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

Diagnosis: legal blindness, Anxiety, Depression, Diabetes Mellitus, Bed Confinement status, Constipation, Dizziness and giddiness, Essential (primary) hypertension, Gastroesophageal reflux disease (GERD), Hyperlipidemia, Iron deficiency anemia, long term use of aspirin, Other specified depressive disorders, Unsteadiness on feet, Urge continence, and Vitamin D deficiency

Treatment: consumer directed personal assistance services (CDPAS) 7 days per week, 12 hours per day

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 12 hours per day

The denial is overturned

 
This case involves an elderly female with a subject of review for the coverage for consumer directed personal assistance services (CDPAS) 7 days per week, 12 hours per day. The External Appeal was initiated for a patient who is elderly, lives alone, legally blind and bedbound. The patient receives 9 hours per day, 6 days per week and 6 hours of Consumer Directed Personal Assistance Services (CDPAS), 1 day per week for a total of 60 hours per week. 

A Letter of Medical Necessity was sent and stated that the patient is completely bedbound, with age-related cognitive decline, dementia and is legally blind. Assistance is required with daily activities such as bathing, dressing, grooming, toileting, transferring from bed to wheelchair, preparing and meal eating and prompting her to take her pre-poured medications. 

In this case, an elderly female patient lives alone in a private home with her son. She has strong and supportive family relationships; her oldest son takes care of all her personal needs. She has a diagnosis of legal blindness, Anxiety, Depression, Diabetes Mellitus, Bed Confinement status, Constipation, Dizziness and giddiness, Essential (primary) hypertension, Gastroesophageal reflux disease (GERD), Hyperlipidemia, Iron deficiency anemia, long term use of aspirin, Other specified depressive disorders, Unsteadiness on feet, Urge continence, and Vitamin D deficiency. Medications include amlodipine, aspirin, folic acid, glipizide, irbesartan, Januvia tablets, Jardiance, lorazepam, lovastatin, meclizine, metoprolol, omeprazole, paroxetine, and Vesicare tablets. Patient is alert, oriented to person, place and time. Patient is self-directing. Son reports that the patient is very stubborn. She is usually understood and her hearing is adequate.  According to the notes from her Doctor of Medicine (MD) she is completely bed-bound and has age related cognitive dementia, bowel and bladder incontinence and muscle weakness. They recommend 24 /7 home healthcare.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for consumer directed personal assistance services (CDPAS) 7 days per week, 12 hours per day is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis
Treatment: Collagen cross links assay
The insurer denied the collagen cross links assay. 
The health plan's determination is upheld. 

The patient is a female with a medical history notable for osteoporosis. The patient's physician requested a collagen cross links assay for the patient.

The patient's physician provided a letter of support for this appeal. The patient has been treated with Evenity and intravenous zoledronate. The physician states that the test "enables us to determine both adherence to and effectiveness of our antiresorptive agents." They also state that the test improves fracture risk prediction and is not an experimental test. The physician also provided literature from Jain, et al on the use of bone turnover markers in the management of osteoporosis. There are no office visit notes for review. There was no discussion regarding concern for lack of adherence to treatment for the patient.

The collagen cross links assay has not been demonstrated to be medically necessary for this patient.

Collagen cross link assays are biological markers of bone turnover. The clinical utility in measuring these levels and making treatment decisions has not been clearly established. Guidelines for the treatment of osteoporosis do not recommend making treatment decisions based off of these levels due to the lack of outcomes data and inconsistencies in measurements of levels between labs. As noted by Eastell, et al, "Much remains to be learnt about how bone turnover markers can be used to monitor the effect of stopping bisphosphonate therapy (e.g. ["for example"], to identify a threshold above which restarting therapy should be considered). More studies are needed to investigate the use of bone turnover markers for assessment of the bone safety of new medications." Furthermore, Williams, et al commented that "there is currently insufficient evidence to establish their ability to fulfill these roles without the concomitant assessment of bone mass density (BMD) with dual-energy x-ray absorptiometry (DXA), nor their use as an independent diagnostic tool. As such, more research is needed to establish their utility, as well as how to adjust for the multiple physiological and pathological factors that can influence levels." Usage of this test to guide clinical decision is therefore not clearly established as medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute otomastoiditis
Treatment: inpatient stay.
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a woman with a history of progressive left acute otitis media/concern for acute mastoiditis with associated symptoms of left otalgia, fever, otorrhea with associated vertigo, nausea, and vomiting. She presented to the hospital. Clinical examination was consistent with left acute otitis media with spontaneous tympanic membrane rupture and progressive mastoid effusion. A computed tomography (CT) examination of the temporal bone was performed, and the findings were consistent with left acute otomastoiditis. 

