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

Diagnosis:  Laceration.
Treatment:  Procedure code 99284.

The insurer is denied coverage for procedure code 99284.  The denial is upheld. 

This is a female patient who presented to the Emergency Room (ER) after having a fall.  The patient sustained a laceration on the right side of his eyebrow.  She underwent debridement and complex plastic surgical repair and was subsequently discharged home.

According to the NCCI manual, "The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service".  However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. . .".  For example, if a physician determines that a new patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E&M service is not separately reportable.  In this case, the consult note from the doctor documented a brief history, a review of medications and allergies and an exam that was focused solely on the patient's laceration.  This level of documentation is not consistent with the description of code 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components:  A detailed history; A detailed examination; and Medical decision making of moderate complexity).  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs.  Usually, the presenting problem(s) are of high severity and require urgent evaluation by the physician but do not pose an immediate and/or significant threat to life or physiologic function.  The doctor's note does not document any of the components required for CPT 99284.  Moreover, per Principles of CPT Coding published by the American Medical Association and the NCCI manual, an E and M code for evaluation of a laceration should not be submitted when the laceration is repaired on the same day.  Thus, procedure code 99284 is not considered medically necessary.

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

The carrier's denial of coverage for procedure code 99284 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior Crowding, Overjet and Overbite
Treatment: D8080 braces and D8670 monthly visit x 8
The insurer denied coverage for D8080 braces and D8670 monthly visit x 8
The denial is upheld.
 
This is a patient that consulted an orthodontist for an evaluation for orthodontic care. Diagnostic testing was performed that included lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images. The orthodontist identified several clinical findings including anterior crowding, overjet and overbite and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 17 total points to support orthodontic care.
 
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 having attained a score of 16 points on the HLD index.  

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 an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 17 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 17 points on the HLD index (3 points overjet, 4 points overbite, 5 points anterior crowding, 5 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note in this case is that the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

Uphold the denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care as it does not meet the accepted criteria for approval. 

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient. In this case, the patient's own orthodontist's completed HLD index total score of 17 points remains below the threshold of 26 points to justify orthodontic care. 

D8080 braces and D8670 monthly visits x 8 is not considered medically necessary for this patient.

The carrier's denial of coverage for D8080 braces and D8670 monthly visit x 8 is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Grave's Ophthalmopathy
Treatment: Tepezza Solr
The insurer is denied coverage for Tepezza Solr
The denial is overturned. 

This is a female patient with Graves' ophthalmopathy.  The patient consulted a provider for complaints of slight pain in her right eye. An examination was performed that revealed her visual acuity to be  20/30 in both eyes (OU) and slight decrease of range of extraocular movements, and bilateral upper lid retraction and rapid tear break-up time (TBUT). The patient's visual field testing was full in both eyes. A computed tomography (CT) scans of the orbits was done that showed findings compatible with mild orbital ophthalmopathy with mild thickening of extraocular muscles and mild right orbital exophthalmos. On follow up examination the patient's visual acuities were 20/25 in the right eye (OD) and 20/30 in the left eye (OS) and slight decreased range of motion with extraocular movements on both eyes, right upper lid retraction greater than the left upper lid retraction, right >left lagophthalmos, and rapid TBUT on both eyes. Medrol was continued and patient advised to stop smoking. The patient's visual acuities were 20/25 OD and 20/30 OS. The patient's exam was unchanged.  The patient's visual acuities were 20/25 in both e yes. The patient's exophthalmometry showed 24mm OD and 22mm OS. The patient's clinical exam showed lid retraction, lagophthalmolos, rapid TBUT in both eyes. Medrol was tapered off and the patient was to try Tepezza (teprotumumab).

Teprotumumab is used for thyroid eye disease, in accordance with accepted standards of good medical practice and is clinically appropriate for this patient's condition. The patient's clinical exam and testing supported active thyroid eye disease, including findings of exophthalmos/proptosis. The patient's computed tomography (CT) scan of the orbit on also showed findings consistent with thyroid eye disease. Teprotumumab is an FDA-approved drug for the treatment of the patient's condition, and has been shown to result in better outcomes with respect to proptosis, clinical activity score, and diplopia and quality of life among patients with active thyroid eye disease (Douglas 2019, Douglas 2020). Thus, Tepezza (teprotumumab) is considered medically necessary for this patient. 

