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

Dental Problems
Dental/Orthodontic Procedure

The patient is a male with a diagnosis of Class I malocclusion, appropriate overjet and overbite. The upper and lower arches are both moderately crowded. The provided record states that teeth 6 and 11 have an anterior open bite and for this reason orthodontics are medically necessary.

The health plan's determination is upheld.

Braces and monthly visits are not medically necessary for this patient.
The patient has appropriate overbite and overjet. There is moderate crowding but that alone does not rise to the threshold of medically necessary. Teeth 6 and 11 are not fully erupted, which is appropriate given the age of the patient.2 Just because a patient has incomplete tooth eruption of the maxillary canines at a young age does not mean the patient has an anterior open bite. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. There does not appear to be any wear present on the teeth due to the patient's occlusion. In the absence of a functional problem, orthodontic treatment would not be medically necessary to prevent future problems and could be done at a later date for esthetics if the patient chooses.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psychiatric/Substance abuse
Treatment: Inpatient Detoxification

The patient requested detoxification treatment for polysubstance use in the context of severe psychosocial stressors including unemployment and diagnosis of hepatitis C, with multiple past substance use disorder treatments. The patient had been using up to 12 bags of heroin daily with intravenous (IV) administration with one pint of cognac plus beer and one gram of cocaine three to six times weekly. The substance use disorder had its onset in adolescence and progressed into adulthood with diagnoses of opioid, stimulant (cocaine) and alcohol use disorders. Patient presented with mild symptoms of withdrawal with Clinical Institute Withdrawal Assessment (CIWA) and Clinical Opiate Withdrawal Scale (COWS) scale scores of 2 and 4 with sweats, gastrointestinal upset, and anxiety and insomnia with normal vital signs. There were no acute general medical or psychiatric issues. Patient had a history of unspecified depressive disorder and post-traumatic stress disorder with report of one psychiatric hospital stay. Patient was taking no psychotropic medications. Patient was admitted and placed on a detoxification regimen with methadone and Librium taper, comfort medications, as well as vitamin replacement therapy. Detoxification was uncomplicated regarding withdrawal management though the patient did have an untimed CIWA and COWS scale score of 12 and 10, respectively with no complaints or apparent distress. Patient received counseling and education from staff. The clinical course was uncomplicated with continued normal vital signs, and the patient was discharged against medical advice upon completion of detoxification with clinically appropriate recommendations for aftercare. The patient refused immediate referral/admission to inpatient rehabilitation substance use disorder treatment. The requested detoxification treatment, withdrawal management and medical services could have been safely and effectively provided at a lower level. There were no co-morbid medical issues or psychiatric disorders warranting inpatient admission. Withdrawal symptoms were not reported as severe, and clinical symptoms were not serious enough to necessitate inpatient level detoxification treatment/monitoring. There were no safety concerns or history of complicated withdrawal from drugs or alcohol. The patient was considered to be motivated for detoxification treatment and had access to substance use disorder services in the community. The health plan's determination is upheld, as medical necessity has not been established for the services in keeping with prevailing standards of professional practice, and consistent with the American Society of Addiction Medicine (ASAM) Criteria and scientific literature. Additionally, medical necessity for the requested inpatient detoxification and other medical services is not met in keeping with NY State OASAS LOCADTR 3.0 Criteria/Guidelines.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Inpatient hospital

The patient is a female. who was admitted to the hospital with a principal diagnosis of supraventricular tachycardia (SVT). She has a history of bipolar, schizophrenia, prior SVT and was sent from the drug rehab center with complaints of palpitations. The palpitations are associated with chest pain, shortness of breath and dizziness. She was admitted on telemetry and an echocardiogram was done which was normal. She was placed on Cardizem by mouth as the SVT resolved. She was monitored on telemetry with no further episodes and sent home with cardiac evaluation.
The inpatient admission is under review.

