated. However, increasing level 2 PCS to 12 hours/day, 7 days/week (total 84 hours/week) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Issues.
Treatment: Braces.
The insurer denied Braces.
The determination is overturned.

The patient is a female with an anterior crossbite on tooth number 7 and tooth number 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 30 to 36 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.  

The requested health service/treatment of braces is medically necessary for the patient. This patient presents with an anterior crossbite on tooth number 7 and tooth number 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and complicated to correct than the patient's existing orthodontic problem. For this reason, the braces are deemed as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Appendicitis.
Treatment:  Inpatient stay.

The insurer denied coverage for inpatient stay.  The denial is upheld.
 
Based on clinical documentation, the patient had acute appendicitis. The patient presented to the emergency department, underwent an uneventful laparoscopic appendectomy, and was discharged the next day. There were no reported complications, and the patient was cleared for discharge by the surgical team by post operative day one. Outpatient appendectomy is as safe and effective, with complication rates, readmission rates, and satisfaction equivocal to those patients kept in observation. [1-3]

The inpatient hospital stay was not medically necessary. Per clinical documentation, the patient presented to the emergency department with a one-day history of right-sided abdominal pain. There was associated nausea, vomiting, and anorexia. Vital signs were within normal limits. White blood cell count was elevated to 22.4. A computed tomography (CT) scan was positive for acute appendicitis. The patient underwent an uneventful laparoscopic appendectomy. The patient was cleared for discharge from a surgical standpoint on postoperative day one. Admission may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities [e.g., chronic obstructive pulmonary disease (COPD), chronic heart failure], or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care. There were no immediate complications documented after the surgery. Peer-reviewed literature also indicates that outpatient laparoscopic appendectomy can successfully be performed in those with uncomplicated appendicitis. Suitable criteria for same-day discharge include hemodynamic stability, tolerating liquids, and pain controlled on oral medications. [4, 5] Surgical documentation notes that the patient was uncomplicated. Therefore, the requested inpatient hospital stay was not medically necessary. Observation care would be more appropriate.  

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 an inpatient stay is not substantiated.