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

This is a patient who was admitted following medical screening, to acute inpatient level services for monitoring and detoxification and withdrawal management of severe alcohol and stimulant (crack cocaine) use disorders. He had experienced moderately severe alcohol withdrawal at the time of admission including tremors, joint pain, nausea, diarrhea and vomiting, irritability, insomnia and anxiety with a Clinical Institute Withdrawal Assessment (CIWA) scale score of 16 (moderately severe withdrawal symptoms). The patient has a history of co-occurring psychiatric disorder and ongoing treatment with Abilify. Following his first day of treatment, the patient began to participate in counseling and educational sessions. The tapering of Librium and vitamins were continued, as well as comfort medications with monitoring and assistance with daily activities. He continued to report tremors, body aches, anxiety and insomnia requiring as needed medications that included Benadryl and trazodone and analgesics. He was noted to have persistent withdrawal symptoms.  The health plan's determination is overturned. The inpatient treatment of this patient's substance use disorders did require the admission and continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder and comorbid cocaine use disorder, and the presentation with moderately severe withdrawal symptoms with persistent withdrawal symptoms throughout the stay. Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Librium which required monitoring, as well as comfort medications and vitamin replacement therapy. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

The patient has a past medical history significant for tobacco abuse, sciatica, coronary artery disease, multiple sclerosis, and chronic obstructive pulmonary disease (COPD) who presented to the emergency department on  with a chief complaint of worsening shortness of breath, difficulties breathing, and a feeling of "fluid" in the lungs when laying down. The symptoms started 2 days before the day of admission. In addition, patient complained of generalized weakness and a cough productive of clear mucus. In the emergency department, the patient's temperature was 102.4F, blood pressure 135/77, pulse rate 124, respiratory rate 22, and oxygen saturation 93%.
In the emergency department, the patient received treatment with intravenous fluids, intravenous Solu-Medrol, several rounds of breathing treatment, intravenous magnesium, and Levaquin. An arterial blood gas (ABG) revealed that the potential hydrogen (pH) was 7.445, partial pressure of oxygen (PaO2) 51, PCO2 36, bicarbonate 24.3, oxygen saturation 85% on room air. The patient was admitted to the hospital with a diagnosis of acute exacerbation of the chronic obstructive pulmonary disease. In the hospital, the patient was treated with supplemental oxygen, bronchodilators, Prednisone, and Zithromax. The requested health service/treatment of inpatient hospital stay was medically necessary for this patient, since the patient developed acute respiratory failure with hypoxia due to COPD/asthma exacerbation, and also met sepsis criteria. Acute respiratory failure with hypoxia is a serious medical condition that requires treatment with supplemental oxygen as well as identification of the reason for hypoxemia with subsequent treatment of the underlying cause.
The presence of acute respiratory failure and possible sepsis increased the complexity of the services provided, and therefore, the patient's condition qualified for an acute inpatient level of care. Despite intense treatment provided in the emergency department, the patient still remained symptomatic, complaining of shortness of breath, and wheezing. This prompted admission to the hospital and initiation of treatment with bronchodilators, corticosteroids, and antibiotics, as well as close monitoring for signs of clinical deterioration of the acute respiratory failure. The health plan's determination is overturned in whole
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance abuse 
Treatment:  Inpatient stay 

Summary:
The Continued Substance-related residential care is medically necessary in order to address issues related to relapse risk with focus on a relapse prevention plan and work on developing coping skills in a case that poses high risk for relapse, in order to address the patient's lack of awareness of the seriousness of his illness with psycho-education and evidence-based psychosocial interventions, including motivational techniques, in order to address the social environment, including use of multiple substances of use with potentially lethal consequences in the context of high risk behaviors, and in order to work on coping skills that will be necessary in building an effective sober support system and continued recovery efforts with community providers while maintaining his occupational functioning.  None of this therapeutic work could have been safely or effectively provided at a lower level of care in view of the multiple complicating factors in this case, including the high risk for relapse, the treatment history of continued use of substances despite access to treatment and failed efforts to curtail his use, and the lack of a reasonable recovery environment that includes high risk behaviors, including use of dangerous combinations of substances.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Coronary Syndrome

Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld. 

