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

Diagnosis: acute depression; bizarre delusions

Treatment: inpatient behavioral health treatment

The insurer denied coverage for 7 days. The denial was modified.

This patient is a female admitted for acute inpatient psychiatric treatment. She was diagnosed with Schizoaffective Disorder, Bipolar; Rule Out Major Depressive Disorder with Psychosis; Rule out immunodeficiency Induced Psychosis. She was discharged with the diagnosis of Schizoaffective Disorder, Bipolar Type. 
 
The insurer has denied coverage for inpatient behavioral health treatment.

The medical record indicates the patient had been residing in a nursing home facility and was experiencing the following symptoms; acute depression with crying spells, thoughts of harming herself, paranoid and bizarre delusions, internal stimulation, and odd mood and behavior. She was prescribed the following medications: Risperdal 4 mg daily and Prozac 20 mg daily at the time of admission. She had a history of extensive mental illness. She had a history of multiple psychiatric hospitalizations and multiple medication trials. She was single, unemployed and undomiciled. She had poor impulse control. She had thought disorganization. She was treated with Invega Sustenna and Risperdal.   

Based upon the information available this patient required acute inpatient psychiatric treatment; the insurer's denial is reversed for a specified date range of time. She had ongoing severe psychosis through the first 3 days. The level of this psychosis could not be safely or effectively treated outside of an acute inpatient setting. The acute inpatient hospital treatment on these dates is consistent with the general standards of medical/psychiatric care, APA Guidelines for the Treatment of Schizophrenia, and InterQual Behavioral Health Criteria 2018 Adult and Geriatric Psychiatry, Hospitalization, Psychiatric, Adult, Mental Health Criteria.  

There is no medical documentation indicating the need for acute inpatient psychiatric treatment for the last 4 days; the insurer's denial for these days is therefore upheld. This finding is consistent with the general standards of psychiatric care and the APA Guidelines for the Treatment of Patients with Schizophrenia.  

The health plan did not act reasonably with respect to the denial of inpatient treatment for one of the specified date ranges.

Based on the above, the medical necessity for the behavioral health inpatient treatment for a specified range is partially substantiated. The insurer's denial is modified. Approve one date range and deny the other date range.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sickle cell crisis

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay. The denial was reversed.

This patient is a male child with a history of sickle cell disease, Type 1 diabetes mellitus-on insulin pump at home, asthma, and priapism, who presented to the Emergency Department (ED) with a complaint of lower back and right leg pain on and off for one month. He has been taking ibuprofen and Oxycodone but ran out of the medications that day. Per the ED provider note the patient reported that the pain worsened on the day he presented to the ED and he called his hematologist who recommended that he go to the ED. The patient denied shortness of breath, chest pain, fevers, cough, congestion, and abdominal pain. He reported that his last urine dipstick was in the 300's in the morning.

According to InterQual Criteria: "Patients with [vaso-occlusive crisis] VOC [who] present with severe pain. The diagnosis is based upon the history and physical examination. The laboratory tests are not useful to confirm the disorder. Analgesic administration should be individualized based on the patient's home regimen. Aggressive and timely pain management is key to rapid resolution of VOC.  ...Additional supportive measures include hydration..." The patient clearly meets this description. 

It is commonly understood and widely published (as noted in the references below) that in children and young adults with sickle cell disease the description of pain is often the only sign of sickle cell crisis. As such, for a patient in whom ambulatory analgesia has not been sufficient, hospitalization for management of pain is standard of care. Hospitalization for management of pain with intravenous (IV) analgesia, IV hydration and to monitor for escalation of care as needed was within standard of care. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The inpatient hospital stay was considered medically necessary for this patient.

Based on the above, medical necessity for the inpatient hospital stay is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: Braces (comprehensive orthodontic treatment)

The insurer denied coverage for Braces (comprehensive orthodontic treatment). The denial was reversed.

This patient is a male child who per the Orthodontic Treatment Program had skeletal class lll, normal vertical growth pattern, permanent dentition, moderate maxillary spacing, mild mandibular crowding, moderate maxillary incisor protrusion, moderate mandibular incisor protrusion, impacted third molars, and anterior crossbite with gingival attachment loss (mandibular right central incisor). Crossbite of individual anterior teeth with clinical attachment loss and recession of the gingival margin are indicated as present on the Handicapping Labio-Lingual Deviation (HLD) Index Report.  

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 3 points on review by internal reviewers.

