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

Diagnosis: Skeletal Class II Malocclusion, Class II Canines, and Excessive Overjet and Deep Impinging Overbite
Treatment: D8080 Comprehensive Orthodontic Services
The insurer denied the D8080 Comprehensive Orthodontic Services. The denial was reversed.  
This is a male patient who presented to an orthodontist for an evaluation for orthodontic care. A comprehensive exam was performed that revealed Skeletal Class II Malocclusion, Class II Canines, and Excessive Overjet and Deep Impinging Overbite. A Handicapping Labio-Lingual Deviation (HLD) index was performed resulting 18 points. Concluding his evaluation it was determined that orthodontic treatment was in order. 

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. 

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 met and does support comprehensive 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 studies.

The carrier's denial of coverage for D8080 Comprehensive orthodontic services is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Neck swelling and discomfort swallowing
Treatment:  Inpatient admission
The inpatient admission was medically necessary. 

The patient is a female with PMH (past medical history) of COPD (chronic obstructive pulmonary disease) on BiPAP (bilevel positive airway pressure) and home O2 (oxygen); asthma, depression, DM (diabetes mellitus), HTN (hypertension), and drug use.  She presented to ED with c/o (complaints of) tender neck swelling and discomfort swallowing, chills. 

The patient's labs were as follows: BUN (blood urea nitrogen)-55 (H), CHL (chloride)-108 (H), Creatinine-2.14 (H), Glucose-64 (L), pH venous-7.32 (L), Potassium-6.6 (H), Venous O2 sat.-63.3, Albumin-5.5 H, AST (aspartate aminotransferase)-87 H, BIILI (bilirubin)-1.6 H, Total Protein-8.5 H, WBC (white blood count)-10.  The patient's vital signs were as follows: BP (blood pressure)-156/77, P (pulse)-108; T (temperature)-97.7; R (respiration rate)-16; SpO2 (pulse oximetry) 95%. 

CT soft tissue neck showed no acute findings.  Oral surgery was consulted and recommended IV antibiotics, warm compress, and hydration. 

The patient was being admitted for possible Ludwig angina.  According to UptoDate: While maintenance of an adequate airway is the primary concern and may necessitate urgent tracheostomy [2, 3], most cases can be managed initially by close observation and intravenous antibiotics.

This patient required inpatient observation and antibiotics.  The treatment team was also worried about possible angioedema, which could also progress given sudden start of the patient's symptoms.  The patient was given steroids, and her airway was monitored. 

Given the patient's history, presentation, and course, the standard of care would indicate that an observation admission or further treatment in the ED would not have been adequate.  Therefore, the inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity and back pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient did not have evidence of a focal neurologic process and radiographs of the lumbar spine demonstrated on the spondylosis without acute finding. There was no loss of bowel or bladder function, saddle anesthesia, or cauda equina impingement.  There was no evidence of spine fracture or spinal infection.  The patient did not have severe pain requiring frequent or continuous administration of parenteral analgesics.  No surgical intervention was required.  The patient had only a very mild degree of acute kidney injury without hyperkalemia, uremia, acidosis, or volume overload.  Dialysis was not required.  

In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Transfemoral Amputation
 
Treatment: Left Transfemoral Microprocessor Knee

The insurer denied the Left Transfemoral Microprocessor Knee. The denial was reversed. 


This is a female patient who is status post left transfemoral amputation. It was reported that she was experiencing occasional phantom pain involving her effected limb.  The amputation stump was noted to be well healed, nontender, medial protrusion of tissues. There was full range of motion of the left hip in flexion and extension. On physical exam it was noted that the patient had the ability or potential ability for ambulation and may have vocational, therapeutic, or exercise activity that demands prosthetic use beyond simple locomotion. She was a K3 ambulator. The implementation of a microprocessor knee would give the patient the optimal level of safety, control, and responsiveness that she was going to demand out of a prosthesis given her everyday living and activities as a new amputee and would also allow her to care for her young age child safely.

