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

Infection 
Inpatient Hospital 

The patient had status post left radical mastectomy with a tissue expander in position who presented to the Hospital and Emergency Department (ED) from a surgical clinic for an emergency evaluation due to concern for infection. The patient reported several days of incisional site pain, chills and abnormal discharge.The patient has a past medical history of poorly differentiated invasive ductal carcinoma, diabetes mellitus, hypertension, hyperlipidemia, cigarette smoking and asthma.
The health plans determination is upheld in whole. No, the inpatient hospital stay was not medically necessary. Although the patient is American Society Anesthesiologists (ASA) Class III, the procedure was low risk (removal of infected expander and partially necrotic flap). The procedure was urgent, not emergent. The patient was not hemodynamically unstable. A single  low blood pressure reading is not sufficient for a diagnosis of hemodynamic instability.
The patient does not have any of the medical conditions listed in the Milliman Care Guidelines (MCG) Ambulatory Surgery Exception Criteria to require admission. The patient had pain following the surgery but was hemodynamically stable. The pain was controlled with analgesics. The required analgesics and antibiotics, but these could have been provided at a lower level of care. The patient did not have any significant physiologic or surgical complications following the procedure. The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder; Opioid Dependence
Treatment: Inpatient admission
The inpatient hospital admission was not medically necessary for this patient.

The intensive treatment of the patient's psychiatric disturbance did not require the admission and continued structure of an acute inpatient level of care or 24-hour monitoring. Moreover, the patient did not display evidence of suicidal plan or intent during his hospital course, as noted in the clinical summary; other symptoms such as severe cognitive impairment (dementia or delirium), thought disorder, mania or psychosis were not present in this case, nor was there psychiatric co-morbidity or substance-related disorders that would have warranted acute inpatient level care. The patient was cooperative with treatment and medication adherent, and the psychosocial stressors in this case were not so severe to require acute inpatient care or 24-hour monitoring. Additionally, the patient had an established treatment provider in the community and access to continued treatment and services at a lower level of care including the offer of PHP level care while in the emergency department. Thus, medical necessity for the admission and acute inpatient level care is not met in this case scenario. 

This answer is consistent with the scientific literature, published guidelines and ASAM Criteria, referenced below, and is in keeping with New York State instruction regarding medical necessity reviews.

The patient's treatment for his psychiatric disturbance and continued treatment of the substance-related disorder could have been safely and effectively provided at a lower level of care. Specifically, the patient did not present with acute general medical complications or severe withdrawal symptoms from alcohol or drugs or complications of the co-occurring substance use disorder. The patient's mood disturbance and associated symptoms related to the PTSD and ADHD and functional impairments did not require acute inpatient level structure or monitoring. There was no imminent risk for suicidal behaviors or documented symptoms that would have necessitated the inpatient admission or continued assessment, safety monitoring and treatment in an acute inpatient setting, as proposed. Again, the psychosocial stressors in this case were not so severe to warrant inpatient level care, monitoring or structure, and the patient had access to treatment at lower levels of care with social supports.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hydronephrosis and kidney stone
 
Treatment: Inpatient admission, diagnostic procedure, monitoring

The insurer denied the inpatient admission. The denial was upheld.

This is a male with past medical history of benign prostatic hypertrophy (BPH), diabetes mellitus type 2, and sciatica. He presented to the Emergency Department with complaints of left sided flank pain, with associated fever, nausea, headache, palpitation, dysuria, and frequency. An abdominal computer tomogram (CT) revealed a left hydronephrosis due to a calculus impacted at the iliac crossing.  A urinalysis showed moderate blood.  Urology consulted with the patient and he was taken for cystoscopy, left retrograde, left ureteroscopy with laser lithotripsy, stone basket extraction, and stent placement. The patient tolerated the procedure well with no complications, and he was discharged home.   

