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

Diagnosis: COVID (coronavirus)

Treatment full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

The patient has a past medical history of bipolar disorder, anxiety, cerebral palsy, and osteoporosis.  The patient presented to the emergency department and had been sent there by the Neurologist for dizziness with associated loss of balance and nausea.  The patient denied fever, cough, or any other specific symptoms.  The heart rate was 105.  The blood pressure was 130/86.  The patient reported since receiving the first dose of the Moderna vaccine he had experienced numbness and tingling in the bilateral hands and feet, muscle tightness, and pain all over his body and a rash on his back.  He was referred to the emergency department to rule out atypical Guillain-Barre syndrome (GBS) versus transverse myelitis.  The patient was admitted to the hospital for a full neurological work-up including magnetic resonance imaging (MRI) and optimization of gait and possible need for home services.  The patient was found to be COVID (coronavirus) positive.  The patient was discharged home with instructions to quarantine and follow-up with the neurologist and psychiatry.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Diagnostic workup for transverse myelitis versus GBS was negative from the vantage point of MRI imaging of the brain and spine as well as from the standpoint of a normal lumbar puncture (LP).  Of import, the diagnostic workup could have been performed in the emergency department (ED) and at an observation level of care.

The inpatient admission is not considered medically necessary for this patient. As noted above, the diagnostic workup for transverse myelitis versus GBS was negative from the vantage point of MRI imaging of the brain and spine as well as from the standpoint of a normal LP.  The diagnostic workup could have been performed in the ED and at an observation level of care. Therefore, the inpatient admission is not considered medically necessary for this 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: Right Total Knee Instability

Treatment full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned

This is the case of an adult female patient with a past medical history of anxiety, osteoarthritis, and asthma, and a past surgical history of right knee arthroplasty who presented to the Hospital with a history of right knee pain. The patient had tried resting and pain medication with minimal relief. The patient underwent revision total knee replacement (right) and tolerated the procedure well, with no complications. The patient received pain management. She tolerated physical therapy and achieved all necessary goals for discharge. She was discharged home.

The medical record demonstrates the patient underwent complex reconstructive surgery with post-surgical problems. Her history was significant for 6 prior knee surgeries (including infected anterior cruciate ligament [ACL] reconstruction). She underwent evaluation for infection prior to the procedure but there would be concern. Close monitoring of vital signs and wound would be necessary. Cultures were pending as risk of recurrent infection would be high. 

Nevertheless, the fact is that she had a drain placed with continued output. She should not be discharged with a drain. Her pain levels were reported to several practitioners with values of 8/10. The records showed she was 'agitated" about her pain. She required multiple doses of Dilaudid and changes in strength were required. Physical therapy records noted "knee buckling" which would indicate necessity of more therapy. 

Based upon the combination of events in a high-risk patient for complications, the admission and length of stay were appropriate. This type of procedure for this woman could not be performed in an Ambulatory Surgical Unit (ASU).

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

The insurer's denial of coverage for full hospital admission overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute kidney Injury

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This patient with chronic kidney disease was admitted for urinary retention.  She was found to have acute kidney injury with hyponatremia and was started on intravenous fluid. Kidney function improved, sodium levels normalized, and she was discharged in stable condition.

This patient was noted for abnormal kidney function; however, her condition was responding to intravenous fluid which is more consistent with prerenal azotemia and no signs of severe renal damage or not immediately reversible condition such as vasculitis or ischemic acute tubular necrosis. She was also noted to have hyponatremia but without severe central nervous system symptoms such as seizures or persistent altered mental status and her sodium normalized in 48 hours.

Her condition could have been safely treated under lower of care.

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The inpatient hospital admission is not considered medically necessary for this patient.

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

Diagnosis: Spastic cerebral palsy, scoliosis, and a seizure disorder

Treatment: the home care / personal care home heath care (HHC) - Level 2 personal care services of 24 hours per day split shift

The insurer denied coverage for the home care / personal care HHC - Level 2 personal care services of 24 hours per day split shift

The denial is overturned.

