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

Diagnosis: Left Knee Pain. 
Treatment: Surgery to smooth damaged cartilage on the surface of the knee (procedure code 29877). 
The insurer denied coverage for surgery to smooth damaged cartilage on the surface of the knee (procedure code 29877). 
The denial is upheld. 

This is a patient who was evaluated by their physician after they reported painful popping to their left knee for approximately one year. The patient denied trauma and stated they had used a brace. The patient's physical examination showed tenderness to the distal vastus lateralis. The provider's recommendations were for cortisone injection, brace, and possible surgery. A magnetic resonance imaging (MRI) showed a nodular lesion (2.1 x 2.2 centimeters [cm]) which represented a possible entrapped loose body. 

The patient returned to the physician  and surgery was recommended and completed. The patient's physician removed synovium and also completed a chondroplasty. 

Chondroplasty/debridement is considered medically necessary when ALL of the following criteria are met: 

.	Pain or mechanical symptoms - This criteria was met. 
.	Partial thickness cartilage lesion or unstable chondral flap documented by MRI - This criteria was not met as there were no positive findings on MRI showing chondral injury. 
.	Failure to respond to at least a 6-week course of conservative management in the absence of a chondral flap - This criteria was not met as no conservative treatment had been provided. 
.	Radiographic imaging consistent with Kellgren-Lawrence grade 2 or lower - This criteria was met. 

Based upon the above criteria, surgery (procedure code 29877) would not be necessary. There was lack of consistency of pathology to the patellofemoral joint (e.g. no pain to the anterior knee, no positive physical findings, and no positive imaging studies). The pathology was localized to the lateral aspect of the knee, a different location. A chondral shaving for an asymptomatic body area would not be indicated. 

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 surgery to smooth damaged cartilage on the surface of the knee (procedure code 29877) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo
Treatment: Office procedure (96910 x 36)
The insurer denied coverage for office procedure (96910 x 36).
The denial is overturned.

The patient has a diagnosis of atopic dermatitis and vitiligo. The patient has been treated with tacrolimus, halobetasol, triamcinolone, and Opzelura. The request is for narrowband ultraviolet B (NBUVB) phototherapy for the treatment of the child's vitiligo.  

Based on the submitted documentation, the use of NBUVB phototherapy is medically necessary for the patient's vitiligo. The patient is a child with limited treatment options. Opzelura topical cream is the only Food and Drug Administration (FDA) approved therapy for vitiligo. The patient has failed high and mid-potency steroids, halobetasol, and triamcinolone. No FDA approved systemic therapeutics are available. NBUVB has been clinically used to treat inflammatory conditions, including vitiligo and atopic dermatitis. Current procedural terminology (CPT) code 96910 (x [times] 36 treatments) is appropriate for treatment of the patient with office based NBUVB phototherapy.  

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

The medical necessity for an office procedure (96910 x 36) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebrovascular accident
Treatment: home health care
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Split Shift)
The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, dementia, hypertension, hyperlipidemia, diabetes mellitus type 2, anxiety, insomnia, and gastritis who had been assigned PCS (personal care services) based on an assessment tool performed assessing the patient at total assistance with task of shopping and maximum assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, and stairs. With tasks of phone use, transportation, bathing, and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene and dressing upper body. The patient was assessed at supervision with tasks of walking, locomotion, transfer toilet, toilet use, and eating well independent with task of bed mobility.

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hour(s) per Day (Split Shift) are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of personal care services 24 hours/day, split shift. Specifically the provider noted the patient needed to be turned and repositioned every 1 hour to prevent skin breakdown. The provider also noted the patient needed frequent changing of soiled diapers to prevent urinary tract infection (UTI) and skin breakdown. The patient's care needs in the overnight hours are such that a PCA (personal care assistant) would not be able to obtain at least 5 hours of uninterrupted sleep. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan indicated the patient had informal support outside of the currently assigned PCA service hours which was not the case. The plan also indicated the patient was not safe to be discharged to the community because of the patient's behaviors of refusing to eat, being combative, refusing medications, and being physically aggressive however psychiatric notes from rehabilitation indicate the patient's medications had been working well to control such behaviors. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). 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, the requested services are medically necessary for this patient. Personal care services 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

Diagnosis: Class III Malocclusion. 
treatment: Braces, Monthly Visits, and Retainer. 
The insurer denied Braces, Monthly Visits, and Retainer. 
The health plan's determination is overturned. 

The patient in question is a young female with a crossbite of tooth number (#) 6. She presents with a skeletal Class III malocclusion with minor spacing in the maxilla and mandible. She is treatment planned for Braces, Monthly Visits, and Retainer to address the crowding and crossbite. 

