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

Diagnosis: Dental Problems (overjet, overbite, ectopic eruption and anterior crowding).

Treatment: Pre-Service request for D8080 Braces and D8670 Monthly Visit.

The insurer denied coverage for the Pre-Service request for D8080 Braces and D8670 Monthly Visit.

The denial is overturned. 

This patient is a male child who presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, ectopic eruption and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 28 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements and the patient is not scheduled to undergo orthognathic surgery. 

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 the use of an orthodontic index, the HLD index. This index provides 6 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 28 points to justify orthodontic care.  This reviewer concurs with this HLD index completed by the orthodontist attaining a total of 28 points (5 overjet, 5 overbite, 3 ectopic eruption, 10 anterior crowding, 5 Iabiolingual spread) which is above the threshold of 26 points to support orthodontic care.

The preservice request for D8080 braces and D8670 monthly visit is considered medically necessary for this patient.

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

The medical necessity for the Pre-Service request for D8080 Braces and D8670 Monthly Visit is substantiated.  The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right ankle sprain
Treatment: Physical therapy 
The insurer denied Physical therapy.
The determination is upheld.

The patient received physical therapy for a right ankle sprain and pain in the right ankle and foot. She received physical therapy. The available records including a letter from the physical therapist (PT) as well as daily physical therapy notes and evaluations were reviewed. At issue is the medical necessity of physical therapy.
The patient's improvement is substantial and complaints have both improved and stabilized. In the therapy sessions under review, the patient has no pain and no strength deficits are documented. The patient's therapy progress note documentation do not support medical necessity per standards of practice for physical therapy. Transition to a home exercise program is appropriate when patients have reached a plateau which is the case for this patient. Skilled physical therapy is not necessary when a plateau has been reached though the home exercise program can and should be continued. It would have been medically appropriate to discharge the patient from active therapeutic care. The physical therapy sessions from were not medically necessary for this patient as she had reached Maximum Therapeutic Benefit.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance use. 
Treatment: Inpatient detoxification treatment services.
The insurer denied coverage for the inpatient detoxification treatment services.
The denial is overturned. 

This is a male patient who was admitted to inpatient alcohol detoxification treatment for alcohol detoxification.  He had withdrawal symptoms including tremors.  He was drinking large amounts of alcohol daily.  He had past inpatient detoxification and inpatient rehabilitation treatment and continued to relapse.  He had past blackouts.  It was reported that he had a sad mood, fatigue, and poor insight.  His alcohol use reportedly interfered with family relationships and finances.  He was put on a Librium taper protocol and given Ativan as needed for alcohol detoxification treatment, as well as Campral, thiamine, folic acid, and multivitamin.  He was discharged with a referral to outpatient rehabilitation treatment. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment.  In this case, this patient had been using large amounts of alcohol daily and had active withdrawal including tremors which put him at risk for severe, complicated, and life threatening withdrawal. 

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he did require 24 hour treatment as he could not safely and effectively be treated for detoxification in a less restrictive setting as he continued to use very large amounts of alcohol daily despite past inpatient detoxification and inpatient rehabilitation treatment, needed detoxification medications including Librium and Ativan for detoxification,  and  continued to drink large amounts of alcohol daily despite negative consequences from alcohol interfering with relational issues, finances, and medical issues.  He reportedly lacked the coping skills to stop alcohol use and needed 24 hour hospital detoxification as he was considered a high risk medically.  He needed 24 hour treatment then as he was at risk for worsened withdrawal symptoms if not in this 24 hour setting then including possible life threatening withdrawal such as delirium tremens which could occur 4 days after alcohol use so he required the entire hospital treatment.  This was a high risk patient who had withdrawal symptoms and was considered a high risk medically for severe, complicated, and life threatening withdrawal.   

Inpatient hospital detoxification treatment was medically necessary.  It did not appear that the health care plan acted reasonably, with good clinical judgment, or in the best interests of the patient then.

