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

Diagnosis: Substance Abuse/Addiction. 
Treatment: Inpatient stay for Detoxification. 

The health plan denied the inpatient stay for detoxification as not medically necessary. 
The reviewer has overturned the health plan determination. 

The patient was admitted to acute inpatient level services for detoxification and withdrawal management of opioid, stimulant (cocaine), cannabis, alcohol, and sedative-hypnotic-anxiolytic (benzodiazepine) use disorders. The patient was using up to 20 bags of heroin daily with intravenous administration. The patient was also using small amounts of alcohol and up to 12 gram of cocaine on a daily basis, as well as one to two marijuana joints intermittently. The patient had experienced severe opioid withdrawal in the past requiring detoxification and had been referred for medication assisted treatment with Suboxone. The patient presented with moderately severe withdrawal at the time of admission with sweats, nausea and diarrhea, piloerection, yawning, aches, and rhinorrhea, as well as anxiety, irritability, and restlessness with a Clinical Opiate Withdrawal Scale (COWS) score of 17. 

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a methadone taper together with vitamin replacement therapy, and medical monitoring. Mental status examination included persistent symptoms of anxiety and irritability with associated symptoms of insomnia addressed with Vistaril and trazodone. 

The requested health service/treatment of Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services is medically necessary for this patient. The presenting clinical features and history and risk for withdrawal seizures and other complications of alcohol/anxiolytic and opioid and stimulant use disorders did warrant the admission and continued inpatient level services with medical monitoring in this case scenario. The proposed inpatient services and detoxification treatment and withdrawal management for severe poly-substance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The patient had severe psychosocial stressors with job loss and functional impairments and continued using heroin despite participating in a medication assisted treatment program with Suboxone. Withdrawal symptoms were managed with tapering dosages of methadone requiring monitoring and as needed use of medications, as well as the availability of comfort medications and vitamin replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. Medical necessity for the admission is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine Criteria and appropriate application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Broken amalgam filling
Treatment: High Gold Content Crown, Tooth 2 (D2790)
The insurer denied the High Gold Content Crown, Tooth 2 (D2790).
The denial is overturned. 

The patient is a female requesting dental benefits for a "High Gold Content Crown" on tooth #2. Per the records, tooth #2 has a broken amalgam filling. 

Yes, the proposed treatment of a "High Gold Content Crown" on tooth #2 is medically necessary.

As evident in the x-rays and photos, the patient presents with a large fracture of the tooth and amalgam filling on tooth #2 that runs mesio-distally along the entire palatal aspect of the tooth. Furthermore, this tooth has been endodontically treated (Root canal Therapy); one of the automatic qualifiers for a crown to be placed is on a tooth that has been endodontically treated.

An endodontically treated tooth has had its nerve and blood supply removed and is therefore brittle and more prone to fracture. The standard of care is crown placement on such a tooth to restore function and protect the tooth from further fracture.

It is clear that there is a significant fracture of the existing amalgam filling on a tooth that was endodontically treated.

Either of these two scenarios alone---(1) Significant and substantial fracture of a tooth, especially with a large filling and (2) Endodontically treated tooth would necessitate the fabrication of a crown to restore the integrity and function of the tooth.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a male with moderate to severe psoriasis affecting the face, scalp, and groin for whom Taltz is requested. He has failed topical steroids and phototherapy in the past. He has been on Taltz for over one year with complete clearance. His prior authorization (PA) lapsed and this is a request to continue treatment with Taltz.

Yes, the proposed treatment with Taltz is medically necessary.

The patient is stable and clear on Taltz for over one year with no side effects. His prior authorization (PA) for the medication lapsed and he experienced a disease flare. It is medically appropriate to continue therapy with Taltz. It is not appropriate to require the patient to have therapeutic trials with other agents as that carries a risk of further disease flare with negative impact on the patient.