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, a Handicapping Labiolingual Deviation 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds 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 studies. 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 healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for Braces (comprehensive orthodontic treatment) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

The patient in question  with a Class I occlusion. The  patient has space in the maxillary arch, excessive overjet, and a deep bite causing soft tissue damage on her palate. Tooth #25 appears to have some recession. The patient has treatment planned for 18-24 months of orthodontics to correct the  malocclusion.Overturn in whole the health plan's determination of medical necessity.

Yes, the requested treatment of braces is medically necessary for this patient. A deep bite on its own is not a reason to treat with orthodontics. However, the patient is already damaging the soft tissue of the palate. The patient is also developing recession on #25. This will worsen with time if left untreated and can lead to periodontal problems in the future (3) that will be more invasive to correct than the orthodontic problem the patient currently has.

The patient's orthodontist has documented that the patient  is damaging the soft tissue of the  palate due to the  deep overbite, and the  cephalometric radiograph confirms a palatally-impinging overbite. Palatal tissue damage is a known side effect of deep bite malocclusions. (1) Additionally, the patient's protrusive incisors are at an increased risk of trauma (2)
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a skeletal Class I occlusion, severe maxillary crowding, mild mandibular crowding, anterior crossbite. The proposed treatment is braces for 24-30 months. The health plan's determination is upheld.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 9 with no auto qualifiers. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, braces are not medically necessary for this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Skeletal Class I malocclusion; maxillary and mandibular spacing; crossbite; and deep impinging overbite and excessive overjet.

Treatment:  Braces (D8080)

The insurer denied coverage for Braces (D8080).  The denial was reversed.

This patient is a female with Skeletal Class I malocclusion, maxillary and mandibular spacing, crossbite, deep impinging overbite and excessive overjet.  The orthodontist has completed the 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 12 points on review by internal reviewers.

The insurer has denied coverage for orthodontic treatment as not medically necessary.

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, a Handicapping Labiolingual Deviation 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 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 studies.  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 healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient.  

Based on the above, the medical necessity for Braces (D8080) is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

High Risk Pregnancy
Inpatient  Hospital
The patient gravida 1, para 0, at 27 weeks estimated gestational age. The patient was referred to labor and delivery from the physician's office with shortened cervix. The patient was noted in the 3 weeks prior to admission to have decreasing cervical length, from 2.7centimeters (cm) to 2.3cm down to 1.7cm the day of admission. The patient  had been on outpatient vaginal progesterone for 3 weeks prior to admission.The health plans determination is overturned in whole.

The traditional justifications for an inpatient admission are failure of outpatient management and care which cannot be provided safely as a lower level of care. This is a very high-risk situation, where a shortened cervix that is continuing to decrease in length represents a high risk of delivery at only 27 weeks estimated gestational age. The patient's physicians attempted to manage this situation with vaginal progesterone and observed the cervix to only shorten further over 3 weeks, a failure of outpatient management. Because of this dangerous risk of preterm delivery, the patient required admission where steroids could be administered, and the patient could be monitored for contractile activity. More importantly, the physicians needed the patient monitored in the hospital. A two-day inpatient stay was medically necessary to stabilize this patient and complete a steroid course.
Multiple professional guidelines point to the predictive value of cervical shortening in patients under 28 weeks. The standard of care would be to admit the patient to the hospital. The  patient received parenteral steroids and monitoring, along with an availability of all the necessary resources should the 27-week fetus deliver. These situations are dangerous and require the utmost attention and monitoring. The admission is medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Constipation
Inpatient Hospital

The patient is a boy with constipation and gastroesophageal reflux who presented to the emergency department with epigastric pain. Upon arrival to the emergency department, he was noted to be afebrile with normal vital signs. His physical examination revealed tenderness to palpation over the epigastric region with a palpable mass in the right lower quadrant. Laboratory values were obtained and were unremarkable. An abdominal x-ray showed a significant amount of stool in the colon. Because he was not improving on outpatient management, he was admitted for further management of constipation and treatment with GoLYTELY for fecal impaction, as per gastroenterology's recommendations. Upon admission, he received GoLYTELY by nasogastric tube, along with intravenous fluids and intravenous Zantac and Protonix. He improved with this treatment, and on the second hospital day he began to pass clear stool. He had only mild epigastric pain at that time and was felt to be stable for discharge to home with follow-up as an outpatient.

