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

Diagnosis: Class I malocclusion
Treatment: Insertion and Adjustment of Braces
The insurer denied the Insertion and Adjustment of Braces
The denial is upheld

This patient is a female with Class I malocclusion. She is missing her permanent second premolars in the upper left and lower left quadrants. 

The prior denial was due to not reaching threshold of 26 on the handicapping scale.

No, the proposed treatment is not medically necessary.
The patient does not reach the 26 threshold on the handicapping index scale, therefore not benefits can be applied. The 26 threshold is the standard in the dental community. There also are no speaking, swallowing or eating issues associated with her teeth.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: D8080 comprehensive orthodontic treatment of adolescent dentition

The insurer denied coverage for D8080 comprehensive orthodontic treatment of adolescent dentition

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 this specified handicapping malocclusion medical necessity requirement on the HLD index. The orthodontist 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 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 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. This reviewer scores 22 points on the HLD index (4 overjet, 5 overbite, 10 anterior crowding, 3 labiolingual spread) which is below the required 26 points for approval of 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. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The insurer's denial of coverage for D8080 comprehensive orthodontic treatment of adolescent dentition is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Live In). 
The denial is overturned.

The patient is a female with past medical history of cerebrovascular accident (CVA), dementia, urinary incontinence, bowel incontinence, osteoarthritis, depression, bedsores, anxiety, diabetes mellitus type 2, long-term use of anticoagulant, hearing loss, hypertension, gout, and coronary artery disease who had been assigned Patient Care Assistance (PCA) services 84 hours/week based on telephonic assessment performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, managing medication, phone use, stairs, transportation, and bathing. With tasks of personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while independent with tasks of bed mobility and eating.

The requested service is medically necessary. There is documentation from the patient's medical providers of worsening cognitive and physical functioning. The assessment tools show an increase in assistance needs with tasks of managing finances, managing medication, stairs, transportation, personal hygiene, dressing upper/lower body, and bed mobility. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use and based on documentation that patient is not ambulatory and has incontinence of bowel and bladder the assessment underestimated the patient's assistance needs with these tasks. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and Instrumental activities of daily living (IADLs). There is documentation of pressure ulcer to sacral area with recommendations by the plan itself to turn and reposition every 2 hours while in bed. The patient's informal helpers are not able to provide care outside of currently assigned PCA services. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care/Personal Care Home Health Care (HHC) - Level 2 Personal care services per 15 minutes increase to  24 hours/day, live-in are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness on The Right Side of Body, Numbness Along The Head, Chest Pain, Dizziness.
Treatment: Inpatient admission. 

The insurer denied the inpatient admission.  The denial is upheld

The patient is a male with a history of stroke. He presented to the emergency ward with the complaint of dizziness, right-sided weakness and paresthesia for four days.

At presentation, the patient had a normal neurological examination documented. CT (computed tomography) brain was negative for acute intracranial pathology. He was admitted to the acute inpatient service for suspected stroke. Subsequent MRI (magnetic resonance imaging) brain was negative. He was discharged.

No, the Inpatient admission was not medically necessary.

The patient presented with a four day history of neurological symptoms. He was not a candidate for acute stroke intervention (Powers et al.). The emergency ward provider documented the patient had a normal neurological examination and negative CT (computed tomography) brain. Based on this, the likelihood of stroke was low, and his condition was incompatible with transient ischemic attack given the duration of symptoms (Mendelson et al.). The neurological evaluation, monitoring, diagnostic studies and treatment could have been safely and effectively provided at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a female with a history of alcohol overuse, bipolar disorder, depression, anxiety, gastroesophageal reflux disease (GERD), and chronic back pain. She presented to the emergency room with altered mental status and nausea. There was a report that she took four to six tablets of gabapentin. The vital signs were unremarkable. She was initially somnolent, but soon thereafter became alert and oriented. Physical exam was notable for mild tremulousness. Labs were notable for an elevated lactic acid and an initially elevated blood alcohol level of 351. Several hours later, the alcohol level dropped to 124. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. There was no acute pulmonary disease on the chest x-ray. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous fluids, intravenous lorazepam and antiemetics as needed, as well as oral medications. The Clinical Institute Withdrawal Assessment (CIWA) score was initially 8, and there was 1:1 supervision. The following day the psychiatrist evaluated the patient and noted a CIWA score of zero. It was concluded that she was not suicidal, the 1:1 supervision could be discontinued, and she should follow up with her outpatient program as scheduled. The remainder of the stay was clinically uneventful, and she was discharged. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. She was hemodynamically stable and there was no severe metabolic disarray. The altered mental status and signs of alcohol withdrawal cleared quickly. Her treatment was straightforward and was not at the acute inpatient level of intensity. There was no evidence of ongoing suicidal ideation. Therefore, based on the standard of care, and the peer reviewed literature cited below, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld 