Based on the documentation of failure of prior therapies and good response to Taltz, it is appropriate and medically necessary for the patient to continue with this treatment for continuation of care. 

Taltz is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis

Treatment: Fecal calprotectin laboratory test (code 83993)

The insurer denied coverage for the fecal calprotectin laboratory test (code 83993).

The denial is overturned. 

This is a female patient with a history of ulcerative colitis. The patient's colonoscopy revealed moderately severe active ulcerative proctitis. The patient's physician advised fecal calprotectin to help determine her disease activity.

The American College of Gastroenterology has published a clinical guideline "Ulcerative colitis in Adults." This guideline states that fecal calprotectin can be used in patients with ulcerative colitis as a non-invasive marker of disease activity and to assess response to therapy and relapse. As per Jin-Feng Lin, et al. (2014)'s meta-analysis for fecal calprotectin for assessment of inflammatory disease activity, there were 13 studies examined in the final analysis. The conclusion was that fecal calprotectin is a reliable marker for assessing inflammatory bowel disease (IBD) activity.

Based on the review of the medical literature, fecal calprotectin is a reliable marker to assess inflammatory bowel disease (IBD) activity in patients with ulcerative colitis. Thus, it is considered medically necessary for this patient's case.

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

The carrier's denial of coverage for the fecal calprotectin laboratory test (code 83993) should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p (status post) Surgery (thyroidectomy)
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a multinodular goiter who had hemithyroidectomy. The operation was without complications.  A closed suction drain was left in the operative field.  The patient's postoperative course was uncomplicated.  The patient was discharged on postoperative day number one.

No, the proposed treatment, inpatient admission, was not medically necessary.

With an uncomplicated course, and no active interventions, the patient could have been managed at a lower level of intensity than acute inpatient care.

The prior determination of the health plan was reasonable given the absence of acute medical management justifying acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (anterior crowding, overjet and overbite).

Treatment: D8080 braces and D8670 monthly visit.

The insurer denied coverage for D8080 braces and D8670 monthly visit.

The denial is upheld. 

This is a female child who presented for evaluation for orthodontic care. 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 21 total points to support orthodontic care.  The insurer has denied coverage for orthodontic treatment.

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, an HLD 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 21 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer's dentist attaining a total of 17 points on the HLD index (i.e., 6 points overjet, 3 points overbite, 5 points anterior crowding, 3 points labiolingual spread) which is below the threshold of 26 points to support orthodontic care. The patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval.

Thus, the coverage for D8080 braces and D8670 monthly visit is not considered medically necessary for this patient.

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

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

Central Nervous System
Nursing Services (including Private Duty Nursing)

Diagnosis: Guillian Barre syndrome 
Treatment: Increase in Personal Care Services (PCS) to 24 Hours per Day/7 Days per Week (Split-Shift) for a total of 168 hours 
The insurer denied Increase in Personal Care Services (PCS) to 24 Hours per Day/7 Days per Week (Split-Shift) for a total of 168 hours. The health plan's determination is upheld. 

The patient is a female with multiple medical problems and recent diagnosis of Guillian Barre syndrome with weakness, along with chronic pain and mobility disabilities. This review is for the medical necessity of an increase in personal care service hours to 24 hours a day 7 days a week, split shift for a total of 168 hours a week. 