The health plan's determination is upheld. The Inpatient Hospital Admission medically necessary for this patient. The patient had a history of SVT since she was a young child. She was taking medication to treat her abnormal rhythm but had missed the dose of medication for the last 4 months. She presented with recurrence of a chronic problem that was under control and back to normal after getting IV Cardizem in the emergency room. At that time with there being no abnormalities in laboratory testing, physical exam or hemodynamic compromise she could have been monitored for a few hours to ensure no recurrence of the rhythm or side effects of the medication given by the EMS and ER physicians while resuming her verapamil. The patient could have been treated in the ER with observation, but there was no indication that she required an inpatient admission. This is supported by the medical literature. She was not hemodynamically unstable, had arrhythmias that remained of immediate concern, had no severe electrolyte abnormalities, and did not require continuous IV medication, cardioversion or cardiac catheterization for intracardiac pressure monitoring.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient Hospital

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

The patient is a girl who presented with fever and vomiting. She was well until 6 days prior to admission when she developed nausea and vomiting. She also had a nonproductive cough. She continued to have daily fevers for the next 6 days and was subsequently brought to the outpatient clinic. She was referred from the clinic to the emergency department due to concern for pneumonia.

The inpatient hospital admission was medically necessary for this patient.
This is a young girl who presented with cough, nausea, and vomiting. She was febrile for 6 days at the time of presentation. She was initially seen in her primary care office but was referred to the emergency department due to concerns of pneumonia. Upon presentation, she was found to have fever, an oxygen saturation of 95%, and crackles on her right lower lung base consistent with clinical pneumonia. She was also found to have an elevated white blood count with a left shift indicated systemic illness. During her time in the emergency department, she became more fatigued and drowsy, and required a bolus of intravenous fluids as well as parenteral ceftriaxone. She was admitted for ongoing treatment of pneumonia with intravenous antibiotics as well as intravenous fluids to maintain her hydration status. Due to her prolonged fever and ill appearance, she required prompt treatment with careful monitoring.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal.
Surgical Services.

Diagnosis: Back pain.
Treatment: Spinal Surgery.
The insurer denied spinal surgery. The health plan's determination is upheld. 

The patient is a male with a complicated past surgical history in regards to his spine. Apparently, he underwent an L3 to S1 decompression and fusion which included anterior interbody spacers placed at each level. There is also a mention of a revision fusion for "broken hardware" although no specifics are given. He then underwent placement of a SCS (spinal cord stimulator). He re-presented to the provider with a 2-year history of slowly worsening lower back pain and pain into both lower extremities. In the earlier notes, the leg pain seemed to be in the posterior thighs but in later preoperative notes the radicular symptoms were primarily described in the anterior thighs. Multiple attempts at conservative therapy were undertaken  including 2 trials of lumbar facet blocks, weight loss, ice and heat, activity modification, physical therapy, and medical management with narcotics and Gabapentin.

The spinal surgery of the lumbar spine, consisting of the LLIF L2-3 and posterior decompression with instrumented fusion and posterolateral fusion, was not medically necessary based on the documentation provided. Generally accepted indications for a spinal fusion is the presence of visible instability at the level(s) planned for a fusion, or the anticipation of creating instability with the extent of the bony removal to ensure complete decompression of the nerves. However, in this case neither gross instability is seen on any imaging study, nor is there the documentation of moderately severe to severe neural foraminal stenosis that would require such bony removal of the facet joints that instability would be created. There was a lack of instability at L2-3 in the flexion/extension views taken at the time of the myelogram, no significant thecal sac compression noted in the radiology report, and only mild canal stenosis and mild to moderate bilateral foraminal stenosis without reported exiting nerve root compression. Thus, the argument that the L2-3 level required such radical decompression that iatrogenic instability would have been created cannot be supported.
Appeal type: Medical necessity
Decision: Upheld

Trauma/Injuries
Inpatient hospital

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

The patient is a man who presented to the emergency department with a chief complaint of an infected wound in his left lower extremity. He reported suffering a gunshot wound two weeks prior to presentation. He was being followed by surgery as an outpatient but was concerned that the wound was infected. He denied pain, fevers, chills and difficulty walking. The patient was admitted for suspected wound infection. The plan of care included intravenous (IV) fluids, IV antibiotics, x-rays of the left lower extremity, and wound care.

