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

Diagnosis: Post ACL reconstruction with patellar tendon autograft

Treatment: Physical therapy treatments

The insurer denied coverage for physical therapy treatments. The denial was reversed.

This patient is a female who underwent an ACL reconstruction with patellar tendon autograft. The documentation indicated the patient should undergo physical therapy twice a week postoperatively. The documentation does indicate the patient was seen for a follow-up. The patient was participating in cardiovascular conditioning and was doing wall sits as well as squats, single leg squats, high step up and leg and hamstring curls.  The patient had not done any jumping. Her incision was well-healed on exam did not have any instability noted. She had good symmetry on a double leg squat to approximately 45 degrees.  She was not comfortable at that time going down to 90 degrees. She had good tone and a negative Lachman's. The physician detailed the patient was progressing beautifully and it was recommended she continue working with physical therapy. A letter of medical necessity indicated at that time has had approximately 18 weeks of postoperative physical therapy making steady progress. The documentation detailed she required additional physical therapy at that time to continue improving strength. The length of treatment requested was 2 sessions a week through early-2020 which was 9 months of postoperative physical therapy.

The current literature supports ACL reconstruction physical therapy guideline of 22 weeks (6 months' worth) of rehabilitation. The patient is participating in cardiovascular conditioning and exercises as tolerated. Prior to injury the patient had a high level of function and played sports. The requested 9 months of physical therapy exceeds the medical policy.

However, it is considered current standard of care for completion of 6 months of post-operative therapy after ACL repair. The prior determination that the patient has plateaued is inappropriate, the lower extremity function score continued to improve, 56/80 and although this considered a point of transition to HEP, the patient had a high level of function pre-injury. 

By standard of care definition, an additional 4 weeks is considered medically necessary for the patient to fully transition into a custom HEP and improve range of motion (ROM) in her right knee.
 
The health plan did not act reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the physical therapy treatments attended for the dates of service specified for postoperative physical therapy is appropriate. The medical necessity is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class II malocclusion, retruded mandible, maxillary and mandibular crowding and incisor protrusion, crossbite, AND deep impinging overbite and excessive overjet.

Treatment: (D8080) and periodic treatment visit (D8760)

The insurer denied coverage for (D8080) and periodic treatment visit (D8760). The denial was reversed.

This patient is a male who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class II malocclusion, retruded mandible, maxillary and mandibular crowding and incisor protrusion, crossbite, and deep impinging overbite and excessive overjet. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of overjet greater than 9 mm with incompetent lips to support orthodontic necessity. 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 only 11 points on review by internal reviewers.

It is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labiolingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. 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.  


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

The medical necessity for (D8080) and periodic treatment visit (D8760) is substantiated. The denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission 

The insurer denied coverage for inpatient admission. The denial was upheld.

This patient is a female who had systemic lupus erythematosus (SLE) along with lupus nephritis and presented with flu-like symptoms.  She was having ongoing abdominal pain.  She was afebrile and the vital signs were stable.  There was no abdominal rebound or guarding.  There was no leukocytosis.  A CAT scan of the abdomen and pelvis was negative for acute findings.  She was told that the pain management options were limited due to her kidney disease.  She was given oral Dilaudid, but she was dissatisfied with her pain regimen and left the hospital.

Clinical indications for admission for undiagnosed abdominal pain (M-05) include the need for surgery that cannot be performed on an ambulatory basis or peritoneal signs.  The patient did not have these conditions.  She also did not have hemodynamic instability, intestinal obstruction, bacteremia, or an inability to maintain oral hydration.

Clinical indications for admission for gastroenteritis (M-170) include a suspected severe infection such as bloody diarrhea, severe abdominal tenderness, hemodynamic instability, and severe dehydration.  The patient did not have these conditions.

This patient had lupus and chronic abdominal pain.  She had a recent diagnosis of Influenza A.  She received intravenous (IV) hydration for her renal disease.  No dialysis was needed.  She was seeking pain control.  IV hydration and pain management could have been given with observation status.  She did not meet MCG criteria for admission for either undiagnosed abdominal pain or gastroenteritis.  The healthcare plan acted reasonably and with sound medical judgment and in the patient's best interest.  An inpatient medical admission was not medically necessary.

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

Digestive System / Gastrointestinal - Appendicitis
Inpatient Hospital

The patient is a male who presented to the emergency department (ED) with a history of progressively worsening abdominal pain, vomiting, and diarrhea of 3-days duration. His evaluation included physical exam, labs, and computed tomography (CT) scan. He was without fever at the time of presentation. The heart rate was 92/minute. Lab data identified a white blood cell (WBC) count of 12 thousand (K). CT scan yielded the diagnosis of acute appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was obtained.
The patient underwent laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated, but suppurative appendicitis. He was provided IV fluid and perioperative antibiotics. The vital signs remained normal following surgery. The patient tolerated a diet and was discharged from the hospital.