The Increase in Personal Care Services (PCS) to 24 Hours per Day/7 Days per Week (Split-Shift) for a total of 168 hours is not medically necessary for this patient.
The patient has been approved for 24 hour a day 7 day a week live-in services. These services are sufficient to meet the patient's medical needs. There is no noted medical reason that the patient requires additional assistance at night that cannot be provided already. There is no noted reason that the aid cannot live at the patient's place of residence due to physical restrictions.
The patient was previously approved for home services; however, due to recent hospitalization with progressive symptoms of Gullian Barre syndrome, the patient requires additional assistance.
The patient has progressive symptoms of weakness and chronic pain. She is dependent on medical services for the majority of her activities of daily living (ADL) and Instrumental activities of daily living (IADL) . The services can be provided in the allotted time allowed by the health plan. The patient has been approved for 24 hour a day 7 day a week live-in services. In the appeal along with other documentation provided, there is no medical necessity noted that we will require split shift services. There is no notation that the patient's caregiver could not give adequate care or have an adequate amount of sleep while providing the services that are medically necessary. The patient does not require frequent nocturnal turning for skin breakdown or ulcers. Split stiff services are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gait ataxia, convulsions, unrinary
incontinence
Treatment: Increase Personal Assistance Services: 84 hours per week
The insurer denied the Increase Personal Assistance Services: 84 hours per week.
The denial is upheld. 

The patient is a female with a history of gait ataxia, frequent falls, unspecified convulsions, fecal urgency/incontinence, urinary incontinence and osteoporosis. Due to impairments related to these conditions, she requires assistance with many of her activities of daily living. Appeal review requested for potential approval of 84 hours per week personal assistance services to offer increased activities of daily living (ADL) support.

No, the proposed treatment of 84 hours per week personal assistance services is not deemed medically necessary. 

This is a female with a history of gait ataxia, frequent falls, unspecified convulsions, fecal urgency/incontinence, urinary incontinence and osteoporosis. Due to impairments related to these conditions, she requires assistance with many of her activities of daily living. However, an assessment of the patient's functionality was recently performed and revealed that the currently approved plan of 35 hours per week personal assistance services is sufficient to meet the patient's current needs. There is no additional documentation noted in the records submitted for this review which demonstrate that the patient has sustained additional functional loss since the date of this assessment. For these reasons, the proposed treatment of 84 hours per week personal assistance services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Neonatal Care

Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.

The denial is modified. 

This is a newborn male infant who was born via spontaneous vaginal delivery. The mother was group B strep (GBS) positive and was prophylactically treated with intrapartum penicillin. The pregnancy was complicated because the mother was positive for COVID-19.  Initially, the infant was in the newborn nursery. However, the infant vomited 3 times overnight, and was transferred to the neonatal intensive care unit and admitted for observation. Blood work and a COVID-19 test were ordered. The infant's basic metabolic panel was normal. The infant remained in the neonatal intensive care unit, and he did not require any intravenous fluids. The infant tested negative for COVID-19. Following transfer to the neonatal intensive care unit, there was 1 other episode of vomiting. 

Despite the maternal history of COVID-19 during pregnancy, the infant initially was assigned to the well nursery on Day 1. Episodes of emesis prompted the transfer to the neonatal intensive care unit on Day 2. Blood pressures were within normal limits.  A partial sepsis work-up was said to be done, but this was only a complete blood count (CBC) and C-reactive protein (CRP). No blood culture was obtained.  No antibiotics were initiated. The history and physical stated the admission was for observation. On Day 3, the infant was discharged. 

The health plan acted reasonably in part.

The insurer's denial is partially overturned as follows: 
a)	Day 1: Only meets criteria for routine newborn care 
b)	Day 2: Meets criteria for Neonatal Care, Continuing Care, Level of 2 for observation for sepsis
c)	Day 3: Only meets criteria for routine newborn care, day of discharge.    

Based on the above, the medical necessity for the inpatient admission is partially substantiated. The insurer's denial is modified.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cervical fracture. 
Treatment: Inpatient stay. 

The insurer denied coverage for the inpatient stay. 
The denial is overturned. 