The patient has spastic cerebral palsy, scoliosis, and a seizure disorder.  The provider letter noted the patient needed a 24/7 assistant and split shift 12/12 hours, 2 people 24 hours.  The patient was awake all night and it was hard for 1 person to take care of him.  The New York State Department of Health's Uniform Assessment System (UAS-NY) noted the patient was severely impaired and never really made decisions.  The patient had short-term and long-term memory problems.  The patient was nonverbal and was not alert to person, place, or time due to cerebral palsy.  The patient was rarely or never understood.  He wore glasses.  He was totally dependent for meal preparation, housework, managing finances, phone use, stairs, shopping, transportation, bathing, personal hygiene, dressing of separate lower body, eating, toilet transfer and toilet use.  His primary mode of transportation was wheelchair or scooter.  He was assisted to shower chair and bathe entirely.  He was frequently incontinent of bowel and bladder.  He was using 13-14 diapers per day.  He needed maximum assistance with managing medications.  And increased to home care/personal care HHC-level to personal care services of 24 hours/day split shift was being requested.

Due to his current medical condition, he is totally dependent with his activities of daily living requiring full assistance. 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 the requested Home Care / Personal Care HHC - Level 2 Personal Care Services of 24 hours per day split shift should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pain, Left Knee

Treatment full hospital admission

The insurer denied coverage for full hospital admission

The denial is upheld

This is a female with a history of asthma, coronary artery disease (CAD), gastroesophageal reflux disease (GERD), hypertension, migraines, osteoarthritis, paroxysmal supraventricular tachycardia (SVT), polycystic ovarian syndrome (PCOS), tarsal tunnel syndrome, and sleep apnea. She presented to the hospital for a scheduled left replacement of the patellofemoral joint. The procedure was performed without complications and the patient had an orthopedically uncomplicated hospital course. The patient was placed on the patellofemoral joint arthroplasty (PFJR) Pathway Protocol. She was monitored in the post anesthesia care unit (PACU) and then transferred to the floors. Postoperative intravenous (IV) antibiotics were given. Xarelto was started for deep vein thrombosis (DVT) prophylaxis. Potassium was supplemented for hypokalemia. Postoperative leukocytosis was likely reactive and secondary to intraoperative Decadron. Labs and vitals were monitored. The patient's condition was stabilized and she was discharged. 

The records demonstrate an uncomplicated surgical procedure with satisfactory/expected postoperative course. The patient underwent an arthroplasty to her patello femoral joint.  The operation was of short duration with reported tourniquet time of 27 minutes. This type of procedure does not involve the medial or lateral compartment. The bone cuts are limited to the trochlea and patella. The blood loss was reported to be minimal. 

The records show no evidence of bleeding (stable hematocrit). There was no evidence of fever. Her vital signs remained stable. She was able to tolerate oral pain medication and did not require additional analgesia.  She was able to participate in physical therapy (PT) on post-operative day (POD) #1 and was found to be independent. She was able to walk 50 feet without assistance. She did not require management of an underlying medical condition. The reported leukocytosis was explained and did not require additional management. The corneal abrasion can be treated as an outpatient. 

These findings do not substantiate the necessity of admission. 

The surgery and post-operative care could have been provided at a lower level of care. 
There were no extenuating circumstances to support the admission and length of stay. The health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the full hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congenitally missing tooth
Treatment: Implant (surgical placement implant body) and implant supported crown on tooth #29
The insurer denied the Implant (surgical placement implant body) and implant supported crown on tooth #29
The denial is overturned.

This is a patient who has congenitally missing tooth #29. The deciduous tooth in this place recently was lost. A provider plans to replace #29 with an implant and restore the implant with a crown.

Yes, the proposed implant (surgical placement implant body) and implant supported crown on tooth #29 are medically necessary.
Teeth maintain the ability to erupt, and so if a tooth is lost, the tooth opposite (if not balanced by teeth either side of the space) may grow into the space that has been left. Teeth can drift into spaces left by missing teeth. When a tooth is removed, certain changes occur. The bone that has been supporting the tooth becomes redundant and will shrink. Thus, restoring any missing teeth is medically necessary and within the standard of care to prevent functional decline and/or complications.