The inpatient hospital admission was not medically necessary. The patient did not have evidence of a high acuity condition during his hospital stay. He did require further care for wound infection, but this type of care is often provided at a lower level in patients who are stable and have no evidence of toxicity, systemic infection, or early evidence of end organ injury. His treatment plan, including the surgical debridement, could have safely and effectively been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Flutter
Treatment: Inpatient Hospital Stay
The insurer denied the Ipatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department complaining of palpitations. He reported drinking two beers daily. His blood pressure was 176/93 millimeters of mercury (mmHg) with a heart rate of 109 beats/minute. His room air oxygen saturation was 98%. His physical exam was remarkable for a tremor that was attributed to alcohol withdrawal versus anxiety, and a rapid heart rate. An electrocardiogram showed sinus tachycardia at 114 beats/minute with premature atrial contractions and left ventricular hypertrophy. A repeat tracing, by report, showed atrial flutter with a ventricular rate of 148 beats/minute. His serum troponin and brain (or B-type) natriuretic peptide (BNP) levels were normal. He was treated with intravenous diltiazem and admitted to the hospital. The left ventricular ejection fraction was normal. He was started on oral diltiazem and an oral anticoagulant. The patient was discharged. The medical necessity for an inpatient admission is at issue.
The inpatient stay was not medically necessary. This patient presented with palpitations and was diagnosed with atrial flutter with a rapid ventricular rate. He was hemodynamically stable, there was no evidence of ischemia, he was not in heart failure, and was not at high risk for a thromboembolism. For patients presenting with acute atrial fibrillation (AF) or flutter, the safety of discharge to home with close follow-up has been well demonstrated. As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter. Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization. Likewise, Conti et al, based on an observational study of 3475 patients concluded, "In patients with AF, beyond the standard approach, the novel organization with an additional intensive observation unit for early pharmacological interventions and an outpatient clinic for elective treatment and short-term follow-up significantly reduced admission irrespective of independent predictors of hospitalizations." This patient had atrial flutter; his heart rate was controlled with diltiazem.  While he had a tremor that may have been due to alcohol withdrawal, he did not have signs of severe withdrawal such as visual, tactile or auditory hallucinations. He was alert and oriented.  Thus, if he did have alcohol withdrawal, it was mild.  According to current recommendations, patients with mild alcohol withdrawal can be monitored on an outpatient basis.  They do not require hospitalization and may not require medication. Based on the records provided, a lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Dx: Dental Problems
Tx: Dental/Orthodontic Procedure:
Denied: Braces/monthly visits
Denial: UPHELD in whole

The patient in question is a male. He has a Class II malocclusion with minor maxillary and moderate mandibular crowding. He has been treatment planned for orthodontics to treat his crowding which was denied by the health plan as not medically necessary. The subject under review is the medical necessity of the treatment with braces and monthly visits.

The health plan's determination is upheld in whole. 

The requested treatment of braces and monthly visits is not medically necessary. The patient does have a slightly deep bite, however, that alone is not a medical necessity to treat. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. There are many ways to correct patients with a deep bite, and there is no strong evidence that one treatment is better than another. Furthermore, deep bites may be corrected in adulthood, so the patient would not lose the ability to correct the malocclusion should he choose to do so later in adulthood.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke work-up

Treatment: Inpatient admission 

The insurer is denied coverage for inpatient admission. The denial is upheld.  

This case involves a female patient at the time of presentation.  This patient presented with complaints of slurred speech.  Emergency medical services detailed the patient had slurred speech and dizziness.  She does have a past medical history which includes diabetes as well as hypertension and premature ventricular contractions (PVC).  The triage vital signs revealed a blood pressure of 145/80 with oxygen saturation of 100% on room air.  The documentation indicated the patient did have improvement in symptoms while in the emergency department.  Therefore, it was noted the patient was not a candidate for TPA due to improvement.  The patient continued however to have ataxia to bilateral upper extremities with weakness to the left leg.  The patient was recommended for imaging.  The CT scan did not reveal any acute pathology.  The recommendation was also made for the patient undergoes laboratory studies.  The patient had a negative troponin and no other significant abnormal levels.  Neurology service consulted; it was noted her complaint of slurred speech had resolved.   The patient was admitted for further work-up.  She underwent an EKG showing a normal sinus rhythm.  Further diagnostic studies to include a CTA of the head and neck did not reveal any significant abnormalities.  While admitted the patient did not have any further adverse events.  The patient continued to undergo further diagnostic and laboratory studies.  The patient underwent a swallow study which was normal.  The patient also underwent an echocardiogram while admitted which showed a normal left ventricular systolic function.  She continued to be evaluated and once deemed stable the patient was discharged.  The patient was discharged with instruction to follow-up.