This is a female patient with a past medical history of cervical plating and cervical spine stenosis. She fell, slipped on a wet floor, and hit the back of her head. The patient denied losing consciousness. The patient initially presented for evaluation immediately following the accident at an outside hospital, where she was cleared. However, the patient reported continued pain, swelling, and paresthesia. The patient talked with her primary care provider who sent her for a computed tomography (CT) scan and consulted with a neurosurgeon. The patient was not able to get an appointment within the next 2 weeks so she was recommended to go to the hospital. The patient underwent a CT scan of the cervical spine which demonstrated a C5/6 fracture of unknown chronicity. The patient was endorsing paresthesia at that time. The patient was transferred for evaluation by a spine surgeon. The patient's past medical history included Hashimoto's thyroiditis, and cervical spinal stenosis. The patient's X-rays of the cervical spine revealed an acute fracture involving the posterior elements of C5 and C6 with distraction in correlation with the recent CT scan. There was an obtuse angle at C5-6 based on the lateral X-ray and sagittal plane of the recent CT scan. The patient was admitted for trauma/spine consultation. The patient underwent surgical intervention including a posterior cervical instrumentation and fusion with correction of kyphotic deformity of the spine. 

Based on the review of the medical record and literature, the inpatient stay was medically necessary for this patient. Considering the presence of cervical instability with neural element compromise, inpatient level of care and intervention were appropriate for this patient's care. 

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

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

Diagnosis: Crowding
Treatment: Comprehensive orthodontic treatment (Braces)
The insurer denied the Comprehensive orthodontic treatment (Braces). 
The denial is upheld. 

The patient is a female. The request is for dental benefits for orthodontic treatment (Braces). Clinical summary indicates that the patient has a class I normal molar relationship and moderate crowding in both arches.

No, the Comprehensive orthodontic treatment is not medically necessary.

While the clinical exam summary indicates that the patient has moderate crowding in both arches, the degree of severity is not supported in the x-rays and photos. The patient has a class I normal molar relationship, and the records do not indicate that the patient has any significant difficulty with eating, breathing or with her speech.

Furthermore, although it is stated in the appeal notes that the patient is biting her lips and cheeks upon chewing; this is not substantiated in the photos. Typically, a significant chronic trauma from occlusion like this would result in substantial visible irritation (redness/swelling) and possible ulceration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan determination.

This patient presented to the emergency department complaining of intermittent left-sided chest pain that was precipitated by eating, movement and exercise. Of note, he had been discharged six days prior after hospitalization for chest pain. Serum troponin levels at that time were normal and gastroesophagoduodenoscopy showed gastritis. His medical history was remarkable for diabetes, hypertension, hyperlipidemia, cigarette smoking, pancreatitis, depression, anxiety, and prior alcohol abuse. In the emergency department his blood pressure was 127/91 mmHg with a heart rate of 114 beats/minute. His physical exam was unremarkable. An electrocardiogram showed sinus tachycardia and was otherwise normal. A serum troponin level was normal, as was a chest X-ray. The patient was treated with aspirin, ketorolac and famotidine and admitted to the hospital to rule out acute coronary syndrome. Two more serum troponin levels were normal. The patient reported improvement but continued to have intermittent pain after eating. A cardiac stress test showed no evidence of ischemia. On A gastroenterology consultant opined that the patient's symptoms were most likely related to his gastritis. The patient was discharged. 

An inpatient level of care was not medically necessary.
This man, with known cardiac risk factors, presented with atypical symptoms that were thought to be possibly represent acute coronary syndrome (ACS). Accordingly, observation in the hospital until ACS could be ruled out was a reasonable approach. On the other hand, he was hemodynamically stable, with normal cardiac biomarkers, and no acute electrocardiographic changes. There is no indication in the records provided that other potentially life-threatening diagnoses were considered likely. He did not require intensive monitoring or infusion of intravenous cardioactive medications. His History, Electrocardiogram (ECG), Age, Risk Factors, Troponin(HEART) score was 2, indicating a low risk for major adverse cardiac events. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care. This approach has been shown to be both safe and cost-effective and is in accordance with the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With NonST-Elevation Acute Coronary Syndromes. Based on the information provided, it does not appear as if there was a medical reason for the delay in performing the cardiac stress test. Therefore, inpatient hospital admission was not medically necessary.