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

Diagnosis: Malocclusion

Treatment: Braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage 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 15 points on review by internal reviewers. The provider is appealing on behalf of the patient.

Upon review of the submitted documentation, 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 the HLD index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not 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 referenced 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.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for D8670 monthly visits services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
 

This is a teenager with a history of asthma. He had been on inhaled steroids and has had frequent asthma episodes in the past. Currently he uses albuterol prior to exercise and when sick with a virus. He had been sick with a cough, fever and chills for 2 days. He awoke at night with shortness of breath on several occasions and was treated with albuterol by his Father. When the episodes of difficulty breathing persisted, he was taken to a nearby emergency room (ER) for treatment. He was noted to have wheezing and a low oxygen saturation of 93%. He tested positive for the influenza virus by a respiratory viral panel. He was treated with oxygen, 3 doses of DuoNeb, dexamethasone and intravenous (IV) magnesium sulfate. When his difficulty breathing and wheezing persisted, he was transferred to another ER for admission to the hospital for ongoing care with a diagnosis of status asthmaticus.

In the ER he was noted to be in respiratory distress with bilateral wheezing and decreased breath sounds over the right lung field. His oxygen saturation was 92% and he was complaining of shortness of breath. A chest x-ray was performed and showed atelectasis of the right middle lobe. He was given a bolus of IV normal saline and started on medication for the influenza A virus. After treatment in the ER he was reevaluated and he was noted to have persistent wheezing and low oxygen saturation and was continued with treatment with oxygen and the decision was made to admit him to the hospital with a diagnosis of status asthmaticus and influenza virus for ongoing treatment with albuterol every 3 hours.  

The insurer has denied the admission as not medically necessary and indicated that there was no documentation in the medical record to support the need for inpatient treatment. 

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. He had been taking albuterol at home and following treatment in the ER he continued to have ongoing respiratory distress with persistent wheezing and increased work of breathing, Based on review of the medical record it was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol and IV fluids with a diagnosis of status asthmaticus. He failed outpatient management of his asthma and had been non-compliant for over 2 years with asthma controller medication. Following treatment in the ER he continued to be in respiratory distress with a diagnosis of status asthmaticus and not stable enough to be sent home.  
Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder bursitis, labral hip tears, and depression
Treatment: Home health care (HHC) level 2 personal care services (PCS), per 15 minutes increase to 45 hours/week, consumer directed personal assistance services (CDPAS)
The insurer denied coverage for HHC level 2 PCS, per 15 minutes increase to 45 hours/week, CDPAS.
The denial is upheld.

This is an adult female with diagnoses of shoulder bursitis, hip labral tear, and depression. She lives with and cares for her 3 children in a private residence. The patient requested an increase in home health care (HHC) level 2 personal care services (PCS), per 15 minutes increase from 30 to 45 hours/week, denied by the insurer and currently under external review.  

The Uniform Assessment System (UAS) report describes the patient's cognitive skills as "Modified independent."  She is self-directing, fully oriented and has a Personal Emergency Response System (PERS). Her ability to perform instrumental activities of daily living (IADLs) including meal preparation, ordinary housework and shopping varies from total dependence to independent. The patient also independently drives a motor vehicle including driving her children to school. She reportedly requires limited assistance for bathing and lower body dressing. The patient is otherwise independent for personal hygiene, upper body dressing, eating, bed mobility, locomotion, toilet transfer/use, and ambulation. She reports frequent bladder incontinence and is continent of bowel. There have been no reported falls over the prior 90 days.  

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested HHC level 2 PCS, per 15 minutes increase to 45 hours/week, consumer directed personal assistance services (CDPAS). Her functional ability has actually improved when compared to the prior UAS report. The patient is essentially functionally independent and any residual functional needs can be appropriately provided and maintained via the more than adequate approved HHC level 2 PCS, per 15 minutes 30 hours/week, CDPAS.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for HHC level 2 PCS, per 15 minutes increase to 45 hours/week, CDPAS is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Hearing Loss (in right ear)
Treatment: Durable Medical Equipment (cochlear implant)
The insurer denied: Durable Medical Equipment (cochlear implant)
The denial is overturned.

The patient is a toddler male with hearing loss. The child has severe to profound right-sided hearing loss. Left-sided hearing is normal. Magnetic resonance imaging of the brain is normal. A right-sided cochlear implant has been requested and was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The cochlear implant is medically necessary.

The patient has single-sided deafness. A conventional hearing aid will be of no benefit to the child. Without a cochlear implant, the child will have no opportunity to develop binaural hearing. 
Studies have shown that children under the age of 5 with unilateral hearing loss benefit from cochlear implantation. This is a safe procedure. Implantation for unilateral hearing loss in pediatric patients under the age of 5 is considered standard of care in major centers in the United States.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Full hospital admission. 
The insurer denied the Full hospital admission. 
The denial is upheld. 