The options in this case to restore function are an implant or a bridge. An implant is the best option. A bridge is considered radical treatment as adjacent tooth structure must be drastically reduced in this process. The bridge has been regarded as the standard of care for some time in the replacement of single and multiple missing teeth. However, to obtain optimal functional and aesthetic results for full-veneer bridges, a significant reduction in the amount of tooth structure is necessary occasionally predisposing to endodontic, periodontal, and structural complications. The abutment teeth often become carious and have an increased rate of needing a root canal procedure. If one of the abutment teeth are lost, a longer span bridge would be required. The implant procedure is more conservative and has a better prognosis. Implants have a high rate of success, do not require procedures on adjacent teeth and are not susceptible to caries.  

The implant procedure is not complete until it has been restored. The crown is needed to complete the restoration and is medically necessary.

Failure to replace the tooth will result in a decrease in masticatory function and drifting of the opposing teeth.
Appeal type: Medical necessity
Decision: Upheld

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

This female with a history of acute lymphocytic leukemia (ALL) in remission and insulin-dependent diabetes mellitus (IDDM) presented to the emergency room (ED) complaining of four days of progressive nausea and vomiting associated with right sided abdominal pain and one day of chest pain.  

The patient's vital signs revealed the following: temperature 98.7, pulse 110, respiratory rate 20, and blood pressure 124/75. Her exam was unremarkable.  Labs revealed the following: white blood cell (WBC) count 10, hemoglobin / hematocrit (H/H) 12.8/36, sodium (Na) 135, potassium (K) 3.2, blood urea nitrogen / creatinine (BUN/Cr) 90/.7 and lactate 1.6.  Her urine analysis was positive for leukocyte esterase, bacteria, white blood cells and red blood cells.  The patient's electrocardiogram (EKG) showed sinus tachycardia.  Her abdominal / pelvic computed tomography showed no abnormality detected (NAD).  The patient was noted to have eight cerebral costovertebral angle (CVA) tenderness and positive McBurney's point with diffuse abdominal tenderness.  She was admitted. The plan of care included intravenous antibiotics for urinary tract infection.  On day two, vital signs were stable (VSS) and the patient was afebrile.  Her nausea and vomiting improved.  The patient was to continue intravenous fluids (IVF), intravenous antibiotics, intravenous Zofran as needed (PRN), and replace potassium.  On day three, vital signs were stable.  She had worse abdominal pain.  The pain was controlled with morphine as needed (PRN).  No surgical intervention was indicated.  On day four, vital signs were stable (VSS).  She was continued on the current management. On day five, vital signs were stable. Her pain had improved.  The plan was to deescalate the pain medications.

No, the proposed inpatient admission was not medically necessary.
The proposed treatment is not consistent with standard of care.

This patient was admitted with urinary tract infection after presenting with nausea, vomiting and abdominal pain. She was hemodynamically stable and afebrile.  She did not have altered mental status.  She did not have renal failure.  She did not have bacteremia.  Imaging was unremarkable.  The patient did not have nausea and vomiting that persisted beyond an observation level of care.  The patient remained clinically stable during the hospital stay.  She was treated with intravenous antibiotics.  Her pain was controlled and she was able to tolerate oral intake.  She was not being considered for surgical intervention.  This patient had an uncomplicated urinary tract infection. The requested inpatient admission was not medically necessary because the patient had not failed a lesser level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: anterior crossbite with gingival attachment loss of the mandibular right canine.

Treatment: D8080 braces and D8670 monthly visit (x12).

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

The denial is upheld. 

This female patient has no documented history.

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 plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 9 points (3 overjet, 2 overbite, 4 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. This is confirmed by several studies. 

Each of the peer-reviewed articles concludes that this index is a valid and reliable determined of need for orthodontic care. As this is an accepted methodology, this had been determined to represent an appropriate approach for assessing orthodontic need.