The health plan acted reasonably. The admission was not medically necessary. The patient had an infection following mastectomies and implant reconstructions. She had a fever to 102 degrees and leukocytosis. She was treated with IV (intravenous) antibiotics. Ultrasound did not show a fluid collection. Her infection improved and she was discharged 48 hours following admission. The patient could have been managed at an observation level of care. According to MCG (Milliman Care Guidelines) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations."  In this case, the patient was hospitalized for 48 hours, and she responded to the treatment of IV antibiotics. She did not require admission because the additional information (ultrasound) did not show a fluid collection and because she responded to treatment with IV antibiotics. 

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

The insurer's denial of coverage for a hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cough; shortness of breath. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned.

The patient is a female. She presented to the emergency room with cough, shortness of breath, difficulty breathing. The patient has a known history of asthma and had been using her Albuterol rescue inhaler for multiple days, multiple times per day. 

Upon presenting to the emergency room, the patient required significant respiratory support including magnesium sulfate as well as supplemental oxygen, in addition to the multiple supplemental albuterol and Atrovent doses given in the emergency department. The patient was noted to have an elevated respiratory rate, heart rate, and a decreased oxygen saturation. 

Yes, the Inpatient admission was medically necessary. 

The patient is a female with known asthma who presented to the emergency department with multiple days of shortness of breath and albuterol use. The patient required significant support in the emergency room including steroids, magnesium sulfate, multiple doses of Albuterol and Atrovent. The patient also required supplemental oxygen. The patient presented with increased respiratory rate and heart rate. 

Upon review of the physical exam, the patient was evidenced to have been in respiratory distress with significant increased work of breathing. Considering this clinical presentation, as well as the need for Albuterol every two hours, it is medically appropriate for this patient to have been admitted as an inpatient admission.  For monitoring of every-two-hour Albuterol, a patient cannot be appropriately monitored and cared for as an observation status. An inpatient level of service is required, as that was overall in that level of clinical monitoring. The denial is overturned. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

As noted above, the patient presented in respiratory distress requiring significant support. This support included magnesium sulfate and multiple doses of Albuterol and Atrovent. Considering the length of symptoms prior to presentation to the emergency department, as well as the medical support needed while in the emergency room, and the age of the patient, an inpatient stay for close monitoring and assessment was medically necessary. Also, receiving Albuterol every two hours as the patient did upon admission, is not medically appropriate for an observation level admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Periodontal disease
Treatment: deep gum and root cleaning on all four quadrants
The insurer denied coverage for deep gum and root cleaning on all four quadrants
The denial is overturned

Upon review of submitted documentation which includes copies of bitewing and periapical radiographs and insurer correspondence, it appears that this patient presented to the dentist for care, with identification of periodontal disease in all four quadrants. Recommended treatment was four quadrants of scaling and root planing. The insurer denied scaling and root planing as requested stating in summary that the information provided does not offer sufficient basis for the requested services such as bone loss or radiographic calculus indicative of periodontal disease. The patient is appealing.

In this case, as regards documentation of the periodontal status, in particular the 
radiographs, it is evident that there is a level of periodontal disease where there is root surface exposure and alveolar bone loss. All four quadrants exhibit multiple areas of radiographic calculus particularly in the molar areas. Appropriate treatment would be the recommended scaling and root planing to address any ongoing periodontal issues. This would be the standard of care treatment given the alveolar bone loss and level of periodontal disease as documented on radiographic findings. As such these services are considered dentally necessary.

Overturned denial and approve coverage for deep gum and root cleaning all four quadrants, as medically necessary as the radiographic documentation support and substantiate this recommended treatment.