This patient is an adult male body builder who was hospitalized for chest pain. He presented to the emergency department for evaluation of chest and left arm pain after an extensive workout and physically straining his arm. The pain was accompanied by palpitation and shortness of breath. His past medical history includes anabolic steroid use. The patient's vitals were stable. Electrocardiogram (EKG) was remarkable for T-wave inversion in the anterolateral leads. Troponin was negative. Other labs revealed markedly elevated creatine phosphokinase (CPK) 9151, aspartate aminotransferase (AST) 170, alanine aminotransferase (ALT) 62, and creatinine 1.15. The clinical impression was rhabdomyolysis from muscle overuse with stable renal function. Treatment included aspirin and intravenous fluids, but no statin. He was seen by cardiology. He was deemed stable for discharge to home with instruction to stay well hydrated and not use steroids. The request for coverage for inpatient hospital admission was denied based on the patient's policy, and the patient is appealing the decision. 

The requested health service was not medically necessary. 

Based on the peer-reviewed medical literature, including the Milliman Care Guidelines (MCG) criteria for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, acute renal failure (ARF) or any other medical condition, and symptom or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received, including treatment of uncomplicated acute rhabdomyolysis from over-exercising, stable renal function and able to take oral fluids is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is an adult male with past medical history of quadriplegia, neurogenic bladder, recent creation of ileal conduit who presents to emergency department with complaint of increased fatigue, episode of unresponsiveness earlier in the day preceded by slurred speech. Patient with mild hypotension in emergency department (ED), responsive to fluids. Patient admitted, given intravenous (IV) fluids/intravenous antibiotics. He improved, was discharged home. The insurer has denied coverage for the hospital admission, citing a lack of medical necessity. The appeal by the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (26th) urinary tract infection. Patient fails to meet clinical indications for admission to inpatient care (hemodynamic instability, ureteral obstruction, altered mental status that is severe or persistent.) Patient does appear to meet guidelines for observation care: Vital sign abnormality.

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

Diagnosis: dizziness/syncope
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

This case involves a woman admitted to the hospital with a chief complaint of dizziness. She experienced a near syncopal episode at home, fell forward, striking her head, but did not lose consciousness. She reported intermittent dizziness spells since getting the COVID-19 vaccine, worsened by changing position. Evaluation by physical exam shows no neurologic deficits or abnormal cardiopulmonary findings.

The inpatient hospital admission was not medically necessary. The majority of the work-up including head computed tomography (CT), computed tomography angiography (CTA) of the head and neck, and brain magnetic resonance imaging (MRI), failing to demonstrate any abnormalities. The echocardiogram failed to demonstrate any cardiac abnormalities. There is no documentation of hemodynamic instability. Orthostatic blood pressures were within the normal parameters. Observation care adequately addresses the patient's problems. There were no focal neurologic deficits, no recurrence of symptoms, and no clear evidence of a life-threatening condition warranting further inpatient treatment. The medical literature supports a lower level of care for this presentation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Migraine.
Treatment: Botox 200 units every 10 weeks
The insurer denied Botox 200 units every 10 weeks.
The determination is upheld.

This is a female patient diagnosed with chronic migraine. The provider is requesting Botox every 10 weeks rather than every 12 weeks. The provider notes that Botox wears off early. The patient has tried and failed beta-blockers, anticonvulsants, and antidepressants for migraine control. The request was denied by the plan because every 10 weeks is not the Food and Drug Administration (FDA) approved interval. At issue is the medical necessity of Botox 200 units every 10 weeks.
While Botox is FDA approved for prevention of chronic migraine, the frequency of every 10 weeks is not supported by all available resources including controlled trials, the manufacturer's prescribing information, compendia, and the Food and Drug Administration approval. Providing Botox treatment for headaches every three months is a national standard, as recommended by the American Headache Society. The treatments are not given more often due to a small possibility of adverse side effects or the generation of antibodies against botulinum toxin. As such, the request for Botox every 10 weeks is not medically necessary based not he available literature and prescribing guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Implantable cardiac monitor
The insurer denied implantable cardiac monitor
The determination is upheld.