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

The carrier's denial of coverage for the D8080 braces and D8670 monthly visit (x12) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male.  At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), paroxysmal atrial fibrillation on propafenone, and bradycardia.  The patient presented for evaluation due to an episode of lightheadedness. There was no syncope, chest pain or fall. The patient was found to be in atrial fibrillation with rapid heart rate. He had a history of bradycardia, so no beta-blockers were used. The patient subsequently converted to sinus bradycardia with a three second conversion pause. He remained hemodynamically stable with normal blood pressures. He was seen in consultation by Cardiology and his propafenone was changed to as needed dosing. He was observed on telemetry to monitor for any additional pauses. The patient was discharged home with a plan for outpatient follow-up for possible ablation.

No, the proposed treatment was not medically necessary.

The patient with a known history of atrial fibrillation and sinus bradycardia, presented with an episode of atrial fibrillation. The patient was hemodynamically stable. The electrocardiogram revealed atrial fibrillation, which subsequently spontaneously converted to sinus rhythm.  The patient had a three second conversion pause, and did not require a permanent or temporary pacemaker. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability.  No cardiac catheterization or electrophysiological (EP) study was planned during this admission. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plaque Psoriasis
Treatment: Tremfya
The insurer denied the Tremfya
The denial is overturned.

The patient is a man with psoriasis affecting his entire body, including intertriginous areas.  He has had psoriasis for several years.  There is a family history of psoriasis.  He has tried and failed topical steroids and prover therapy.  His medical history is significant for type 2 diabetes, high blood pressure, high cholesterol and high triglycerides.

Yes, the treatment with Tremfya is medically necessary.
The patient has severe psoriasis for which systemic therapy is indicated. He is not a candidate for phototherapy because of the location of psoriasis in intertriginous areas, which cannot be reached by phototherapy. In the era of biologic therapies for psoriasis, the use of methotrexate, cyclosporine, or acitretin is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to biologic therapies. Additionally, the patient's medical history is such that conventional systemic agents are not appropriate first-line therapies (high blood pressure, high cholesterol and triglycerides).

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments.

Based on the above data, Tremfya is medically necessary for this patient.

The patient has severe psoriasis for which systemic therapy is indicated. He is not a candidate for phototherapy because of the location of psoriasis in intertriginous areas, which cannot be reached by phototherapy. In the era of biologic therapies for psoriasis, the use of methotrexate, cyclosporine, or acitretin is not the most appropriate first-line treatment because their long-term safety and efficacy are inferior to biologic therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diagnosis: Fever, chills, dysuria, hematuria.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with no significant medical history who presented to the hospital with three days of fevers and chills, and thereafter also reported dysuria and hematuria. This is a query regarding necessity of the inpatient level of care. 

The patient presented to the Emergency Room. His urine culture was positive for Escherichia (E.) coli and he was treated with intravenous antibiotics which was converted to oral route. The patient was hemodynamically stable and tolerating oral intake.

No, the proposed acute inpatient hospital admission was not medically necessary.
An inpatient level of care was not medically necessary, as the patient could have safely and effectively been managed at a lower level of care. The request would not be necessary as it would not be the least intensive and/or most appropriate alternative among diagnostic and treatment options provided and not provided in the most efficient setting.

Based on the Milliman Care Guidelines (MCG) 24th Edition for Urinary Tract Infection (UTI) and Sepsis and Other Febrile Illness without Focal Infection, inpatient admission is indicated for the following conditions: hemodynamic instability, vomiting that is severe or persistent, altered mental status that is severe or persistent, persistence or worsening of clinical findings despite observation care treatment, parenteral antibiotics needed beyond observation care treatment, pregnancy, immunocompromised state, new coagulopathy, urinary system finding that requires an invasive procedure or places the patient at increased risk for systemic illness or delayed recovery, acute renal failure, temperature greater than 104.9 or less than 95, need for intravenous (IV) hydration, parenteral antibiotic regimen or isolation or support or another condition, treatment, or monitoring requiring inpatient admission. 

Based on available data, these criteria were not met. Therefore, the dates of service are not recommended at an inpatient level of care.