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

Diagnosis: Malocclusion

Treatment: D8080 braces and D8670 monthly visit x 12

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12

The denial is overturned


Upon review of the submitted documentation including lateral cephalometric radio graph, panoramic radio graph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index attaining 17 points by internal review is when 26 points or greater is needed to approve braces. The orthodontist is appealing on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. It is agreed that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several (1-3).

Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces and D8670 monthly visit x 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient had an inpatient hospital admission for syncope. 

The final adverse determination letter states that the admission was not medically necessary. The letter states that the admission was for syncope. There were no abnormal vital signs, altered mental status, cardiac issues that required immediate intervention, dehydration, or injury. 

The emergency department (ED) admission states that the patient had syncope. The patient's vitals were stable and mental status was stable. The discharge summary showed no signs of medical instability.

"Syncope is the transient loss of consciousness and postural tone, with spontaneous recovery. It accounts for approximately 1% of all emergency department visits and $5.6 billion in healthcare costs annually. In a very small subset of patients, syncope may be a warning sign for serious outcomes or death, but identifying these patients is challenging, as the emergency clinician must distinguish between life-threatening causes and the more common, benign etiologies" (Morris, J. 2021).

"Syncope is a common reason for ED attendance and it presents a major management challenge with regard to the appropriate workup and disposition. Nearly 50% of patients are admitted, and for many this is unnecessary" (Reed, M. J. 2019).                                                         

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

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

Central Nervous System
Pain management

Diagnosis: Migraines
Treatment: Pain management
The insurer denied Intravenous Ketamine Infusion(s.) 
The health plan's determination is upheld. 

The patient is a female diagnosed with CADASIL (Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) and chronic migraines. The patient has tried and failed various treatments for prevention of chronic migraine. These include anticonvulsants, antidepressants, beta-blockers, and Botox. 

Intravenous Ketamine Infusion(s) are not medically necessary for this patient.
Treatment of chronic migraine with intravenous ketamine is not indicated. Controlled studies are lacking to show that this drug is safe and effective for treatment of chronic migraine. There is a paucity of peer-reviewed literature. One case series in which patients with chronic migraine were treated with intravenous ketamine infusion found that the treatment lead to "short term improvement in pain severity." This study called for placebo controlled trials. Another study that examines the use of ketamine infusions for chronic migraine and new persistent daily headache found that "ketamine infusions may be beneficial" and called for controlled trials to confirm this. Another study looked at the administration of ketamine in the emergency room for headache and found that it did not improve headache outcomes. Overall, high quality data is lacking to support ketamine infusions for migraine.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a man admitted to the hospital with dyspnea, orthopnea, and elevated blood pressure. After running out of his blood pressure medications for several days, the patient reported several days of symptoms. There were no complaints of chest pain, palpitations, or cough. A chest x-ray was completed, which showed no acute cardiopulmonary disease. Initial blood pressure was quite elevated to 208/96. Oxygenation status was normal, and the heart rate was normal. Glasgow Coma Scale calculated at 15. Cardiac enzymes were drawn in the emergency department and were negative. The patient was placed on telemetry in an observation unit bed for monitoring. 

Based on the provided documentation, inpatient admission was not medically necessary. The clinical scenario is a patient with underlying hypertension and chronic kidney disease who ran out of medications and presented to the emergency department (ED) with elevated blood pressure and dyspnea. There is no sign of severe volume overload, pulmonary edema, refractory to diuretic therapy, or acute coronary syndrome. Cardiac enzymes are negative, invasive cardiac work-up completed within 24 hours, shows no evidence of obstructive disease. The patient was restarted on guideline-directed medical therapy with a beta-blocker and ACE (Angiotensin-converting enzyme) inhibitor and discharged home. There is no documentation of repeated intravenous (IV) diuretic therapy administration for refractory heart failure symptoms. The patient has nonischemic cardiomyopathy, likely due to hypertension, and was appropriately treated with reinitiation of a baseline antihypertensive regimen. There were no major electrolyte derangements, severe hypoxemia, or other hemodynamic instability. The entire work-up can be completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Other- syncope  
Treatment: Inpatient emergency admission
The health plan denied Inpatient emergency admission.
The determination is Upheld. 