The inpatient hospital admission was medically necessary for this patient. The patient had significant vertigo, nausea, vomiting, and otorrhea and was unable to tolerate oral antibiotics nor did the patient's condition improve sufficiently with outpatient treatment. Acute otitis media/otomastoiditis, which is not responsive to oral antibiotics, is a potentially life-threatening condition that requires prompt recognition and treatment. The patient required intravenous antibiotics in this situation until such time as the patient's vertigo, nausea, and vomiting were sufficiently improved to safely tolerate oral antibiotics. The patient was subsequently discharged after receiving intravenous antibiotics and was deemed medically stable for discharge.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit x 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12

The denial is upheld 

Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, and overbite, ectopic eruption and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 26 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 11 points by internal reviewers. Dr. Nishat Shahabuddin is appealing the decision.

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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 11 points on the HLD index (3 ectopic eruption, 5 anterior crowding, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer review d 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 x 12 is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Autism
Treatment:  Cubby bed
The insurer denied a Cubby bed.
The determination is overturned.

This is a patient with severe autism. He is noted to be non-verbal. He is further noted to be extremely strong and fast with a history of climbing out of cribs and pack and plays. He is unable to safely follow directions or take any safety precautions. His treating physician and applied behavioral analysis (ABA) therapists have requested a Cubby bed for him for safety in the home. At issue is the medical necessity of the Cubby Bed.

The Cubby Bed is medically necessary for this patient. It is detailed at length in the initial letter of medical necessity and then the updated letter of medical necessity that patient is a safety risk to himself, and that a multitude of safety measures have been attempted and failed prior to request of the Cubby Bed. The letters of medical necessity for the patient detail the many interventions trialed and failed prior to requesting the Cubby Bed.
The literature in autism is clear that best care for autistic patients included ensuring safety, helping to facilitate sensory regulation and ensuring best sleep routine and restful sleep. The Cubby Bed is medically appropriate for the patient and provides the medically necessary safe sleep environment. The Cubby Bed further provides a safe sensory environment for the autistic patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Odontogenic abscess with associated cellulitis 
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.


This is a female patient with a history of odontogenic abscess with associated cellulitis extending to the soft tissues of the neck. A workup revealed an elevated white blood cell count, elevated C-reactive protein, and imaging consistent with perapical lucency of tooth number (#) 18 which was ultimately extracted by oral maxillofacial surgery. She required intravenous hydration, intravenous antibiotics after failing a trial of oral antibiotics, and ultimately extraction while an inpatient in the hospital. The patient was subsequently treated with intravenous hydration and intravenous antibiotics until the symptoms improved sufficiently to be able to tolerate and complete therapy with oral antibiotic administration. She was discharged. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient admission was medically necessary for this patient. The patient had significant signs and symptoms concerning for a progressive odontogenic infection with regional spread to her soft tissues of the neck. The patient's condition did not improve sufficiently with outpatient treatment. Odontogenic abscess and regional cellulitis, that is not responsive to oral antibiotics, is a potentially life-threatening condition that requires prompt recognition and treatment. The patient required intravenous antibiotics in this situation until such time as patient's trismus was sufficiently improved to safely tolerate oral antibiotics. The patient was subsequently discharged after definitive treatment (extraction of tooth # 18) after receiving intravenous antibiotics and until the patient was deemed medically stable for discharge and thus could be managed on an outpatient regimen. The patient was evaluated daily to determine continued need for hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Complete tear of rotator cuff. 
Treatment: Shoulder surgery (29807 x (times) 1) - shoulder arthroscopy, with repair of a "SLAP (superior labral tear from anterior to posterior) lesion". 
The insurer denied the shoulder surgery (29807 x 1) - shoulder arthroscopy, with repair of  a "SLAP lesion". 
The determination is upheld. 

This is a male patient who was diagnosed with a traumatic complete tear of the left rotator cuff. The left shoulder magnetic resonance imaging (MRI) report documents the presence of an impaction type fracture of the greater tuberosity of the humerus with full thickness tearing of the supraspinatus tendon. The labrum was noted to be grossly unremarkable, and the long head of the biceps tendon was within normal limits.
The patient has had left shoulder pain and weakness for one month duration after lifting a refrigerator. The patient reported constant pain that has resulted in difficulty performing daily activities. The pain is rated 7/10 and worse at night. Objectively, there is left shoulder flexion and abduction 150 degrees, 3/5 strength, tenderness over the bicipital groove and greater tuberosity, positive impingement signs, positive Jobe's and empty can test, positive Speed's and O'Brien's tests, positive drop arm test, arc test, and cross body adduction. The provider interpreted the left shoulder MRI with findings that include a full thickness supraspinatus tear, and biceps tendinosis. The treatment options were discussed. The plan includes a left shoulder arthroscopy with rotator cuff repair, possible allograft, and biceps tenodesis. The prior treatment for the condition has included ice/heat and over the counter medications. 
At issue is the medical necessity of Shoulder surgery (current procedural terminology (CPT) 29807 x 1). 