The carrier's denial of coverage for the inpatient detoxification treatment services is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 

Treatment: Full hospital admission. 

The insurer denied coverage for the full hospital admission. 

The denial is upheld. 

This is a female patient with a history of multiple sclerosis in remission, gastroesophageal reflux disease (GERD), and migraines. The patient presented to the Emergency Room (ER) with complaints of chest pain. This patient presented with atypical chest pain and had a past medical history of recurrent non-cardiac chest pain.  The patient's diagnostic work up performed several years earlier for recurrent chest pain included cardiac catheterization which was normal. Upon presentation, this patient had a normal physical examination and no electrocardiogram (EKG) abnormalities. The patient's serial troponin tests were negative. The patient's echocardiogram revealed a preserved left ventricular ejection fraction (LVEF) and no wall motion abnormalities, and the patient's myocardial perfusion testing was normal. 

As per literature review, this patient's pretest probability of coronary artery disease was low. 1) Utilizing the HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score, the patient was considered low risk. 2) Utilizing the thrombosis in myocardial infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. 3) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (2018). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the 6 weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. The patient's care could have been safely provided at a lower level of care, such as observation status. 

As per review above, the full hospital admission was not medically necessary for this patient. 

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

The medical necessity for the full hospital admission is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Presyncope, rule out acute coronary syndrome (ACS).
Treatment: Inpatient hospital admission.
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld. 

This is a male patient who had a past medical history of hypertension, pulmonary tuberculosis, and a cerebrovascular accident.  He presented to the emergency department (ED) with dizziness.  The ED documentation noted the patient had felt dizzy since early in the morning.  He felt dizziness before leaving his house and walking to the subway station to go to work and felt more dizziness like he was going to black out and went back home.  He presented to the ED for an evaluation.  He felt his surroundings were spinning.  He denied worsening with change in position, hearing loss, ringing in his ears, nausea, vomiting, weakness, or numbness, urinary, or fecal incontinence, loss of consciousness, chest pain, palpitation, skipping heartbeats, diaphoresis, or seizure activity.  He admitted he had been diagnosed with hypertension but rarely needed or took his medication.  The physical examination revealed a normal examination including a normal examination of cranial nerves II through XII.  There was no motor or sensory deficit.  His electrocardiogram (EKG) showed a left bundle branch block.  The patient was diagnosed with presyncope rule out acute coronary syndrome (ACS).  He was to undergo laboratory testing and treatment with symptomatic therapy with meclizine and Tylenol.  His urine ethyl alcohol screen was positive.  The problems included abnormal EKG, syncope, and alcohol intoxication.  The computed tomography (CT) scan of his chest was reviewed with apical cavitary lesions that were noted as no new findings from a prior CT scan.  The patient was admitted for further evaluation and management.  Neurology and Cardiology were consulted.  Neurology reported that the patient reported he had similar symptoms in the past.  The dizziness and right-hand numbness were noted to be improved and most likely caused by acute on chronic cerebellar dysfunction associated with alcohol consumption.  The patient was stabilized.

The health care plan acted act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient admission is not considered medically necessary for this patient.

The patient presented to the hospital with significant dizziness with vertiginous component. The patient's workup, including diagnostic imaging studies, EKG, toxicology, and specialty evaluations could have been performed in the ED setting and/or at an observation level of care. The care provided was appropriate for an observation level of care; inpatient admission was not medically necessary.

The medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neoplasm of the right submandibular gland.
Treatment:  Inpatient admission.

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

The patient is a female with neoplasm of the right submandibular gland. She has a past medical history of breast cancer. She underwent submandibular gland excision and selective right neck dissection.

The operative procedure was uncomplicated. The patient had a JP (Jackson-Pratt) drain in place following the procedure. The patient was afebrile, and vital signs were stable following the operative procedure.