This patient is a male who presented to the Emergency Department (ED) in late 2019 with complaints of chest pain accompanied by diaphoresis. The patient reported that pain radiated to the left arm and neck and teeth. He had a history of hyperlipidemia, a recent cough, and fibrosis of lung. He was admitted to telemetry where he had a computed tomography (CT) angiogram which was negative for a pulmonary embolism. However, it was noted that there were chronic interstitial changes to the right lower lobe and bronchiectatic changes bilaterally. He was evaluated by Cardiology who determined that his pain was non-cardiac in origin due to his negative cardiac enzymes and normal EKG. He was stable for discharge with recommendations for follow up in the outpatient setting. 

This patient did not need acute hospitalization. He was afebrile, and hemodynamically stable. He was not hypoxic. CT angiogram was negative for pulmonary embolism. Cardiac enzymes and EKG were normal. WBC was normal as were the electrolytes. The patient could have been placed in observation status while diagnostic testing and treatment were continued. He did not have a pneumonia or acute coronary syndrome. The patient had 3 negative Troponins, was on oral medication.

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

This patient presented to the hospital with a chief complaint of pelvic pain. The patient reported heavy bleeding followed by mild bleeding. Patient had a complaint of left lower quadrant pain for 3 days. The patient rated the pain at 8 of 10 and intermittent that was unrelieved with Tylenol.Patient reported feeling chills and nausea but no documented fever or vomiting. There was  some burning with urination. Patient had a recent urinary tract infection 3 weeks ago. The patient noted mild vaginal discharge for 3 days.
The patient reported a history of menorrhagia,  irregular periods that lasted 7-14 days with heavy flow and dysmenorrhea. Gonorrhea and chlamydia cultures were collected. The patient had a normal pelvic ultrasound. Patient was to be treated empirically with doxycycline. A plan was made to reexamine the patient in the morning. There was thought that this may represent a ruptured hemorrhagic cyst versus gonorrhea /chlamydia versus pelvic inflammatory disease or Mittelschmerz pain. The patient was taken to the operating room  where she underwent a diagnostic laparoscopy with lysis of adhesions and chromotubation of the tubes with excision of present endometriotic lesions. The patient tolerated the procedure well without complications. 
The inpatient admission was not medically necessary, the HP determination is upheld in whole. The surgery was uncomplicated and the surgical time for completion of surgery was normal. There was no excessive blood loss with an estimated blood loss of minimal per the operative note. There was no damage to the patient's bowel, bladder, or other intra-abdominal structures. The patient was noted to meet all aspects of care required for discharge on the date of the procedure based upon the documentation reviewed. The Milliman Care Guidelines (MCG) Guideline entitled "Laparoscopic Gynecologic Surgery, Including Myomectomy, Oophorectomy, and Salpingectomy" were reviewed. The MCG Guideline allows for extension of care to inpatient for certain conditions. The patient had none of the conditions. Based on review of the medical documentation, the referenced peer reviewed literature, and the MCG Guidelines, there was no medical necessity for acute inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sepsis of unknown origin

Treatment: inpatient hospital services 

The insurer has denied coverage for inpatient hospital services. The denial was upheld.

The patient is a female who presented to the emergency room at 23+ weeks gestation with complaint of nausea, vomiting and diarrhea. Initially, her vitals were stable. However, in the emergency department, she became hypotensive and febrile. She was admitted with a diagnosis of sepsis of unknown origin. She was started on intravenous antibiotics and IV fluids.  Her nausea and vomiting had subsided and she was afebrile with stable vital signs.

The inpatient hospital services are not considered medically necessary for this patient's care and management. The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.

This patient presented with nausea and vomiting and diarrhea suggestive of gastroenteritis. However, because of elevated temperature, tachycardia and sudden decrease in blood pressure, sepsis was suspected and admission was medically necessary. However on the date of admission, the patient was stable. She had stable vital signs, she was afebrile, her laboratory and radiological tests were all normal, and continuous admission was not medically necessary.