The carrier's denial of coverage for Tepezza Solr should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea
Treatment: Inpatient admission 
The insurer is denied coverage for the inpatient admission.
The denial is upheld.

This is a male patient that came to the hospital complaining of shortness of breath and tingling sensation to his left arm and left leg. The patient was transferred from another facility for a cardiac catheterization. It was noted that overnight telemetry at the prior facility demonstrated sinus bradycardia with a heart rate of 39 beats per minute. The patient was admitted to the hospital with Dyspnea. An electrocardiogram (EKG)  was performed that was negative for a myocardial infarction. Cardiac troponins excluded an acute myocardial infarction. A cardiac catheterization was performed and revealed normal coronaries. The patient tolerated the procedure well and he was discharged with instructions to follow-up with his physician on an outpatient basis.
The acute inpatient admission was not medically necessary. The patient underwent an uneventful cardiac catheterization procedure with no complications. He remained hemodynamically stable, was ambulatory, and was tolerating oral intake. There were no hemodynamic or clinical complications or concerns noted. Per MCG 23rd Edition Guideline Cardiovascular Surgery or Procedure GRG: SG-CVS (ISC GRG), cardiac catheterization is an outpatient procedure. The patient did not meet inpatient admission criteria following the procedure. 

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 inpatient admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient is a male who was sent to the emergency department (ED) for chest pain. His chest pain was associated with nausea, dizziness and shortness of breath. His chest pain started 3 hours prior to arrival and resolved after aspirin was given, it lasted for one hour. His chest pain was described as central pressure, non-radiating, started while lying in bed. The patient reported that dizziness and nausea were similar to his previous attack of vertigo.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient with several coronary risk factors presented with atypical chest pain. He had associated nausea and dizziness. He was appropriately evaluated and managed.

However, there were no signs of acute coronary syndrome or other urgent cardiac syndrome which would justify inpatient admission. His vital signs were stable. His cardiac enzymes were normal. The ECG was not entirely normal but was without evidence of dynamic changes. The rest of his labs were unremarkable. His Hgb was just slightly low and no management was necessary for that. His asthma was stable
The patient did not have indications for an inpatient admission. He could have been managed, most appropriately, at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was brought to the emergency department (ED) by 911 personnel after she had a choking episode.  The baby had a sibling that died of SIDS (sudden infant death syndrome) in 2007.
The ED triage note says that the "mother was breast feeding the baby when the baby choked, vomited the milk, and the mother suctioned the baby.  The mother wanted the baby checked."  The vital signs and physical exam were normal.  The ED progress note says the baby had an episode of choking.  The parents reported that after mom breast fed her, she tried to burp her, but no gas came out, so 10 min later she laid her down to change her when she noted she was throwing up the milk, and it also came out by her nose.  Soon after that she was breathing, but 'more softly,' as per dad, and was limp with watery eyes, no loss of consciousness (LOC), no change in skin color or cyanosis; the whole event lasted about 2-3 minutes.
She was diagnosed in the ED with a high risk brief, resolved, unexplained event.  She was admitted for observation and monitoring and had no further events.  The parents were taught cardiopulmonary resuscitation (CPR), and the baby was discharged home.  The health plan's determination is upheld.
The American Academy of Pediatrics published a practice guideline for BRUE (brief resolved unexplained event). BRUE is the new term for what used to called ALTE (apparent life threatening event) and before then, "near SIDS."
According to the new guideline, choking episodes alone are not BRUEs, but this baby's episode was accompanied by a change in tone, so this baby did have a BRUE according to the guidelines. Also according to the guideline, because the baby was under 60 days old, the baby did not have a "low risk" BRUE for which outpatient management is appropriate.
Since this baby did not have a low risk BRUE, and had a prior sibling who died of SIDS,  it was appropriate to observe the baby overnight.  However, this could have been done at a lower level of care than an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Chest pain
Inpatient hospital