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

The deep gum and root cleaning on all four quadrants is considered medically necessary for this patient.

The insurer's denial of coverage for deep gum and root cleaning on all four quadrants is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dental problems
Treatment: Porcelain Crown (Tooth 03 and Tooth 30) 
The insurer denied Porcelain Crown (Tooth 03 and Tooth 30). 

The health plan's determination is overturned. 

The patient is a female who presents for evaluation and treatment of teeth # (number) 3 and 30. Provided for review are previous letters of appeal and denial, a narrative from the provider explaining the status of teeth #3 and 30 over the course of multiple dates, multiple radiographic images, one pages of American Dental Association (ADA) claim forms, and clinical images.

The requested Porcelain Crown (Tooth 03 and Tooth 30) is medically necessary. Full coverage restorations are indicated in instances when decay or injury to the tooth cannot be addressed by a direct restoration. As the tooth structure for both teeth #3 and 30 has suffered from extensive loss, there is no longer sufficient cuspal tooth structure to retain a direct restoration requiring full coverage. 
Therefore, the planned treatment of porcelain ceramic crowns for teeth #3 and 30 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

This female was hospitalized for acute pulmonary embolism. Her past medical history (PMH) included: paroxysmal atrial fibrillation (A-fib), chronic anemia and past, but no active vaginal bleeding since transfusion and hormonal therapy. 

The patient's vitals were stable. Treatment included oral anticoagulant (OAC) and the patient was discharged to home. 

This is an appeal of the denied claim the requested acute inpatient hospital stay was not medically necessary for this patient.

No, the proposed inpatient hospital admission was not medically necessary.
Based on the documentation reviewed, according to the peer reviewed medical literature and the provided Milliman Care Guidelines (MCG), there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for that level of care hospital stay.

Per the Milliman Care Guidelines for pulmonary embolism, criteria for inpatient admission is not met, including documentation of hemodynamic instability, respiratory distress, hypoxia, chronic cardiopulmonary disease, hemoptysis, syncope, right ventricular dysfunction or strain, positive cardiac biomarkers or high risk for anticoagulation. In this particular case, there was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. The care the patient received for acute, uncomplicated pulmonary embolism, like in this case, is routinely provided safely and effectively at a lower level of care.

Certain patients with acute pulmonary embolism who were considered to have low mortality risk were treated successfully as outpatients, according to study results published in Chest. While pulmonary embolism treatment usually includes hospitalization for all patients, the current evidenced -based guideline endorses treatment on an outpatient basis is feasible in select patients with pulmonary embolism. Therefore, based on the submitted information and the current published medical literature, inpatient hospital admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary retention.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He was transferred from outside hospital for management of urinary retention. He was seen in outside ED (emergency department) for vomiting, fever and congestion and straight catheterization for urine reported to be normal. He was seen later at another ED (emergency department) for suprapubic pain and no void for more than 12 hours.

The patient was catheterized for 80 ml (milliliters). He was noted to have low CO2 (carbon dioxide) and ketones in his urine. He received a one liter bolus of fluids. A bladder scan demonstrated volume of 200ml (milliliters). The patient refused to void.

After inpatient admission, the child subsequently voided 200ml (milliliters) successfully. The urine was negative for infection. He was encouraged to eat and drink overnight, and he continued to void. He was discharged to home the following day.

The inpatient admission was denied coverage by the health plan as not medically necessary. This denial is being appealed.

No, the Inpatient admission was not medically necessary.
The patient is a male with no documented prior history of urinary retention in the past. He presented with urinary retention after being catheterized for urine sample for work up of fever, nausea vomiting. In the ED (emergency department), the child was fluid resuscitated but did not void and was admitted to inpatient for management of urinary retention.

The child remained hemodynamically stable after the fluid bolus, voided on his own and required no intervention. This child could have been managed at a lower level of care, given the absence of hemodynamic instability after the fluid bolus in the emergency room, the lack of urinary tract infection and no other reported medical problems.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient responded well to the fluid bolus with increase in urine output and resolution of the tachycardia. His blood pressure remained stable, as did his respiratory rate. The child was being encouraged to eat and drink. The child's overall medical status warranted a lower level of care.