The patient is a female with a past medical history of bipolar disorder who was admitted with complaints of syncope and a fall while in an inpatient psychiatric unit. Her vital signs were notable for a blood pressure (BP) of 81/67 millimeters of mercury (mmHg) and a heart rate of 38 beats per minute (bpm). Her physical exam was notable for no focal deficits. She was alert and oriented and her lab work was unremarkable. Imaging studies were obtained. A computed tomography (CT) scan of the head showed no acute intracranial pathology, her chest x-ray (CXR) showed no acute disease, a transthoracic echocardiogram (TTE) showed an ejection fraction (EF) of 60 percent (%). Her electrocardiogram (EKG) showed sinus tachycardia. The patient was diagnosed with vasovagal syncope and was treated with intravenous fluids (IVF), telemetry monitoring, and cardiology consultation, which determined the cause was not cardiovascular in nature. The patient was discharged in stable condition.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient emergency admission was not medically necessary for this patient. The patient presented with complaints of syncope and a fall. The patient did not have structural heart disease, a hematocrit (HCT) level of less than 30, shortness of breath (SOB), or family history of sudden cardiac death. Additionally, the patient did not have any history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy, left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, QT interval abnormalities or conduction blocks. The patient did not have a subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT), ventricular tachycardia (VT), confirmed acute coronary syndrome, evidence of heart failure, cerebrovascular accident, shock, coma, major trauma, cardiac arrest, or exertional syncope. The patient was evaluated by cardiology and it was determined that the cause of the syncope was not cardiovascular in nature, with considerations for medication-induced and vasovagal causes. The patient was diagnosed with non-cardiogenic syncope and treated with clinical monitoring and biochemical and radiological work-up. Overall, this patient could have been safely treated at an alternative level of care.
Regarding the provided criteria, the patient did not have hemodynamic instability, severe altered mental status, cardiac disease, or finding that required immediate intervention. She had no pacemaker or automatic implantable cardioverter defibrillator (AICD) malfunction, no inherited cardiovascular condition predisposing her to arrhythmias, no severe dehydration, or syncope causing injury during hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cough, eye redness
Treatment: inpatient stay
the insurer denied the inpatient stay.
The health plan's determination is upheld. 

This is the case of an infant female twin who presented to the emergency department (ED) with cough and congestion and eye redness. There was no fever or trauma or concern for foreign body. The patient is living at a shelter with her mother, twin brother, and 22 month old sibling. Child protective services were involved with this family.
ED vitals were T (temperature) 36.3oC, heart rate (HR) 138-151, respiratory rate (RR) 34-38, and O2 (oxygen) saturation 100% room air. Weight was 14lb (pounds). Exam noted left eye redness and reducible umbilical hernia, it was otherwise reassuring. 

The requested inpatient admission was not medically necessary for this patient. However, the patient was at increased risk for poor outcomes due to housing instability (living in a shelter) and lack of alternative caregivers. Therefore, admission for observation would have been appropriate. This could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient is an adult with a past medical history of morbid obesity, hypertension,  asthma, chronic obstructive pulmonary disease (COPD) on oxygen, obstructive sleep apnea (OSA), obesity hypoventilation syndrome (OHS) on continuous positive airway pressure (CPAP). At home the patient was on oxygen at 3-4 Liters/minute. The patient has a history of  polysubstance abuse.

The patient presented to the hospital with complaints of shortness of breath (SOB) and wheezing. The patient had a previous hospitalization for the same symptoms and reportedly used cocaine post hospitalization prior to return to the emergency department.

Vital signs at presentation were: Temperature 98.1 degrees Fahrenheit, Respiratory Rate 22 breaths per minute, Blood Pressure 107/73, Oxygen saturation was 94 % (percent) on room air. White blood cell (WBC) was 13.5K and electrolytes were within normal limits. The patient was found to have bilateral lung wheezing and rhonchi. On examination the abdomen was soft and non-tender. The patient was alert and oriented to person, place and time and was admitted for asthma/chronic obstructive pulmonary disease (COPD) exacerbation.

The patient was treated with Duo Nebs, Prednisone 60 milligrams (mg) X 5 days and inhaled corticosteroids. The patient has chronic hypoxic and hypercapnic respiratory failure for which she is on home oxygen and nightly continuous positive airway pressure/ bilevel positive airway pressure (CPAP/BiPAP).

This patient did not need acute inpatient hospitalization. The patient could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient had been discharged the previous day after a stay for a week and had symptoms again after using cocaine.

The patient improved with treatment. The patient was treated with oral medications after admission. 

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

The medical necessity for inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080, braces, and D8670, monthly visits (x12)

The insurer denied coverage for D8080, braces, and D8670, monthly visits (x12)

The denial is overturned

This patient is under the care of an orthodontist for the treatment of severe crowding. The patient has 6 crowded out of the arch to the buccal and 7 is palatally positioned with bone loss between 6 and 7. There is also a crossbite on tooth 10. There appears to be attachment loss there as well.

This patient has bilateral anterior crossbites and there is documented bone loss which supports the requested services. This patient meets Handicapping Labio-Lingual Deviation (HLD) criteria for approval due to the bilateral anterior crossbites and documented bone loss. Therefore, the D8080, braces, and D8670, monthly visits (x12) are considered medically necessary for this patient.