According to the Centers for Medicare and Medicaid Services, determination of the type of knee prosthesis will be made by the treating physician and/or the prosthetist based upon the functional needs of the beneficiary. The Centers for Medicare and Medicaid Services states that an electronic knee is covered in patients who have a functional level that is measured at level 3 or higher. The patient underwent a thorough evaluation and was found to be a functional level 3. This was noted to be the first prosthesis for this patient. The Centers for Medicare and Medicaid Services supported that the electronic knee is appropriate for a patient with a functional level of 3 or higher. 

The carrier's denial of coverage for Left Transfemoral Microprocessor Knee is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of Malignant Melanoma of the superior thoracic spine that was biopsied. The Melanoma was read out as having a Breslow depth of 0.31 millimeter (mm), no ulceration, and with no mitotic figures per square millimeter field. Regression was present, but no perineural or lymphovascular invasion, or microsatellitosis were observed on histologic examination. The tumor was staged as pT1a pNx pMx. A DecisionDx-Melanoma Gene Expression Assay was reported as having a result of Class 1, Sub-class 1A), consistent with the lowest risk of near-term metastatic disease. The use of the DecisionDx assay is under review.

The health plan's determination is upheld. The DecisionDX melanoma assay is not medically necessary for this patient. The DecisionDx-Melanoma test does not have any proven clinical utility, appropriate use, or improved outcomes in the staging or treatment of melanoma. It is not in accordance with generally accepted standards of medical practice in the United States, is not clinically appropriate for this patient's clinical condition. The standard treatment is observation and follow up based on the tumor's histologic features. No modern dermatology textbook mentions this requested gene expression assay as part of the staging of a melanoma to determine if a specific test or work-up is indicated. This patient has a relatively superficial melanoma with no ulceration or significant number of dermal mitoses, so that wide excision and appropriate followup only is indicated for this patient, regardless of whether or not the DecisionDx-Melanoma test (unproven and without consensus and support at this time with respect to a role in diagnosis, staging, prognosis, and treatment) was performed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major depressive disorder
Issue under review: Continued inpatient admission

Determination:
The Continued inpatient admission was not medically necessary.

The patient was admitted due to major depression with suicidal ideation. By the dates of service under review, the patient described her mood as good. She had future plans to return to her parents in California. She denied active suicidal plans or intent. Although she continued to have "ups and downs" with fleeting suicidal ideation, this was consistent with her diagnosis of borderline personality disorder and could not be expected to respond to continued acute inpatient treatment.

The patient's care could have been provided safely and effectively in a less restrictive setting from the dates of service under review going forward.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: fibrodysplasia ossificans progressive (FOP)
Treatment: Gleevec

The proposed treatment with Gleevec is medically necessary. 

Fibrodysplasia ossificans progressiva (FOP) is a disorder in which muscle tissue and connective tissue such as tendons and ligaments are gradually replaced by bone (ossified), forming bone outside the skeleton (extra-skeletal or heterotopic bone) that constrains movement.  This process generally becomes noticeable in early childhood, starting with the neck and shoulders and proceeding down the body and into the limbs. Recent reports have demonstrated the Imatinib is effective for the treatment of this disorder. Episodic soft tissue swellings (or flare ups) can arise in the neck and back. In one report, seven patients with FOP were treated with Gleevec which improvement in the patients overall condition and decrease in the intensity of the disease. Due to the rarity of the disease, there are no large cohort studies and there is no other known effective therapy for this disorder. Therefore, the use of Gleevec is considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance abuse
Treatment: Continued inpatient admission

The proposed treatment, continued inpatient admission, was medically necessary for this patient.