The patient was discharged on postoperative day number 1 for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

The patient had an uncomplicated course following resection of submandibular gland and selective neck dissection.  There were no active interventions, and the patient was discharged on postoperative day number one.  The patient could have been managed at a lower level of intensity than acute inpatient care.

The patient did not meet criteria for acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Inpatient admission.

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

The patient is a male who had presented to the emergency department with the complaints of upper abdominal pain. This pain was intermittent and had lasted one month prior to presentation. The pain was noted as ten out of ten. The pain radiated to the back via the left side. The patient felt as if he was having a heart attack. He had nausea, emesis and early satiety with eating. 

On evaluation, the patient had abdominal pain. The electrocardiogram (EKG) and emergency department (ED) evaluation did not reveal its cause. The patient had a prior history of uncontrolled diabetes, hypertension, tobacco use, alcohol dependence, acute pancreatitis. The patient received supportive care. A cardiac event was ruled out. The patient underwent a computed tomography (CT) scan of the abdomen. An endoscopy showed gastritis and a Schatzki's ring. The patient's diabetes medications were adjusted. The patient was discharged when deemed stable.

No, the proposed inpatient admission was not medically necessary.

The treatment as provided was medically appropriate; however, the care rendered was not medically necessary at the level at which it was provided.

The plan's denial of acute inpatient services for the care as rendered was appropriate using sound medical judgement and considering the best interests of the patient.

The patient did not require an acute hospital setting to rule out a cardiac event.  Likewise, the endoscopy could have been provided at a lower level of care. The care as provided could have been rendered at a lower level of care in its entirety.  

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had abdominal pain; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring, severe electrolyte dyscrasias or any other indication for an acute admission.  Neither McQuaid or Smith or Squires et. al. mandate a full acute admission in this clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease.
Treatment: Humira 40mg, eight injections in four weeks, pre-service.
The insurer denied the Humira 40mg, eight injections in four weeks, pre-service.
The denial is upheld. 

This is a male. He has been diagnosed with Crohn's disease with fistula. He has been on Humira for a few years. He had symptoms with low drug levels and high antibodies. Humira was increased to 40 milligrams (mg) weekly. The patient has had symptoms and low drug levels and high antibodies. His physician requested Humira 40mg, eight Injections in four weeks (two injections a week or 80 mg every week).

No, the proposed treatment with Humira 40 milligrams, eight Injections In four weeks, is not medically necessary.

Dubinsky et al. conducted a multicenter trial of Humira weekly dosing in children with Crohn's disease. They concluded that "Weekly adalimumab dosing was clinically beneficial for children with Crohn's disease who experienced nonresponse or flare on EOW (every other week) dosing. No increased safety risks were observed with weekly dosing". In this study, the Humira dose was 20 milligrams or 40 milligrams every week.

There has been no any clinical studies to use adalimumab 80 milligrams weekly in children with Crohn's disease. The current treatment guidelines or consensus do not have specific recommendation for Humira 80 milligrams weekly (Bronsky; van Rheenen). Thus, the requested Humira 80 milligrams weekly would not be medically necessary.  It is not in accordance with generally accepted standards of medical practice and it is not clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient's Illness, Injury or disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment, depression, anxiety,
hypertension, severe bilateral knee arthritis
Treatment: Increase Personal Care Aide Hours to 7 Days per Week 12 Hours per Day (84  hours per week)
The insurer denied the Increase Personal Care Aide Hours to 7 Days per Week 12 Hours per Day (84  hours per week).
The denial is overturned. 

The patient is a female with a history of cognitive impairment, depression, anxiety, hypertension, severe bilateral knee arthritis, chronic low back pain with lower extremity radiculopathy and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 84 hours per week Personal Assistance Services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 84 hours per week Personal Assistance Services is deemed medically necessary.