Most individuals with acute gastroenteritis can be managed in the outpatient setting. Potential indications for hospitalization include the presence of alarm symptoms or signs or individuals at risk for complications (e.g. dehydration), including:

Volume depletion/dehydration 
Intractable vomiting
Abnormal electrolytes or renal function
Excessive bloody stool or rectal bleeding
Prolonged symptoms (more than one week) 
Age 65 or older with signs of hypovolemia 
Comorbidities (eg, diabetes mellitus, immunocompromised)

As of the date of admission the patient had none of the above.

The management that this patient received during her admission could have been easily done in a less acute setting. Once the provider ascertained that there was no evidence of sepsis and that the patient was stable, she could have been discharged.

Based on the above, the medical necessity for the inpatient hospital services at the acute level of care is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with history of asthma, hypertension, gastroesophageal reflux disease (GERD), anxiety, depression and post-traumatic stress disorder (PTSD), who presented to the emergency department (ED) for an intentional overdose of Effexor.  The patient had suicidal ideation and took 20 pills of Effexor.  In the ED, poison control was contacted and recommended 12 hour cardiac monitoring and intravenous fluids.

The health plan's determination is upheld.  The inpatient stay was not medically necessary.  The patient's vital signs were stable, and there was no toxicity that was evident due to her overdose.  This patient did not have any movement problems, dysrhythmias, hyperthermia, or QT prolongation that would indicate significant toxicity from an Effexor overdose.  There were no clinical needs that were being treated and no necessary interventions that required an inpatient level of care.  The patient's only treatment was intravenous fluids and cardiac monitoring, which did not require an inpatient stay.  This patient could have been monitored at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pronation, pes planus, and ingrown toenail
Treatment: Custom foot inserts, L3000
The custom foot inserts are not medically necessary. 

The request is for custom L3000 UCBL type of custom orthotics. The records provided do not establish that the patient needs custom foot inserts. The patient does not display any pathology of which an over the counter device would not be sufficient. Also, there is nothing in the biomechanical assessment that shows the patient has severity for custom foot orthotics. Lastly, the letter of medical necessity is non-specific and does not add any additional supporting information towards the medical necessity of custom foot inserts for this patient. Therefore, the custom foot inserts are not medically necessary at this time. 

Medically appropriate alternatives were also offered to this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Flutter with Rapid Ventricular Response
 
Treatment: Inpatient Admission 

The insurer denied the Inpatient Admission. The denial was upheld.

This is a male patient who presented to the emergency room (ER) with a rapid heart rate, palpations, a non- productive cough, low grade fever, and epigastric discomfort for 3 days. He has a history of stage 4 melanoma to the base of his tongue, paroxysmal atrial fibrillation, and tachycardia-bradycardia syndrome. The patient had been evaluated for his symptoms earlier that day at an outside hospital. Laboratory work up was done, and his chest x-ray was normal; he was discharged home. After further discussions with his primary care physician he went to the ER for further evaluation. He had an electrocardiogram (EKG) which revealed atrial flutter with rapid ventricular response. It was noted that the patient had a white blood count (WBC) of 14.5 and a temperature of 101F; he received antibiotics. An Echocardiagram was preformed which showed normal ejection fraction and left ventricular systolic function, with mild left ventricular dysfunction, mildly dilated left atrium, and mild thickening of mitral valve leaflets. The patient received intravenous fluids and Diltiazem 20mg, with no change in his heart rhythm. The patient was monitored on telemetry and his medications were adjusted to control his heart rate. The patient was discharged home when he was medically stable. 

The patient presented with atrial flutter. The remainder of the cardiac workup was unremarkable, including unremarkable cardiac troponin. He remained clinically and hemodynamically stable. The inpatient admission was not medically necessary for this patient. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing. 

The insurer's previous denial for inpatient admission is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion and anterior crowding
 
Treatment: Orthodontic treatment

The insurer denied the orthodontic treatment.  The denial was upheld.

This patient presented for evaluation for orthodontic care.  The patient's orthodontist identified findings including overjet, Class I malocclusion, anterior crowding and has recommended orthodontics.  The orthodontist completed the HLD index, attaining 13 total points to support orthodontic care.  The insurer denied coverage for orthodontic treatment, having attained a score of 17 points on the HLD index.  