The requested benefit of the continued inpatient admission could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using heroin while in medication assisted treatment with buprenorphine together with use of alcohol on a daily continuous basis; and, daily use of a benzodiazepine anxiolytic (Xanax) and cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring; detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient presented with onset of drug and alcohol withdrawal symptoms, and, the patient's social environment was not conducive to detoxification. Thus, the continued detoxification treatment of this patient's substance use disorder did necessitate the continued structure of an inpatient level detoxification setting and monitoring. The patients history of substance abuse (frequency and quantity) together with the drug-infested social environment, and severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and, New York State instruction for medical necessity reviews including the LOCADTR Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient admission was medically necessary in this case scenario, and is therefore a covered service in this case scenario. 

The patient's clinical features and treatment dimensions did warrant continued inpatient level detoxification services thru discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions. Moreover, the continued detoxification treatment through discharge could not have been safely or effectively provided with lower level services as noted above. Thus, the requested benefit is not excluded under the plan, and should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the New York State LOCADTR 3.0 Criteria/Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history significant for a seizure disorder who was not on antiepileptic medications. She presented to the emergency department after she had a seizure. Apparently, the patient was taking Keppra in the past but according to the records, this medication caused musculoskeletal pain and also poorly controlled her seizures. She was scheduled to start Dilantin, but because she was under physical and emotional stress, she did not.

The patient was admitted to the hospital with the diagnosis of a generalized tonic-clonic seizure. She received treatment with Tegretol; the neurology service was consulted. Because of the lightheadedness, patient's blood pressure medications were held.
When seen by a neurologist, the patient was back to baseline and her exam was nonfocal. The neurologist recommended to start treatment with Tegretol and titrate the dose with patient's outpatient neurologist and epilepsy clinic. The health plan's determination is upheld.
The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient, considering her fast recovery from the breakthrough seizure, lack of significant neurological abnormalities on the exam, and lack of any concomitant conditions requiring admission at the acute inpatient level of care.
She presented to the hospital after she had a seizure. She had been diagnosed with a seizure disorder in the past and was off seizure medications despite previous recommendations for the antiepileptic drug regimen. As a result of that, the patient developed a breakthrough seizure, which was associated with a postictal state.
At the same time, when the patient was seen by the admitting physician, her condition continued to improve. She was afebrile, hemodynamically stable, and had no neurological signs on physical exam.
Taking into consideration these circumstances, admission for observation was warranted in order to initiate treatment with antiepileptic drugs and to watch for breakthrough seizures and/or side effects of the antiseizure medications.
At the same time, the patient's clinical condition improved very quickly and she was discharged home from the hospital on the next day after admission.
This patient did not require any treatments or diagnostic tests necessitating admission at the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac Catheterization and Percutaneous Coronary Intervention
 
Treatment: Inpatient Admission

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


This is a female patient who presented to the hospital for a scheduled cardiac catheterization. She has a history of osteoarthritis, hypertension, hyperlipidemia, peripheral artery disease, coronary artery disease, and chronic non-healing foot ulcers. As scheduled, the patient had the cardiac catheterization with the placement of 3 stents. She was admitted for post procedure monitoring. The patient experienced no post procedure complications. She was discharged home when medically stable.

The medical literature indicates that ambulatory catheterization as well as electrophysiological studies, pacemaker placement, peripheral angioplasty, angiography, non-aortic endovascular repair, vascular access placement or simple intravenous fistula. The documentation indicated that the patient underwent a peripheral angiogram. The patient had 3 stents placed. Following the procedure, there were no complications. The procedure permits up to 48 hours for hospital observation as appropriate. However, the procedure is considered ambulatory. There were no clinical indications to support the need for this inpatient stay.