The patient is a female with a past medical history significant for hyperthyroidism and osteoporosis who presented to the emergency department with complaints of chest pain and shortness of breath. Reportedly, she was in her usual state of health until almost 2 weeks before the day of admission when she started to experience chest pain that she described as pressure. The pain was constant. She stated that the pain was alleviated by rest. The patient also stated that the shortness of breath was aggravated by walking and she had to stop walking a couple of blocks. Apparently, the patient was seen by her cardiologist as an outpatient and was scheduled for a stress test. It was reported that during the stress test the patient became severely short of breath and was brought to the emergency department.

The health plan's determination is upheld. The inpatient stay was not medically necessary. During this period of time, the patient remained afebrile and hemodynamically stable. The symptoms that brought the patient to the emergency department significantly improved after the transfusion of packed red blood cells.
There was no evidence of ongoing active bleeding, hemolysis, respiratory failure, heart failure, acute coronary syndrome, or acute peripheral ischemia that would justify admission at the acute inpatient level of care in the case of anemia. Neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency department (ED) on with a history of progressively worsening abdominal pain of several days duration. His evaluation included a physical exam, labs, and a computed tomography (CT) scan. He was without a fever at the time of presentation. Vital signs were normal. Lab data identified a white blood cell count (WBC) count of 14 thousand (K). The CT scan yielded the diagnosis of acute appendicitis without perforation. Treatment was initiated with IV fluid and antibiotics. A surgical consultation was obtained.
The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy. The operative note describes an acute, non-perforated, appendicitis. He was provided IV fluid and perioperative antibiotics. His vital signs remained normal following ED presentation. He tolerated a diet and was discharged from the hospital. The health plan denial letter states that CPT code 47562 (cholecystectomy) was denied due to lack of medical necessity.
The health plan's determination is upheld.
CPT 47562 was not performed in this case. The records indicate that this patient presented to the emergency department (ED) with acute appendicitis and underwent an appendectomy. 
While CPT 47562 was not medically necessary, CPT 44970 was medically necessary and appropriate based on the submitted medical records. Appendicitis was supported by presenting symptoms and exam findings and diagnostic results (labs and CT scan). This procedure was also appropriately performed with an ambulatory designation in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility.
Treatment: In-vitro Fertilization (IVF).
The insurer denied the In-vitro Fertilization (IVF).
The denial is upheld. 

No, the In-vitro Fertilization (IVF) is not medically necessary.

The patient is a female with a diagnosis of infertility due to age-related decrease ovarian reserve. The patient has failed five prior IVF (in vitro fertilization) cycles.

Cycle #1: Two eggs fertilized. None made it to blastocyst.

Cycle # 2: One embryo tested and was abnormal.

Cycle # 3: No egg recovered.

Cycle # 4: Four eggs retrieved. One abnormal embryo transferred.

Cycle # 5: Four eggs retrieved no fertilization.

The patient has documented decrease ovarian reserve based on her response to prior stimulations and AMH (anti-mullerian hormone) levels.

IVF has been increasingly used to combat age-related infertility. It has become clear that the decline in fertility with increasing female age is largely due to a rapid decrease in oocyte (egg) quantity and quality, with a higher proportion of oocytes displaying genetic abnormalities. Despite significant improvements in medical stimulation and laboratory culturing of embryos, IVF success rates associated with decrease ovarian reserve is exceedingly rare.

The aim of any treatment is the final result. In this case, the aim is to have a healthy live birth. Based on this patient's history, AMH levels, prior response to ovarian stimulation, prior failed five IVF cycles with not a single good embryo to transfer, the odds of aneuploidy are significantly increased, and the odds of conceiving are minimal if any.

At this time, the only treatment available for patients such as this patient is the use of donor eggs. This is in accordance with scientific data and standard of care.

Based on all the available scientific evidence, the odds of success are much less than 5% with IVF and therefore not medically necessary.