Cousin, T. (2020), "Introduction: State Medicaid agencies rely on treatment need indices to identify patients with orthodontic medical necessity. The Handicapping Labiolingual Deviations (HLD) index is the most common orthodontic index in the United States. States which have adopted the HLD index have modified it without supporting validation studies. The purpose of this study was to validate all state-modified HLD indices currently used in the United States and to investigate the implementation of the Washington(WA) state HLD modification, HLD(WA)... Results: There were many qualitative differences among state-modified HLD indices. State-modified HLD indices had a mean between-state agreement of 79.1%(percent), a mean sensitivity of 41.6%, and a mean specificity of 92.9%. The optimal point thresholds were lower than the current point thresholds for all state-modified HLD indices. When the implementation of HLD(WA) was evaluated, we found a mean approval rate of 35.4% and a mean denial rate of 52.4%. While total mean approval and denial rates were not significantly different among clinic types, there were significant differences among clinic types in the number of applications approved and denied according to index guideline versus reviewer override (p less than (<).01). Conclusions: Our results suggest that state-modified HLD indices fail to identify a considerable percentage of handicapping malocclusions. There is also a lack of consensus among state Medicaid programs on what constitutes a handicapping malocclusion. In addition, our study indicates that there are differences in approval and denial rates among clinic types."

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080, braces, and D8670, monthly visits (x12) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is the case of a patient that presented to the hospital following an episode of syncope. Past medical history was significant for hypertension and chronic kidney disease. The patient reported drinking two beers and then playing ping pong. Following the game, the patient became lightheaded and passed out. Upon awakening the patient became nauseous and vomited. On arrival to the hospital vital signs were stable with blood pressure (BP) 125/75 and pulse 78. Physical exam revealed no abnormality. 12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm without ST or T wave abnormalities. Serum blood testing revealed a mild elevation in troponin at 18 and an elevated creatinine of 1.7. The patient was admitted to the hospital for monitoring and treatment. Echocardiogram revealed normal left ventricular function and wall motion.  The patient was diagnosed with neural reflex syncope and discharged the following day. 

The health plan acted reasonably and with sound medical judgment and in the best interest of the patient. This patient presented with lightheadedness and syncope. Physical examination and serum blood testing revealed no major abnormalities. Echocardiography revealed a structurally normal heart with a normal left ventricular ejection fraction and no rhythm abnormality was noted on ECG (electrocardiogram) or telemetry. This patient falls into a low to intermediate risk group for syncope. According to American Heart Associations (AHA)/ American College of Cardiology (ACC)/ Heart Rhythm Society (HRS) guidelines such patients should be managed utilizing a structured emergency department (ED) observational protocol (1). In a study of individuals presenting to the emergency room, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (2). In this case, the patient had a normal echocardiogram and a normal 12 lead ECG. Acute inpatient admission was not medically necessary for this patient. 

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

The medical necessity for an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Myo-pericarditis. 
Treatment: Full inpatient hospital admission. 
The insurer denied coverage for the full inpatient hospital admission. 
The denial is overturned. 
 
Asked to review the case of a gentleman with no significant past medical history that presented to the hospital complaining of chest pain and shortness of breath for several days. Upon arrival to the hospital, vital signs were stable, Blood Pressure 142/107 and pulse of 76 beats per minute. No abnormal findings were noted on physical exam. 12 lead electrocardiogram (EKG) revealed diffuse ST elevations across the precordial leads.  Serum blood testing revealed an elevated troponin (1.95- 2.6) The patient was transferred to Mount Sinai Hospital for additional work up. Echocardiogram revealed a preserved left ventricular ejection fraction without significant pericardial effusion. The patient was treated for myopericarditis with ibuprofen and colchicine. 

This patient presented with chest pain, abnormal electrocardiogram and elevated serum troponin levels. His pretest probability of coronary artery disease was low. (Reference 1) Despite this, clinical presentation and initial evaluation supported a diagnosis of acute myocarditis. The patient was appropriately admitted for diagnostic testing and treatment.  Echocardiography revealed a preserved left ventricular (LV) ejection fraction. The patient responded to treatment with anti-inflammatory medication and was discharged with plans for outpatient cardiac magnetic resonance imaging (MRI). 

Patients with myocarditis require observation and treatment. Up to 9% (percent) of patients presenting with myocarditis can develop fulminant myocarditis resulting in lethal ventricular arrhythmia and cardiogenic shock. (Reference 2). Guidelines recommend hospital admission for patients presenting with myocarditis and note that 12-25% (percent) of patients may acutely deteriorate, develop progressive heart failure and die. (Reference 3) In conclusion, acute inpatient admission was medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.