The health plan's determination is overturned. This is a young boy who presented with chronic constipation with fecal impaction, that had persisted despite attempted outpatient therapy. He had numerous emergency department visits in the past, and had also been under the care of a gastroenterology specialist; however, he continued to have symptoms, and on the evening prior to admission had pain that was extremely severe. Upon presentation to the emergency department his x-ray continued to show significant stool impaction. He required hospital admission for disimpaction, intravenous fluids and medications, and close monitoring for potential worsening of his clinical status. In fact, the admission was recommended by the gastroenterology specialist who was caring for him as an outpatient.
Hospitalization is necessary for severe constipation if several attempts at outpatient management have failed to yield abundant stool and symptoms continue. The inpatient regimen typically includes nasogastric administration of a balanced electrolyte solution (e.g., GoLYTELY) to flush out the colon, since it's very difficult for young children to take the necessary quantity by mouth.
The decision making at the time of admission for this patient was consistent with his young age, the presence of chronic constipation and severe pain that has persisted despite multiple attempts at outpatient treatment, his history of several prior emergency department visits for the same problem, and the need for specialist recommended disimpaction with intravenous fluids and close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Overturned

The patient  with severe fistulizing Crohn's disease  complicated by end ileostomy after an extended right hemicolectomy due to perforation and pelvic abscess. The required a wound vac for months postoperatively. In  the patient had an exploratory laparotomy, takedown of complex enterocutaneous fistula, small bowel resection, and anastomotic resection. The patient  failed Pentasa, Remicade (due to infusion reaction), and high-dose (weekly) Humira (due to anti-Humira antibodies). The patient  has had intravenous Stelara induction, with significant improvement in energy and rectal output.The health plans determination is overturned in whole . Yes, the medical necessity of Stelara is supported over the use of Entyvio. Current medical literature supports the medical necessity of Stelara in this case. A large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease, as this patient has [1]. Another study showed a 73% response in patients with anti-tumor necrosis factor (TNF) resistant Crohn's Disease, and 80% of responders-maintained remission for 1 year [2]. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications [3]. Current medical literature supports the continuation of Stelara in this patient in which induction with Stelara has already started.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who began receiving physical therapy following a left-sided hernia repair. Records indicate that a prospective review for coverage of physical therapy approved coverage up to a maximum of three (3) time to modality codes. The provider billed more than 3 modalities including current procedural terminology (CPT) code 97110 (Therapeutic exercises and treatment for strength and movement recovery). It was noted that the claim was retrospectively reviewed and determined to not be medically necessary as it must be skilled in nature. At issue is the medical necessity of therapeutic exercise.
Question(s):
The health plan's determination is upheld.
The request for an additional 4th timed unit in this case for the service dates in question is not medically necessary or supported from a skilled care and time perspective and lack of skilled intervention described in the clinical documentation. The patient was approved for three timed procedures and paid for the services on the dates in question which was noted to match the allocated 40 to 45 minutes of skilled services. Time services are typically 15 minutes each and the provider was paid for 3 timed services, which would be up to 45 minutes of skilled timed services. The provider billed for 30 minutes of neuromuscular reeducation to include proprioception/balance training, balance therapy exercise, lumbar mobility on theraball and also billed 30 minutes for therapeutic exercises to include hip mobility, hip stability, core stabilization. The flowsheet is handwritten and somewhat difficult to read but consisted primarily of stretching, stretching, pelvic tilt, bridging, planks, etc. These exercises would not require 30 minutes of skilled supervision and 15 minutes of this time could have been spent independently performing these exercises with no need for supervision/skilled physical therapy (PT). These are very basic exercises and the patient had already participated in 6 visits of physical therapy prior to this and should have been able to perform these exercises and stretches independently. There is no identifiable need for a 4th timed modality that was not skilled in nature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervicalgia, and myalgia of the auxiliary muscles of head and neck

Treatment: Physical therapy (PT) services rendered for dates of service specified

The insurer denied coverage for physical therapy (PT) services rendered for dates of service specified. The denial was upheld.

This patient is a female with generalized musculoskeletal pain complaints including neck pain, shoulder pain, headaches and an underlying diagnosis of Lyme disease.  Treatment included physical therapy for a specified time. The physical therapy treatment notes provide insufficient objective clinical information to support the medical necessity of the services provided for the treatment dates under review.  The physical therapy treatment notes fail to provide evidence of significant improvement that supports the medical necessity of continuing a structured physical therapy program. Subsequent treatment notes over the next several weeks failed to demonstrate substantial improvement.

The continued treatment without evidence of significant improvement is consistent with maintenance therapy and is not medically necessary.  Subsequent treatment could have been provided via a home exercise program. 

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient for much of this case. 

From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, physical therapy (PT) services rendered for dates of service were not medically necessary.

Based on the above, the medical necessity for the physical therapy (PT) services rendered for dates of service specified (one unit of manual therapy [97140]); and two units of therapeutic exercise (97110) and one unit of each neuromuscular reeducation (97112) and manual therapy (97140) for each of multiple dates specified is not substantiated.  The insurer's denial is upheld.