Based on all of the above, the denial of coverage of more IVF cycles is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a past medical history (PMH) of osteoarthritis (OA), obesity, gastroesophageal reflux disease (GERD), migraines and hypertension (HTN) and was admitted with complaints of (c/o) abdominal pain associated with nausea, vomiting and dizziness after taking new HTN medications. The abdominal pain was noted to be improving in the emergency department (ED) without any nausea or vomiting noted during the ED stay. Vital signs were notable for temperature 100.2 degrees Fahrenheit and pulse 94. The physical exam was notable for dry mucus membranes (MM), and clammy, mild generalized tenderness in abdomen without rebound/rigidity. Lab work was notable for electrolyte abnormalities, mild leukocytosis, and mild transaminitis. A chest x-ray (CXR) showed interstitial prominence, transthoracic echocardiogram (TTE) showed no significant abnormalities, right upper quadrant (RUQ) ultrasound (US) showed fatty liver disease (FLD) and an electrocardiogram (EKG) showed normal sinus rhythm (NSR) without ischemic changes. The patient was diagnosed with dehydration and gastroenteritis and treated with anti-emetics, antacids, and intravenous (IV) fluids. The patient also received cefoxitin due to potential concern for choledocholithiasis. The patient was discharged on 5/4/2019 in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o abdominal pain associated with several episodes of nausea and vomiting. The patient did not have associated high-risk features, such as renal failure, congestive heart failure, or liver failure, nor did the patient have any hemodynamic instability. In addition, while the patient had electrolyte abnormalities, the patient responded to electrolyte repletion, nor did the patient have bowel obstruction, diabetic ketoacidosis, or appendicitis. The patient was hemodynamically stable, the pain was documented to have improved while in the ED, there was no acute kidney injury, pyelonephritis, ascending infection, toxic appearance, unstable vital signs, or immunosuppression. The patient presented with acute viral gastroenteritis with dehydration, was treated and responded to IVF, anti-emetics, one day of IV antibiotics and pain control, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal.
Treatment: Inpatient Hospital.
The insurer denied: Inpatient stay.
The denial is: Upheld in whole.

The patient is a female who presented to the hospital with right sided abdominal pain of 4-days duration. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the right upper abdomen. The white blood cell (WBC) count was 11 thousand (K). Abdominal computed tomography (CT) identified cholelithiasis/cholecystitis. Comorbid health conditions included hypertension. The complete metabolic panel identified normal serum transaminases. Bilirubin was normal. She was initially treated with intravenous (IV) fluid and IV antibiotics. Surgical consultation was obtained. She was treated with laparoscopic cholecystectomy. The operative dictation and the anesthetic record describe an uncomplicated cholecystectomy procedure. The patient was started on a diet following surgery.
The patient was treated with post-surgical monitoring, IV fluid, IV analgesia, and antiemetics. The immediate post-surgical recovery was uncomplicated.  Following surgery, the patient had stable vital signs. Pain was controlled. The diet was advanced.
The patient remained clinically stable and was discharged from the inpatient setting.

The health plan's determination is upheld in whole.

No, the inpatient stay was not medically necessary for this patient who presented to the emergency department (ED) with cholelithiasis/cholecystitis.
There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation.  Serum chemistries identified normal bilirubin and transaminases. CT scan showed a gallstones and findings of cholecystitis. Surgery consultation was obtained and surgery (laparoscopic cholecystectomy) was performed. The perioperative period was uncomplicated and there is no documentation of failure to achieve discharge criteria, conversion to open surgery, care for comorbidities, procedural complications, or any other condition requiring inpatient admission. In this case, none of these indications existed to justify an inpatient level of care.  
 The patient was discharged from the hospital following surgery. Acute inpatient care was not medically necessary for this patient as the care and treatment provided could have been rendered in a lower level of care status. This level of care would have provided for surgical consultation, perioperative care and monitoring, provision of intravenous (IV) antibiotics and fluid, and overnight care. 
Based on the submitted clinical documentation, an inpatient level of care was not medically necessary.