This is a male patient with a history of hypertension, hyperlipidemia, type 2 diabetes and paroxysmal atrial fibrillation (AF). He began having episodes of rapid irregular heart rate and lightheadedness. These occurred about twice/year and lasted up to two hours. During an episode, an electrocardiogram showed AF. Metoprolol and apixaban were prescribed. An echocardiogram was performed and was normal. The metoprolol was discontinued due to bradycardia. The patient had four episodes of palpitations lasting up to 60 seconds. Per his watch, his rhythm during these episodes was AF. Per a visit note, the patient wished to enroll in a clinical trial of pulsed electrical field ablation of AF. The patient wore an event monitor. He had a two-hour episode of lightheadedness and palpitations. His rhythm during this episode was AF. The medical necessity for an implantable loop recorder to assess the frequency of his AF is at issue.
Based on the documentation provided, an implantable loop recorder (ILR) is not medically necessary.
ILRs are small devices implanted subcutaneously for ambulatory electrocardiographic monitoring. Their battery life is several years and they have proven useful in establishing a diagnosis in patients with infrequent unexplained syncope or palpitations for which external ambulatory monitoring has been nonrevealing. They have also been effective in monitoring for occult atrial fibrillation (AF) in patients with cryptogenic stroke.
This patient has recurrent, symptomatic paroxysmal atrial fibrillation that recently has been occurring once to twice a month and has been documented by electrocardiographic monitoring on multiple occasions. He has elected to undergo catheter ablation. In this instance, it is unclear what the indication for the ILR is. While it would provide information as to the frequency and burden of his AF, including asymptomatic episodes, this would not be expected to impact the patient's treatment. Guidelines for catheter ablation of paroxysmal AF (PAF) endorse the use of the procedure in patients with recurrent, symptomatic AF; AF frequency and burden in symptomatic patients do not affect this indication. Guidelines for anticoagulation are not contingent on AF burden documented by ambulatory monitoring either before or after catheter ablation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, heart failure.
Treatment: Increase Consumer Directed Personal Assistance 
Program (CDPAS) Services to a Total of 30 Hours per Week.
The insurer denied: Increasing Consumer Directed Personal Assistance Program (CDPAS) Services to a Total of 30 Hours per Week.
The denial is overturned.

This is an adult male patient who has medical conditions that include heart failure, diabetes, and hypertension. The denial of an increase in consumer-directed personal assistance program (CDPAS) services to a total of 30 hours per week is being appealed. The health care plan approved a total of 15 hours per week. The Uniform Assessment System (UAS) evaluation completed 5 months ago shows modified independent cognition and a need for assistance with all activities of daily living (ADLs), except eating. Compared to the Uniform Assessment System evaluation last year, there has been a decline in all activities of daily living, except cognition and eating. The patient has bowel and bladder incontinence. A statement from New York State and a letter from the Provider notes the patient needs assistance with activities of daily living and the currently approved hours are insufficient to meet his needs. He has had a recent increase in urinary incontinence.

The requested health service is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals including assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. The denial of an increase in consumer-directed personal assistance program (CDPAS) services to a total of 30 hours per week is being appealed. The health care plan approved a total of 15 hours per week. The Uniform Assessment System (UAS) evaluation completed 5 months ago shows modified independent cognition and a need for assistance with all activities of daily living, except eating. Compared to the Uniform Assessment System evaluation from last year, there has been a decline in all activities of daily living, except cognition and eating. The patient has bowel and bladder incontinence. An appeal statement requests additional hours to assist with activities of daily living. The information provided shows that this patient has significant limitations in functioning. The approved consumer-directed personal assistance program of 15 hours per week is insufficient to meet this patient's need for assistance with activities of daily living. The proposed increase to 30 hours 
per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Dental issue
dental/orthodontic

Diagnosis: Class I malocclusion and severe mandibular crowding
Treatment: Braces/Monthly Visits/Retainer 
The insurer denied Braces/Monthly Visits/Retainer 
The health plan's determination is overturned. 

The patient in question is a female with a Class I malocclusion and severe mandibular crowding. Both teeth #22 and #27 are displaced to the labial and are starting to have gingival recession on the labial. Tooth 27 in particular is showing minimal attached gingiva. She is treatment planned for Braces/Monthly Visits/Retainer. 

Braces/Monthly Visits/Retainer is medically necessary for this patient. 
The patient has mandibular incisor crowding, along with some recession developing on teeth #22 and 27. These two teeth are moving labial within the mandibular arch. Studies have shown that even untreated dentitions show increased irregularity with time, which will make treating this occlusion at a later time more difficult. If these teeth continue to migrate labially, they could lose bone support which can cause more recession. Further recession of these teeth could also lead to the need for periodontal grafting on these teeth.
Braces/Monthly Visits/Retainer are medically necessary. Teeth 22 and 27 have gingival recession that will likely worsen with time. Studies have shown that tooth position is a significant factor in the success or failure of treatments for gingival recession.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with no significant medical history who presented to the emergency room (ER) with nausea and lightheadedness. Associated vomiting and presyncope were noted. There was no chest pain or shortness of breath noted.
The patient was admitted for pre-syncope. Neurology was consulted. No significant abnormal findings were noted.

Inpatient hospital admission was not medically necessary. The patient did not present with syncope with high-risk features. The neurological exam was non-focal. There were no abnormal findings on telemetry. No major electrolyte abnormalities or dangerous cardiac arrhythmias were noted. The patient remained hemodynamically stable with no abnormal cardiac findings. A lower level of care was appropriate.