Per MCG Health Renal Colic & Kidney Stones, the patient did not meet clinical indications for admission to inpatient care. These include hemodynamic instability, acute renal failure, bilateral obstruction, transplanted kidney with obstruction, urinary tract infection (UTI), etc. Also, per MCG Health Urologic Surgery or Procedure GRG, the patient is noted to have met the General Recovery Course discharge parameter within 24 hours post procedure. As per the guideline, this procedure may be performed in the Ambulatory Surgery setting.  

The carrier's denial of coverage for inpatient hospital admission is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Preeclampsia
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient had a classic presentation of postpartum preeclampsia with severe features with a history of hypertension and preeclampsia with her delivery, headache and shortness of breath, blood pressures elevated into the severe range despite treatment with antihypertensives, and derangement of liver enzymes.  In this setting, it is not necessary or desirable to wait four hours for confirmation of the severe range of the blood pressures, although this patient in fact did sustain the blood pressures for the requisite time period.  

The ACOG practice bulletin addressing the diagnosis of preeclampsia with severe features clearly states the consensus that only preeclampsia patients lacking severe features are candidates for outpatient management. 

A major contributor to the morbidity of postpartum preeclampsia is a failure to recognize the signs and symptoms of preeclampsia and to appropriately treat with intravenous magnesium sulfate and intensive monitoring and control of blood pressure as well as to monitor for signs and symptoms of multisystem organ failure.  These patients are at risk for pulmonary edema, renal failure, malignant hypertension, stroke, liver complications, disseminated intravascular coagulation, and death.  Immediate hospitalization and intensive inpatient monitoring and treatment are essential.  Therefore, the hospitalization was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Gastrointestinal Bleeding /Bleeding of the Intestines.
Inpatient Hospital

  This is a patient with a history of hypertension, hyperlipidemia and diabetes who presented to the emergency department at the hospital with rectal bleeding.The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and monitoring of blood counts. Gastroenterology service consulted and recommended diagnostic colonoscopy.The health plans determination of medical necessity is upheld in whole. The inpatient hospital stay is not medically necessary for this patient. This patient  with a history of hypertension, hyperlipidemia and diabetes who presented with rectal bleeding. On presentation, the patient was hemodynamically stable without fever, tachycardia or hypotension. The patient's bloodwork was notable for anemia without leukocytosis or significant electrolyte derangements. The patient was admitted to the medical floor and treated with conservative management with intravenous fluid hydration and monitoring of blood counts.Based on the Milliman Care Guidelines (MCG) guidelines, the patient did not have active gross bleeding per rectum, failure to control bleeding, unstable comorbid illness, coagulopathy, suspected or known ischemic colitis, previous aortic graft placement, hemodynamic instability, complicated anemia, severe pain requiring inpatient management, absent bowel sounds, intestinal obstruction, low platelet count, severe electrolyte abnormalities, acute renal failure, high fever, require parenteral nutrition or immediate surgery and therefore an acute inpatient level of care admission was not medically necessary.
The determination is consistent with generally accepted standards of medical practice as supported by nationally recognized peer reviewed literature and guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anxiety and depression with suicidal ideation

Treatment: Inpatient mental health treatment

The insurer denied coverage for inpatient mental health treatment. The denial was upheld.

This patient is a male who was admitted to inpatient mental health treatment in this hospital due to depression and anxiety. He reported overwhelmed anxiety and depression with suicidal ideation though denied plan or intent. He had used cocaine a few weeks prior to admission. He was smoking cannabis. He had past suicide attempts by Tylenol and opiates overdose. He had a past but not current history of alcohol, opiate, and benzodiazepine use. He had past inpatient substance detoxification and rehabilitation treatment. He had past legal issues for drugs sale. He had diagnoses of Major Depressive Disorder, PTSD, cocaine abuse, cannabis use, and anxiety disorder. He took Remeron, Risperidone, and Paxil and was discharged with referral to outpatient mental health treatment.

The insurer denied coverage for inpatient mental health treatment in this hospital as not medically necessary treatment. They stated that he did not have active suicidal or homicidal intent or plan, had no psychosis, and was not considered an imminent danger to self or others.