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autonomic Syncope
 
Treatment: Inpatient Admission

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

This is a young female patient who presented to the emergency department (ED) with complaints of three episodes, two which occurred on the same day. It was reported that the patient had been in a recumbent position for a period of time for a dental procedure.  Upon presentation to the ED the patient's vital signs were stable. Cardiology consulted on the patient. The patient was admitted to telemetry for monitoring. She had an electrocardiogram that was normal. Her orthostatics were normal. She was encouraged to increase his oral fluids and increase the salt in his diet. Neurology consulted on patient. An electroencephalogram was performed and was noted to be within normal limits. The patient was safely discharged home the following day

After review of the history, ECG and documentation provided, the denial of the inpatient admission should be upheld. The following is the rationale for diagnosing autonomic (non-cardiac) syncope (vasovagal or postural) in this patient which does not require hospital admission. (1, 2)

The history of poor oral intake for an extended period after a dental procedure is certainly a predisposing factor to two of the episodes (reference 1 below).

In two of the episodes the syncope occurred after a prolonged period of recumbency.("borderline" orthostatics in ED)

A documented prodrome occurred in one episode typical of vasovagal syncope.

CG was performed and was normal (no evidence of Long QT syndrome, pre-excitation, Brugada syndrome or arrhythmia),

A pediatric cardiologist was consulted and recommended outpatient follow up.

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

Diagnosis: Osteomyelitis
 
Treatment: Inpatient Admission

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

This is a female patient who presented to the emergency department with complaints of worsening pain in her sacral area, she rated it 10/10 in intensity. On evaluation, the patient was noted to have a 3.5 x 2x 1 cm stage lll decubitus ulcer and was noted to be hypertensive-215/146. A laboratory work up was initiated. Infectious disease consulted on the patient. Urine and wound cultures were obtained which strongly suggested the presence of infection. A computer tomography was performed which revealed a soft tissue density of the posterior subcutaneous tissue, but no abscess collection. There was also changes noted near the coccyx concerning for osteomyelitis. The patient was treated with intravenous (IV) fluids and IV antibiotics. The patient remained afebrile and hemodynamically stable. She was transferred to a skilled nursing facility for long term IV antibiotic therapy and outpatient surgical wound debridement. 

According to documentation, patient presented with worsening pain (grade 10 out of 10) at site of decubitus sacral ulcer. She was hypertensive to 215/146 on initial presentation and laboratory results including urinalysis, urine and wound cultures strongly suggested with presence of an acute on chronic infection. Medical records indicated "probe to bone" and radiographic studies supported presence of osteomyelitis requiring long-term intravenous antibiotics and surgical debridement. Based on these worrisome abnormalities in a high-risk patient with numerous co-morbid conditions, hospital admission was medically necessary. 

The carrier's denial of coverage for the inpatient hospital services at the inpatient level of care is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Deep overbite
Treatment: Braces
The braces are medically necessary.

The patient has a very deep overbite. "Deep impinging overbite with severe soft tissue damage," is one of the "automatic qualifiers" according to the handicapping index. The patient has this condition, and her teeth are "overclosed", i.e. her upper front teeth close into her palatal gum tissues. This case has medically necessity due to this, and the patient needs orthodontic correction.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with normal Class I bimaxillary protrusive occlusion. There is moderate spacing of the upper and lower incisors.
The subject under review is the medical necessity of braces.

The health plan's determination is upheld. 

The treatment of braces is not medically necessary for this patient. The patient has a Class I occlusion with dentoalveolar protrusion. The occlusion is functional and stable. Therefore, treatment is elective, and not medically necessary. 

This type of case - Class I occlusion with dentoalveolar protrusion - would most likely never qualify as medically necessary according to the guidelines and rules that apply to the Handicapping Labio-Lingual Deviation (HLD) malocclusion Index. In addition to the automatic qualifiers - for congenital abnormalities like cleft palate, impinging overbite with palatal soft tissue damage, crossbite of individual anterior teeth and severe facial skeletal deviations secondary to facial trauma, medical necessity requires a combination of three variables: a) severe skeletal discrepancy in the sagittal, vertical or transverse dimension; b) severe tooth size arch length discrepancies (crowding) and c) posterior or anterior crossbite.