The health plan's determination is upheld.

This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan confirmed the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, IV antibiotics and appendectomy. The early post-surgical course was uncomplicated, and the patient was clinically stable. He was stable for discharge from the hospital.
The submitted clinical documentation does not support the need for inpatient admission for this patient. The patient required urgent surgical intervention for acute appendicitis, however, a lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care. There was no documentation of hemodynamic instability, intra- or peri-operative complications, severe pain, or unstable comorbidities. The member tolerated oral hydration, diet and medication. Pain was well controlled.
The patient could have been appropriately treated at a lower level of care status. Inpatient care was not required or medically necessary in this case as this level of care was not in accordance with generally accepted standards.
Appeal type: Medical necessity
Decision: Upheld

Appendicitis
Inpatient hospital stay

This patient had no significant past medical history  who presented to the  (ER)  with complaints of worsening right lower quadrant pain. Vital signs were stable on presentation and labs were essentially normal. There was no elevation in the white blood cell count. A  (CT) scan was obtained that was read as acute appendicitis with a mildly dilated appendix and mild surrounding inflammation. A surgical consult was obtained, and the patient underwent a laparoscopic appendectomy. The procedure was uncomplicated, and the patient was discharged home from the recovery room after having had a sandwich, stable vital signs and pain controlled with oral medication. The health plan's determination of medical necessity is upheld in whole. Uncomplicated and routine laparoscopic appendectomy can be performed at a lower level of care, such as an observation or ambulatory/outpatient level of care. This patient had rapid intervention with decision to proceed with surgery from the ER, the procedure was uncomplicated and routine. The patient was doing well post-operatively and was able to be discharged directly from the recovery room having met standard discharge criteria within a single day. The patient did not require an acute inpatient stay and met a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure 
Treatment: Inpatient admission 

Summary:
The patient is a female with history of depression and seizure disorder. She presented to the emergency room for urgent evaluation of altered mental status, agitation, and seizure activity. Prior to going to the emergency room, she was seen by her primary care physician due to leg weakness, a sensation of numbness in her knees, and strange behaviors for two days. She reported having a fall earlier in the day but denied head trauma and loss of consciousness. She used a cane for assistance with ambulation due to arthritis. She admitted she had missed some doses of her seizure medication and had a witnessed seizure at her primary care physician's office. Emergency services were called and the patient was brought to the emergency room. 

The patient had a witnessed seizure and a given history of medications noncompliance. Rescue antiepileptic medication was given in the emergency room and anti-antiepileptic management was reinstated. At this juncture, the patient could have been managed at a lower level of care, such as outpatient or observation setting. The patient was rapidly improving and reached her baseline was in just a few hours after her antiepileptic treatment was reinstated. Therefore, she did not require acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Intensive outpatient substance use treatment

Summary:
The patient is a male. He was admitted for substance use disorder rehabilitation treatment of moderately severe alcohol and cannabis use disorder. The admission to intensive outpatient program (IOP) level-of-care was prompted by legal issues in which the patient had his second DUI arrest and was mandated to seek treatment. At the time of admission, the patient had not used alcohol since mid 2019. The patient reported no intense craving and denied history of delirium tremens or withdrawal seizures. There were no general medical issues or psychiatric disorders in this case, and the patient denied use of other substances of abuse other than tobacco.

The Intensive Outpatient substance Use treatment in this case scenario, was amenable to treatment at a lower level of care. The patient was externally motivated and able to effectively engage in rehabilitation services, and, the patient did not need the structure or monitoring of an IOP setting in order to safely and effectively participate in rehabilitation substance abuse treatment. There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted IOP level services and treatment. Moreover, the patient demonstrated his motivation for involvement in the substance use disorder, as noted in the clinical summary. Thus the requested benefit of Intensive Outpatient substance Use treatment is not medically necessary for this patient.

This answer is consistent with prevailing standards of professional practice, ASAM Criteria, and the scientific literature, referenced below, as well as New York State instruction for medical necessity reviews together with the NY State OASAS LOCADTR 3.0 Criteria, applicable in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure disorder

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial upheld.