This reviewer agrees with the decision to deny coverage for inpatient mental health treatment in this hospital as the chart notes did not provide enough specific evidence to support that he could only be treated safely and effectively in a 24 hour acute psychiatric hospital then or that he could not be treated in a less restrictive level of care then. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors reports that patients with suicidal intent or plan are in need of inpatient treatment, but this patient had reports of suicidal ideation without intent or plan. He had reports of depression and anxiety and substance use including recent cocaine use which he reports may have contributed to worsened symptoms but there was no specific evidence reported to support that he was considered an imminent danger to self or others or that he had inability to adequately care for his basic needs. He had medication changes which resulted in improvement as he had Remeron added to Paxil and Risperidone. It was reported that he was not fully compliant with his psychrotrophic medications. There were no reports of suicidal intent or plan throughout his hospital stay.

Inpatient mental health treatment at this hospital was not medically necessary. It appeared that the health care plan acted reasonably and with sound medical judgment and in the best interests of the patient then.

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Issue under review: Upper airway stimulation device

Determination: 
The health plan should cover the Upper airway stimulation device.

Otolaryngology's academy's recommendations as well as the literature support that this procedure is the treatment of choice for OSA seen as seen in this patient (1-4). She has the appropriate diagnostic findings and has not tolerated CPAP.  The procedure is not E/I; it is accepted standard of care. 

It is the position of the AAO-HNS (our professional body) that this is standard of care (1).

This patient has severe OSA, which is a potentially life threatening disorder.  The patient requires therapy and has not tolerated CPAP.  At this point hypoglossal nerve stimulation is the only therapy that can be beneficial besides a tracheostomy, which has severe life altering consequences.  As such, hypoglossal nerve stimulation is the best option.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Issue under review: Upper airway stimulation device

Determination: 
The health plan should cover the Upper airway stimulation device.

The patient is an adult female with a history of OSA.  AHI on sleep study was 27.3 with a BMI of 28.2.  The patient could not tolerate CPAP and underwent a sleep endoscopy where there was no complete concentric collapse at the velum.  The provider is requesting placement of an Inspire hypoglossal nerve stimulator system to treat the patient's OSA.  

There is support in the literature for the efficacy of the Inspire hypoglossal nerve stimulator for the treatment of a subset of patients with OSA who have failed, or cannot tolerate, CPAP therapy.  A prospective multi-center study documented a reduction of AHI out to 12 months.  In addition, there was a randomized, controlled withdrawal arm of the study which reported AHI reduction out to 18 months.  Therefore, based on current scientific literature, scientific evidence would support the efficacy of upper airway stimulation therapy with a hypoglossal nerve stimulator for a subset of patients with OSA who meet FDA criteria for the procedure.  

In this particular case, the patient would meet FDA criteria for the device in terms of BMI, age, AHI and sleep endoscopy findings (there was no complete concentric collapse on sleep endoscopy).  The patient has had a previous reported failed CPAP trial.  There would be no contraindications to the procedure based on the information provided.  Therefore, based on the information provided, the medical appropriateness of the requested service would be confirmed as the requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Obstructive sleep apnea
Issue under review: Upper airway stimulation device

Determination: 
The health plan should cover the Upper airway stimulation device.

For this patient, the proposed procedure is required to treat their sleep apnea, which is not controlled by more conservative measures.  It meets the standard of care and is not for the convenience of the patient.

The procedure and device are FDA-approved, as referenced below, and recognized in the treating community as efficacious and safe for properly selected patients.  This patient with moderate sleep apnea and favorable anatomy is a good candidate for this intervention.  By virtue of review of the literature, it is neither experimental nor investigational, which were the categories of exclusion in the plan policy.  This is particularly evident with the withdrawal study by Woodson referenced below which showed the efficacy of the therapy and the reversal of efficacy by discontinuing the stimulation.  

For this patient, the proposed procedure is required to treat the sleep apnea, which is not controlled by more conservative measures.  It meets the standard of care and is not for the convenience of the patient.