The requested health service/treatment of Shoulder surgery (CPT 29807 x 1) is not medically necessary for this patient. 
The article cited from the Open Orthopedics Journal concluded that superior labral tear from anterior to posterior (SLAP) lesions are treated surgically with either fixation of the superior labrum or tenotomy/tenodesis of the long head biceps tendon. The article cited from the American Journal of Sports Medicine concluded that labral debridement or biceps tenotomy is supported over labral repair when an associated rotator cuff injury is present for those older than 40 years. The MRI is noted to be negative for labral pathology. The examination is positive for Speed's and O'Brien's tests and there is tenderness over the bicipital groove. The patient has previously been authorized for an arthroscopic rotator cuff repair, coracoacromial ligament release, distal claviculectomy, and biceps tenodesis. There was no rationale, and insufficient imaging findings, to support a SLAP repair (29807) in addition to these other supported procedures. Based on the available information, Shoulder surgery (CPT 29807 x 1) is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypersomnia 
Treatment: Sleep Study 95805 x 1 -  Sleep Latency Test. 
The insurer denied the Sleep Study 95805 x 1 -  Sleep Latency Test. 
The health plan's determination is overturned. 

This is a female patient who is seeking approval for a sleep study. The physician assistant wrote an appeal letter stating the patient requires an in-lab sleep study and a Multiple Sleep Latency Test (MSLT). The patient's Epworth Sleepiness Scale score was 14. The patient is having sleep paralysis, nightmares, and sleep walking. It was suspected that the patient may have a disorder of hypersomnia. There is no drug or alcohol use. 

The sleep study is medically necessary. For the work up of narcolepsy, the patient had excessive daytime sleepiness and will have a polysomnogram (PSG) preceding an MSLT. This meets the health plan policy. Additionally, according to current literature and standard of care, it does not appear the patient has a significant risk of obstructive sleep apnea (OSA) and thus it is prudent to test the patient for other disorders of hypersomnia with the testing in question. Proceeding with this test is appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: back surgery
Treatment: inpatient stay
The insurer denied an inpatient stay. The health plan's determination is overturned. 

The patient is a female with a history of low back pain and L (left) leg symptoms for 2 years. Prior treatments include physical therapy (PT) and other conservative treatments. The patient was taken to the operating room (OR) and underwent L (lumbar) 4-S (sacral) 1 laminectomy and fusion. Intraoperatively, one drain was placed. No complications were reported. Foley was discontinued on postoperative day (POD) 1. Lovenox and SCDs (sequential compression devices) were ordered for deep vein thrombosis (DVT) prophylaxis. Physical therapy (PT) and occupational therapy (OT) were ordered for post-operative rehabilitation. A PM&R (physical medicine and rehab) consult was placed for post-operative care. 

The inpatient hospital admission was medically necessary.
The patient underwent a L (lumbar) 4-S (sacral) 1 fusion. She experienced no complications post-operatively. She was able to be safely discharged home on postoperative day (POD) 4 after expected recovery as an inpatient in the hospital. Lumbar fusion benchmark length of stay is 1-3 days and standard of care is to perform this as an inpatient. Given the invasive nature of this major surgical procedure and the necessary post-operative care as per above, inpatient care was medically necessary post-operatively. The treatment received was within generally accepted standards of medical practice and would be clinically appropriate at the inpatient level of care. The patient does not meet a lower level of care due to the complexity of her procedure and necessary care as per above. Therefore, inpatient admission on the denied days was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blepharochalasis upper eyelid
Treatment: Blepharoplasty upper eyelid (with excessive skin 
weighing down lid) (code 15823)
The insurer denied: Blepharoplasty upper eyelid (with excessive skin weighing down lid) (code 15823)
The denial is upheld.

The patient is an adult female. She complained of vision obstruction due to upper eyelid dermatochalasis. She has difficulty driving.

The proposed treatment was not medically necessary.

According to the American Academy of Ophthalmology, blepharoplasty procedures and repair of blepharoptosis are considered as functional/reconstructive surgery to correct: 
- Visual impairment with near or far vision due to dermatochalasis, blepharochalasis, or blepharoptosis
- Symptomatic redundant skin weighing down upper lashes
- Chronic, symptomatic dermatitis of pretarsal skin caused by redundant upper lid skin
- Prosthesis difficulties in an anophthalmic socket
Documented patient complaints which justify functional surgery and are commonly found in patients with ptosis, pseudoptosis, or dermatochalasis include interference with vision or visual field, difficulty reading due to upper eyelid drooping, looking through the eyelashes or seeing the upper eyelid skin, or chronic blepharitis. Photographs should demonstrate one or more of the 
following: 
- The upper eyelid margin approaches to within 2.5 millimeters (1/4 of the diameter of the visible iris) of the corneal light reflex
- The upper eyelid skin rests on the eyelashes
- The upper eyelid indicates the presence of dermatitis
- The upper eyelid position contributes to difficulty tolerating a prosthesis in an anophthalmia socket
- Visual fields recorded to demonstrate a minimum of 12 degree or 30 percent loss of upper field of vision with upper lid skin and/or upper margin in repose and elevated (by taping of the lid) to demonstrate potential correction by proposed procedure or 
procedures. This patient's photos show that the upper eyelid skin rests on the lashes for both upper lids. However, the right untaped visual field test shows 16/20 fixation losses, making the test unreliable. In addition, taped visual field tests are not provided for review. The American Academy of Ophthalmology guidelines are not met. The request is not medically necessary.