This patient is a male with a prior medical history to include seizure disorder who presented to the Emergency Department with complaints of a seizure. The documentation detailed the patient was on Keppra however, was noncompliant in taking his anti-seizure medication. The documentation indicated the patient was confused and was previously seen in the Emergency Department with seizures. The patient has not been going for scheduled follow-ups. While being prepped the patient did have a generalized seizure that was controlled with 2 mg of Ativan. The physical exam did indicate the patient was confused and postictal. The patient was confused with poor responses. It was recommended the patient undergo multiple laboratory studies. The patient was also recommended to receive intravenous (IV) Keppra. The recommendation was made by the neurologist to admit the patient to pediatric floor. The documentation indicated he continued treatment and monitoring and the following day the patient became verbally abusive and very agitated physically. He insisted he wanted to go home. The patient used foul language and was physically threatening. Multiple physicians had been consulted regarding the patient's situation. They agreed to discharge the patient as he was insistent on going home. The documentation indicated upon discharge the patient denied any complaints of vomiting or dizziness. The patient was discharged the following day with instruction to follow-up with a Neurologist.

According to current literature a pediatric patient may be admitted to inpatient services for seizures when there is evidence of hemodynamic instability, a complex febrile seizure, the patient is status epilepticus or repetitive seizures are evident that are not controlled with emergent treatment. Furthermore, an admission may be noted when there are cardiac arrhythmias of immediate concern, altered mental status that is severe or persistent or there is a metabolic disorder or new focal neurologic deficits. Within the documentation none of the above was noted. The documentation detailed the patient had a history of seizures as well as autism. The documentation indicated the patient had one witnessed seizure and no further events. The documentation does not detail a failure of lower levels of care or any of the above indications. Therefore, it appeared the patient was clinically stable enough to receive services at a lower level of care such as observation. 

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

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

Diagnosis: Multiple teeth in failing condition

Treatment: Lower false teeth

The insurer denied coverage for lower false teeth. The denial was upheld.

This patient is a male patient who initially presented to his dentist's office for an emergency exam and surgical extraction of teeth #'s 14 and 15. During the course of several months, the patient had the following teeth extracted in this order:  #'s 14, 15, 16, 18, 19, 2, 3, and 31 due to having multiple teeth in failing condition.  The patient and his dentist are requesting lower false teeth to address the patient's dental condition. The dentist recommended a lower partial denture to be fabricated after the extractions.  The insurer has denied this service stating this treatment is not medically necessary as there is no evidence of treatment for periodontal disease.  The patient is appealing the decision. 

Although, based on the narrative letter, multiple teeth were extracted, there is no objective supporting documentation to support or substantiate the recommended treatment.  At bare minimum a copy of radiographs would be required; however no documentation has been provided for review by the dentist.

Therefore, as the documentation is inadequate to justify the recommended treatment, the lower partial denture is deemed not medically necessary.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.
 
The carrier's denial of coverage for the lower false teeth is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient hospital

The patient is a female with diabetes, hypertension, coronary artery disease (CAD) status/post (s/p) percutaneous coronary intervention (PCI) who was admitted to the hospital with complaints of chest pain.
The electrocardiogram (ECG) at that time was normal with nonspecific t-wave abnormalities and the echocardiogram obtained revealed a normal ejection fraction (EF) with no wall motion abnormalities. The cardiac enzymes were normal and the patient was sent home for noncardiac chest pain to follow up with her primary care provider. The inpatient hospital stay is what is under review.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient presented with non cardiac chest pain with no acute changes on ECG, no hemodynamic compromise, no evidence of congestive heart failure or abnormal rhythms and the heart function was normal by echocardiogram. The EF was normal, there was no wall motion abnormalities, and the cardiac enzymes were normal. There was no indication that the patient needed to be kept in the hospital for an inpatient admission based on the clinical information and supported by the medical literature. The patient could have been evaluated and cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) complaining of several episodes of substernal chest pain with associated dyspnea and left arm and leg numbness over the preceding two hours. The patient had been admitted to a different hospital with syncope and similar symptoms the week prior and had undergone catheter ablation of frequent premature ventricular beats. In the ED the patient's blood pressure was 133/79 millimeters of mercury (mmHg) with a heart rate of 75 beats/minute. The respiratory rate was 17/minute with a room air oxygen saturation of 100%. The physical exam, electrocardiogram and chest X-ray were normal. The serum troponin level was 0.041 ng/ml (upper limit normal .034 ng/ml). The patient was treated with Aspirin and was admitted to the hospital. A repeat troponin level was 0.046 ng/ml. The patient was seen by a cardiologist who opined that the patient's chest pain was not ischemic in origin. 

The health plan's determination of medical necessity is upheld in whole.

No. The requested health service/treatment of an inpatient stay was not medically necessary. This patient presented with atypical chest pain. The electrocardiogram was normal. While the serum troponin level was minimally elevated, the records provided do not indicate that there was significant concern for acute coronary syndrome (ACS). The HEART (history, electrocardiography, age, risk factors, troponin) score was 1, indicating a low risk for major adverse cardiac events. Other than Aspirin, no specific treatment for ACS was administered. While it was reasonable to monitor the patient until ACS could be ruled out, this did not require an inpatient level of care.