It is evident that the patient exhibits a malocclusion.  However, to assess for necessity for orthodontic care, New York State requires the Handicapping Labio-Lingual Deviation Index Report.  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 13 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer, attaining a total of 17 points on the HLD index (4 overjet, 4 overbite, 5 anterior crowding, 4 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.  

The Handicapping Labiolingual Index has been shown through peer-reviewed articles to be an accepted methodology which has been determined to represent an appropriate approach for assessing orthodontic need.  

The carrier's denial of coverage for D8080- Comprehensive orthodontic treatment of the adolescent dentition and D8670-Periodic orthodontic treatment visit is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of left-sided cerebrovascular accident (CVA) and residual mild right hemiparesis. The patient was under the care of a physiatrist is for right groin pain and apparent right lower limb radicular pain in the setting of lumbar spondylosis. The patient had been prescribed physical therapy (PT) by his physiatrist. The patient did complete some physical therapy visits, but was later denied continuation of PT. Additional PT visits are under review.

The health plan's determination is upheld. The additional PT is not medically necessary. The patient has a long-standing history of chronic right sided radicular low back pain beginning and groin pain after the patient underwent inguinal hernia repair. According to the medical records provided for this review, the patient has had multiple courses of outpatient physical therapy for these issues.  There are no PT notes submitted for review.  Furthermore, there are only records submitted from the physiatrist from one specific encounter. Thus, there is no way to determine whether or not the patient had been making clinical progress with PT during this specific treatment course. Based on this, there is lack medically documented support for continued PT at this time. Therefore, the additional PT is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Edentulous space

Treatment: (D6010) implant placement, tooth #13; (D6057) custom abutment tooth #13; (D6058) abutment supported porcelain/ceramic crown tooth #13

The insurer has denied coverage for (D6010) implant placement, tooth #13; (D6057) custom abutment tooth #13; (D6058) abutment supported porcelain/ceramic crown tooth #13. The denial was upheld.

Based on review of the submitted documentation which includes copies of periapical radiograph, narrative letters of support and treatment notes in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for edentulous space in the area of the left maxilla #13 area.  The treating doctor recommended endosteal implant to be placed at the site after discussion of treatment plans.  The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only procedure or appropriate treatment and cite that an alternative appropriate therapy, as per the alternate benefits provision of the insurance contract, would initially be a removable partial denture which would restore form, function and esthetics but there are enough posterior contacts with remaining dentition to exclude this as well.  Therefore the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.

Upon review of the objective documentation which primarily consists of the periapical radiographs and treatment notes, it is evident tooth #13 was non maintainable as noted and restoration of the space was to be considered. He suggested an endosteal implant and associated services. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include a removable partial denture or a fixed three unit bridge as cited by the insurer. Therefore as partial dentures and fixed bridges remain standards of care in general dental practice, the alternate benefits provision of the insured's contract is valid and therefore the endosteal implants are considered elective and not medically necessary.  

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

Uphold denial of coverage for (D6010) implant placement, tooth #13; (D6057) custom abutment tooth #13; (D6058) abutment supported porcelain/ceramic crown tooth #13 as not medically necessary, as an appropriate alternative standard of care treatment would be a removable partial denture or a fixed bridge.  Therefore, as other acceptable alternative treatments are appropriate this renders the endosteal implants not medically necessary.

Based on the above, the medical necessity for (D6010) implant placement, Tooth # 13; (D6057) custom abutment, Tooth 13; and (D6058) abutment supported porcelain/ceramic crown, Tooth # 13 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decay and periodontal issues
Treatment: D0367 - CT scan
D6010 - Implant placement, teeth 11, 13, 22, 27, 4, 6
D6104 - Bone graft at time of plant placement tooth 11, 13, 22, 27, 4, 6
The proposed treatment is medically necessary. 

The patient has severe decay and periodontal issues on his remaining natural teeth. His dentition is not restorable. Extracting all his remaining teeth and placing implants (with bone grafts for good stability of the implants) to ultimately support dentures is a very reasonable treatment plan for this patient. The patient does not have very good jawbones (too bulbous) to make conventional dentures on, as well as an active gag reflex, which a conventional denture will activate. These are good reasons that implant supported dentures are the best way to treat this patient, so he does not compromise his diet which would make his medical issues worse.