This is a female with a history of cognitive impairment, depression, anxiety, hypertension, severe bilateral knee arthritis, chronic low back pain with lower extremity radiculopathy and gait ataxia. Due to impairments related to these conditions, she requires assistance for completion of the majority of his/her activities of daily living (ADLs). Recent correspondence from the patient's medical provider indicates that due to the patient's rapid progressive physical, functional and cognitive decline, her ability to complete activities of daily living (ADLs) has decreased dramatically. Hence, the currently approved plan of 42 hours per week Personal Assistance Services is not sufficient to meet the patient's current needs. For these reasons, the proposed treatment 84 hours per week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Not specified.
Treatment: CT (computed tomography) Scan.

The insurer denied the CT scan.  The denial is upheld. 

The patient is a female. Her computed tomography (CT) scan was denied, because there was no clinical information.

No, the proposed computed tomography (CT) scan is not medically necessary.

A computed tomography (CT) scan may be needed for pathology, orthognathic surgery or implants. There are no clinical records documenting the need and rationale for a computed tomography (CT) scan.

The plan denied the computed tomography (CT) scan appropriately, as there is no information showing why the computed tomography (CT) scan is necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental - not specified.
Treatment: D5110 - complete upper denture; D5214 - partial lower denture.

The insurer denied the D5110 - complete upper denture; D5214 - partial lower denture.
The denial is upheld. 

This is a female for whom a full upper denture and lower partial denture have been denied, as these services have been provided within the last 96 months.

No, the proposed D5110 - complete upper denture and D5214 - partial lower denture are not medically necessary.

There is not enough clinical information to support that the full upper denture and partial lower denture are medically necessary. The clinical documentation consists only of a panorex radiograph, which shows six upper teeth that are not documented as indicated for removal and no reason is provided. The lower molars are missing, and there is no indication as to why a new partial denture is needed, nor is the health of the teeth provided. There is no clinical information as to what teeth are going to be abutments, nor is there any information regarding the periodontal status of the teeth. Partial dentures are covered only for recipients with good oral health and hygiene, good periodontal health.  The mobility status of the remaining teeth is not known. The standard of care is to treat the periodontal disease and re-evaluate the status of the teeth after this treatment. 

Assessment of the following factors is important for optimal treatment planning:  1) Age and condition of prosthesis, 2) Denture position relative to facial landmarks, 3) Extensions, 4) Interocclusal distance, 5) Occlusal relationships, 6) Occlusal vertical dimension, 7) Retention, 8) Soft tissue support, 9) Stability, 10) Chewing stability, 11) Esthetics, 12) Evidence of self-adjustment, 13) Hard and soft microbial deposits and stain, 14) Phonation, and 15) Patterns of tooth wear.

The indications for servicing or remaking the upper denture would depend on evaluation of the above. Because there are no examination notes regarding the denture and need for removal of teeth, the upper denture and replacement of the lower denture are not indicated.

Of note - the records consist of radiographs that do not provide any additional information. The clinical notes do not contain any examination notes and list only upper tooth numbers.

There is not enough clinical information provided to support that any treatment is needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath.
Treatment: Inpatient admission.

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

The patient is a male. He has a history of asthma and morbid obesity. He presented to emergency room with worsening shortness of breath.

The patient was admitted to acute in-hospital level of care for asthma exacerbation. Despite emergency room treatment, the patient continued to have wheezing and SOB (shortness of breath). After 24 hours of hospital admission, the patient's SOB (shortness of breath) and wheezing significantly improved.

The patient was able to ambulate and was able to tolerate oral diet. The patient's vitals were stable. The patient had minimal wheezing.

No, the Inpatient admission was not medically necessary.

The patient was able to ambulate and was able to tolerate oral diet. The patient's vitals were stable. The patient had minimal wheezing. No treatment was provided that could not have been provided at a lower level of care. This would not have been reasonably expected to compromise the patient's health or safety. Treating the patient at a lower level of care would have been entirely consistent with the standard of care in the medical community. Therefore, the Inpatient admission was not medically necessary.