The principal specialty in Otolaryngology (the American Academy of Otolaryngology- Head and Neck Surgery) has examined the scientific support for hypoglossal nerve stimulator in sleep apnea and concludes:

The American Academy of Otolaryngology-Head and Neck Surgery considers upper airway stimulation (UAS) via the hypoglossal nerve for the treatment of adult obstructive sleep apnea syndrome to be an effective second-line treatment of moderate to severe obstructive sleep apnea in patients who are intolerant or unable to achieve benefit with positive pressure therapy (PAP).  Not all adult patients are candidates for UAS therapy and appropriate polysomnographic, age, BMI and objective upper airway evaluation measures are required for proper patient selection.  

This patient has had proper evaluation and meets clinical criteria for this intervention.
Appeal type: Medical necessity
Decision: Upheld

The patient has a skeletal Class II malocclusion. The patient has mild maxillary and mandibular crowding, moderate overjet, and moderate overbite. The proposed treatment is braces for 18-24 months.The health plan's determination is upheld, in whole.
The service of Braces is not medically necessary for this patient. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. The Handicapping Labio-Lingual Deviation (HLD) index is the standard used when evaluating a patient for medical necessity of braces (comprehensive orthodontic treatment. The HLD index scores each case by looking at the patient's overjet, overbite, crowding, labio-lingual spread, presence or absence of a unilateral posterior crossbite. 
The malocclusion would score a 20 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9-millimeter (mm) or greater and underbite 3.5mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary. The patient scored a 20, thus making this case not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a male with maxillary and mandibular crowding and many unerupted permanent teeth. He has a deep bite. The orthodontist mentioned in the diagnosis that #6 and #11 are impacted. The patient was treatment planned for 30-36 months of comprehensive orthodontics with canine exposure and ligation, but the plan was denied due to lack of medical necessity.

The health plan's determination is upheld.

The patient is preadolescent and in the mixed dentition phase of development. Neither tooth #6 nor #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure as maxillary canines usually erupt at 11-12 years of age. There is still much time to see if the tooth will erupt successfully on its own without orthodontic intervention.

Orthodontic treatment is not medically necessary for the patient at this time. He is in the process of losing his remaining primary teeth as they are replaced with permanent teeth. Research indicates the following risk factors for impacted canines in patients over 10 years of age 2:
1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph.)
2) The canines cannot be palpated, and occlusal development is advanced. (Occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption.)
3) The lateral incisor is proclined and tipped distally. (Photographic evidence does not indicate proclined lateral incisors.)
4) On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided.)
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: skeletal Class I malocclusion, maxillary and mandibular spacing and anterior protrusion and excessive overjet and deep impinging overbite.  

Treatment: Comprehensive Orthodontic Treatment (D8080)

The insurer denied coverage for Comprehensive Orthodontic Treatment (D8080). The denial was reversed.

This patient is a female patient with skeletal Class I malocclusion, maxillary and mandibular spacing and anterior protrusion and excessive overjet and deep impinging overbite.  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 the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 16 points on review by internal reviewers.

Upon review of the submitted documentation, 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, as of September 1, 2012, 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 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. Each of the referenced peer reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care.  As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The carrier's denial of coverage for Comprehensive Orthodontic Treatment (D8080) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Small teeth
Treatment:  Resin fillings teeth #7 and #10

The proposed resin fillings on teeth #7 and #10 are not medically necessary. 

The fillings requested are cosmetic in nature.  They are being requested to make two teeth that are on the smaller side, larger.  There is no restorative need to do these fillings.  The treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic hepatitis C
Treatment: Zepatier

The proposed treatment with Zepatier is medically necessary.

The patient has genotype-1 disease, and is in need of treatment. Although not the formulary preferred agent, Zepatier, in the C-EDGE trial, was found to be safe and efficacious, with a sustained viral response (SVR) of 92% in treatment naive genotype-1a patients. 

As the patient has hypertension (HTN) that is stable on Avalide, and as Avalide has a drug interaction with the formulary preferred agents, and would need to be changed, the proposed Zepatier is clinically appropriate and accepted standard of medical care and medically necessary, and the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient by denying it.