The patient presented with slurred speech and dizziness with past medical history of diabetes and hypertension. The patient underwent imaging study with CT and CTA of the head and neck. 
The patient presented with mental status changes with acute confusional state. CT of the Brain and CTA were unrevealing. There was no evidence for stroke or transient ischemic attack (TIA). Care provided could have been performed on an observation basis given the lack of serious acute findings warranting an inpatient admission. Follow up could have been established on an expeditious basis on an outpatient setting. Therefore, the entire admission was not medically necessary. 

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

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

Diagnosis: Tooth pain
Treatment: Tooth colored cap (crown) for tooth #20
The insurer has denied Tooth colored cap (crown) for tooth #20.
The denial is upheld.

The patient is an adult female requesting benefits for a crown on tooth #20. There is no periapical x-ray of tooth #20 presented that would help to understand the need for a crown. The only x-ray submitted that shows the tooth, only shows a small part of the top of the tooth. A better x-ray showing the apex (end) of the tooth is needed. Without this x-ray, it cannot be concluded that there is a need for a crown at this time.  Therefore, the requested crown is not medically necessary at this time.
Appeal type: Medical necessity
Decision: Upheld

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

The Inpatient admission was not medically necessary.

This patient is a female with history of pre-diabetes. She presented with a two-week history of generalized weakness, dizziness, nausea, polyuria, and polydipsia, and she was diagnosed with type 2 diabetes with hyperglycemia. 

The patient's glucose was 600 mg/dL. pH was 7.34 (7.35-7.45). The patient's blood pressure was 119/88, heart rate 87. She was treated with insulin drip and stopped at 18:15. Endocrinology consulted. She was started on subcutaneous insulin. 

This patient presented with hyperglycemia and dehydration with a new diagnosis of type II diabetes. She was not hemodynamically unstable. She did not have significant acidosis (pH 7.34) to support a diagnosis of diabetic ketoacidosis. She did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. She was noted to be alerted and oriented and was noted not to be in acute distress. Her hyperglycemia improved quickly with intravenous insulin, and she was transitioned to subcutaneous insulin. These insulin doses could have been titrated under observation or as an outpatient. She did not have vomiting and no fever or other evidence of infection. Therefore, the requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Numbness, pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female with a history of fibromyalgia, anxiety and depression who presented to the emergency ward with the complaint of whole body numbness for over one month duration with intermittent pain, shakiness and numbness. Magnetic resonance imaging (MRI) prior to admission showed non-specific white matter changes. MRI during admission was not changed. She had a normal neurological examination except for subjective sensory components. 

The patient presented with subjective symptoms for over one month and negative MRI imaging. There were no features on her examination or clinical history that suggested an acute or evolving neurological condition that would require inpatient evaluation. The diagnostic studies, monitoring and clinical evaluation could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness, dizziness, blurred vision
Treatment: Inpatient admission

The Inpatient admission was not medically necessary.

The patient is a male with a history of stroke.  He presented with the complaint of generalized weakness, dizziness and blurred vision.  At presentation, he had a normal neurological examination and CT brain.  He was evaluated by a neurologist, and no change to his treatment regimen was recommended. 

The patient presented with nonspecific complaints and a normal neurological evaluation. There were no concerning features on history, diagnostic studies or examination to suggest an acute neurological event.  The patient's complaints could have been safely and effectively evaluated, monitored and treated at lower level of care. Therefore, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cognitive impairment, hypertension, elevated cholesterol, arthritis, and depression

Treatment: Personal Care Assistance, Level II, 12 hours/day, seven days/week, for a total of 84 hours/week

The patient is a female with significant past medical history of cognitive impairment; hypertension; elevated cholesterol; arthritis; and depression.  She lives alone with assistance of personal care aid approved for eight hours per day seven days per week.  The patient is dependent on services for meal preparation, house work, shopping, transportation, bathing, personal hygiene, upper and lower body dressing, toilet transfers, bed mobility, locomotion and eating.  The patient is currently stable based on Uniform Assessment - New York Comprehensive Community Assessment Report.  Results of recent survey of Personal Care Assistance recommended consistent with 56 hours per week approved by health care plan.  

Based upon the comprehensive community assessment report and survey of personal care assistant hours, the patient's medical needs are met with the approved eight hours per day seven days per week totaling 56 hours. There is concern from the patient's family regarding the patient's falls, confusion, hallucinations, forgetfulness, and decline in mental status. However, there is no documentation in the provided medical records that the patient's current needs cannot be met with the currently approved 56 hours.