The braces, monthly visits and retainer are medically necessary for this patient. 
This patient presents with an anterior crossbite on tooth 6, as well as significant spacing. 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 costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental malocclusion

Treatment: braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld

 
Upon review of the submitted documentation including lateral cephalometric radiograph, 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, overbite, anterior crowding and posterior unilateral crossbite, among other findings and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 21 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstances does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 21 points. 

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 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 21 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 21 points on the HLD index (4 overjet, 4 overbite, 5 anterior crowding, 4 labiolingual spread, 4 posterior unilateral crossbite) which is below the threshold of 26 points to support orthodontic care. Of note is in this case, the patients own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval. In this case the patients own orthodontists completed HLD index total score of 21 points remains below the threshold of 26 points to justify orthodontic care.

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 braces and monthly visits is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: back pain
Treatment: Pain Injection: Nerve Block for Back Pain
The insurer denied Pain Injection: Nerve Block for Back Pain 
The health plan's determination is upheld. 

The patient is a male with complaints of back pain. The pain occasionally radiates to the right leg. He occasionally gets foot drop. There is a past medical history of multiple sclerosis. He has had physical therapy. Physical exam showed 5 out of 5 muscle strength, full range of motion, paraspinal and sacroiliac tenderness bilaterally. The patient is currently utilizing multiple medications. An magnetic resonance imaging (MRI) demonstrated multilevel degenerative changes. A Peripheral nerve cluneal block is under review.

The Pain Injection: Nerve Block for Back Pain is not medically necessary for this patient. Peripheral nerve blocks are not supported for the treatment of chronic back pain. A cluneal nerve block is not recommended, as there is no high-quality evidence to support the use of this treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right arm weakness
Treatment: Inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a female with a past medical history of anemia and prolactinoma presented to the emergency department with right arm weakness. She reported waking up feeling normal, but at 6:00 a.m., she noticed weakness in her right upper extremity and difficulty walking with a sense of weakness in her right leg. The patient denied falls, trauma, dizziness, vision changes, nausea, vomiting, numbness, tingling, confusion, slurred speech, or facial asymmetry.

The inpatient hospital admission was not medically necessary.
Based on the nationally accepted standards of care, admission at the acute inpatient level of care is usually indicated for patients with acute ischemic stroke with neurologic findings whose National Institute of Health Stroke Scale (NIHSS) score is greater than two, also when there is evidence of hemorrhagic transformation, altered mental status, significant dysphasia, aphasia, gait impairment.
This was not present in this clinical case. The brain imaging studies did not demonstrate evidence of edema or large acute infarction. According to the consultation note from the neurologist, the NIHSS score was 0.
Furthermore, there was no evidence of hemodynamic instability or cardiac arrhythmias of immediate concern. The echocardiogram was unremarkable, ruling out severe valvular disease, and atrial myxoma. There was no evidence that the patient had respiratory abnormalities associated with acute stroke.
There were no reports of severe uncontrolled hypertension requiring any intervention. The patient did not need prolonged cardiac telemetry monitoring beyond 24 hours. There was no need for any urgent procedures such as thrombectomy or thrombolysis. There was no need for parenteral anticoagulation. Therefore, the acute inpatient level of care was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: sickle cell disease
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is a male who presented for care with bilateral severe knee pain, right worse than left, and acute cough. His past medical history is significant for sickle cell disease, glucose-6-phosphate dehydrogenase (G6PD) deficiency, and obesity. The knee pain was sudden in onset, and constant in nature. He tried home pain medication, specifically Percocet 10 milligrams (mg), a total of 3 doses, but this did not alleviate his pain. Emergency medical services (EMS) brought the patient to the emergency department (ED) for acute medical management. In the emergency department (ED), he was documented to be in distress from pain syndrome, had tenderness to the knee joints bilaterally, and was treated with intravenous (IV) morphine. 

The inpatient hospital admission was not medically necessary for this patient.
This patient was admitted for treatment of sickle cell pain crisis. He had failed oral pain medicines at home and presented to the ED for further more aggressive care. While he was given intravenous fluids and intravenous (IV) pain medication in the ED, he was only given 1 dose of IV morphine, and was not given any Toradol or other treatments. In addition, while he required intravenous pain medications in the hospital setting, along with IV fluids, he only continue with the IV treatments through hospital day 3, and he spent the remaining 2 days in the hospital without IV therapy. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a female who was admitted to the hospital in transfer from another facility where she had presented with chest pain and dyspnea. She was found to be in pulmonary edema. By report, an echocardiogram showed normal left ventricular systolic function, severe mitral regurgitation (MR) and mild pulmonary hypertension. Her medical history was remarkable for end-stage renal disease on hemodialysis, hypertension, thyroid cancer and catheter ablation for supraventricular tachycardia. Prior to transfer, she was treated with intravenous diuretics and hemodialysis. She was transferred for evaluation for possible surgical treatment of her MR and continued management of pulmonary edema. 

Based on the documentation provided, the inpatient hospital services were medically necessary.
This woman was hospitalized with acute decompensated heart failure (ADHF). She had several high risk features. She was hyponatremic with a serum sodium level of 132. Hyponatremia in patients with ADHF is associated with increased in-hospital and post-discharge mortality, prolonged hospital length of stay, and frequent rehospitalization. She was anemic with a hemoglobin level of 9.4. Anemia is associated with poor prognosis in patients hospitalized with ADHF, particularly those with heart failure with preserved ejection fraction (HFpEF), like this woman. In the study reported by Caughey et al, anemia was associated with a mortality hazard ratio of 2.1 in patients classified with HFpEF. This woman also had underlying end-stage renal disease, an additional negative prognostic indicator. Given this patient's multiple high risk features, careful and continuous monitoring with the ability to intervene emergently, if needed, was medically necessary. This required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Respiratory
Inpatient hospital

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

The patient in this case is a female with a past medical history of heart failure, hypertension (HTN) and obesity who was admitted to the hospital with an increase in her baseline dyspnea. She is noted to have had progressive worsening of dyspnea for the last several days prior to admission. She is documented as having dizziness during these episodes. The dyspnea does improve some with rest but not completely. She follows with pulmonary for management of her pulmonary hypertension. She required oxygen at 4.5 liters per minute (LPM) via nasal cannula and is on Tyvaso and Sildenafil for her pulmonary hypertension. 

The inpatient hospital admission was medically necessary. This case involves a patient who is diagnosed with pre-capillary pulmonary hypertension and has been started on two medications. She endorses complaints of dizziness during dyspnea. It is this, in conjunction with her pulmonary hypertension, shows that her pulmonary hypertension is so bad that it is impacting cerebral perfusion, based on the supplied documentation. Untreated pulmonary hypertension or admitted patients without access to their home regimen can have rebound pulmonary hypertension that is difficult to manage. An inpatient admission is medically necessary to manage these patients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain	
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The denial is upheld.

The patient was sent by her physician to the hospital for evaluation of jaundice. She was having abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The liver enzymes and lipase were elevated. An ultrasound showed a contracted gallbladder with gallstones. There was no bile duct dilatation. The bilirubin was 10 and she was diagnosed with obstructive jaundice. She underwent an endoscopic retrograde cholangiopancreatography (ERCP) with stent placement and stone removal. Subsequently the bilirubin went up to 13.5. A magnetic resonance cholangiopancreatography (MRCP) and liver biopsy were planned. The biliary stent was subsequently removed. Vitamin K was given, and the interventional radiology (IR) department did a liver biopsy. The Mayo End-Stage Liver Disease (MELD) score was 24. She was placed on Ursodiol. 

Milliman Care Guidelines (MCG) M-570 lists clinical indications for admission for Liver Disease. Acute liver failure is an indication if there is a coagulopathy as well as hepatic encephalopathy. In this case the patient did not have hepatic encephalopathy. She also did not have infected ascites, hepatorenal syndrome, severe vomiting, or an inability to maintain oral hydration after observation care. 

MCG M-555 lists clinical indications for admission for Gallbladder or Bile Duct Inflammation or Stone. Both acute cholecystitis and acute cholangitis are indications for admission if there are systemic signs of inflammation. The patient did not have acute cholecystitis or acute cholangitis. She also did not have hemodynamic instability, common bile duct obstruction, severe dehydration, or bacteremia. 

This patient required a workup for jaundice. There was initially a concern about a common bile duct (CBD) stone but then it was felt that she had hepatocellular disease. This workup including the ERCP, and liver biopsy could have been done on an ambulatory basis. There was no evidence of acute cholangitis or sepsis. She did not meet MCG criteria for admission for either Liver Disease or Gallbladder or Bile Duct Inflammation or Stone. 

Based on the above, the insurer's denial is upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for inpatient hospital stay was not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Inpatient hospital

Diagnosis: right hip osteoarthritis
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case describes a male patient with advanced right hip osteoarthritis. He failed conservative treatment for this condition and opted to undergo elective right total hip replacement surgery. The surgery was successful with no documented complications. The patient recovered well after this elective operation and was deemed stable for discharge home with home health services. 

The requested inpatient hospital admission was not medically necessary for this patient.
The records in this case document that this patient underwent Mako robotic assisted right total hip replacement surgery. This operation was successful with no documented complications. There was no documentation of post-operative infection, excessive bleeding or evidence of deep vein thrombosis that would mandate a two night inpatient hospital admission. The patient progressed well with post-operative physical therapy and was deemed stable for discharge with home care services. Therefore, the medical records in this case do not establish the medical necessity of the inpatient hospital admission. The care could have been completed at a lower of care.