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

Orthopedic
Pain management

Diagnosis; back pain
treatment: nerve treatment to the spine 
The insurer denied nerve treatment to the spine. The health plan's determination is overturned. 

This is a male with chronic low back pain and neck pain. For his low back pain, he had a LESI (lumbar epidural spinal injection), and Bilateral L (lumbar) 4 - S (sacral) 1 radiofrequency ablation (RFA). His back pain is across his waistline, worse with walking and standing. Pain is disabling with a significant impact on activities of daily living (ADL) and quality of life. A follow up visit indicated that after the RFA the patient continues to have low back pain. On physical exam (PE), there was pain with extension and facet loading. An magnetic resonance imaging (MRI) scan showed multilevel degenerative spondylosis without high-grade spinal canal stenosis and Modic type 1 and 2 at L4-L5-S1 level. 

The nerve treatment to the spine is medically necessary for this patient.
The Intraosseous nerve ablation procedure was designed to treat low back pain from vertebral body by ablating intraosseous nerves. There are multiple clinical trials demonstrated the efficacy of this intervention. This patient's persistent back symptomatology is consistent with vertebrogenic pain. He had tried extensive treatments including epidural injection, lumbar medial branch blocks, RFA and pain medications without adequate improvement. His pain is severe with a negative impact of activities of daily living (ADL). Given this patient's clinical scenario, the nerve treatment to the spine is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is upheld.


This is a patient with a Class I occlusion with a 6-millimeter (mm) overbite and 4-mm overjet. The patient has moderate maxillary and mandibular crowing and is treatment planned for 24-30 months of orthodontics to correct the malocclusion. At issue is the medical necessity of braces and monthly visits.

There is no medical reason to correct the patient's malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. Aligning the teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) The patient has a 4 mm overjet but this amount of overjet does not affect oral health related quality of life. (3) If the teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. The requested orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Cardiac
Home health care

Diagnosis: coronary artery disease
Treatment: home health care
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Live In). The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, hyperlipidemia, hypertension, peripheral vascular disease, ischemic cardiomyopathy, history of endometrial cancer, tremor, neuropathy, hearing loss, Parkinson's disease, spinal stenosis, osteoarthritis, urinary incontinence, osteoporosis, gastroesophageal reflux disease (GERD), anxiety, depression, and diabetes mellitus type 2 who had been assigned PCA (personal care assistant) services.

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Live In) is medically necessary for this patient.
There is documentation from the patient's daughter and cardiologist of worsening physical functioning following hospitalization and rehabilitation stay for cardiac diagnoses. There is documentation from the plans own assessment that the patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The plan assumed the patient had informal help outside of the currently assigned hours which is not the case. The requested increase in PCA services is not solely for safety and supervision but to assist patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Live In) are medically necessary. Assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular
Inpatient Hospital

Diagnosis: Dizziness and Numbness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient has a history of asthma, gastric ulcer, vomiting, and hypokalemia. She presented to the emergency room with a 2-month history of dizziness and numbness and tingling of the hands and feet. The vital signs were normal, as well as the remainder of the physical exam. Lab results were notable for a hemoglobin of 16.3 grams per deciliter (g/dL), sodium 130, and a potassium of 2.4. The patient was admitted for further treatment and evaluation.
At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.
Upon admission, the patient was treated with intravenous fluids as well as oral and intravenous potassium supplementation. The following day, the patient was feeling better and the potassium was up to 4.3, the sodium improved to 134, and the hemoglobin was down to 14.4. A vitamin B12 deficiency was noted and was treated with parenteral cyanocobalamin. An magnetic resonance imaging (MRI) scan of the brain and cervical spine was normal. The remainder of the stay was clinically uneventful and the patient was discharged.
Based on a review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, lab results, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The symptoms and laboratory abnormalities resolved quickly with straightforward therapy. This treatment, including consultations and imaging, was not at the acute inpatient level of intensity. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: D8080 braces and D8670 monthly visit.
The insurer denied coverage for D8080 braces and D8670 monthly visit.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to impacted permanent maxillary right canine. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and Medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD), 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 impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care using this criterion. This reviewer concurs with the findings of the insurer of attaining 19 points on the HLD index (3 points overjet, 3 points overbite, 10 points anterior crowding, 3 points labiolingual spread). 

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. 

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 D8080 braces and D8670 monthly visit services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive Heart Failure
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient has a history of chronic systolic heart failure, coronary artery disease (CAD), prior percutaneous coronary intervention (PCI), diabetes mellitus (DM), right lower extremity (RLE) deep vein thrombosis (DVT) status/post (s/p) inferior vena cava (IVC) filter, hypertension, systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) who was brought to the emergency department (ED) by Emergency Medical Services (EMS) for evaluation of shortness of breath, leg swelling and chest pain for 2 days. The chest pain was relieved at home after taking sublingual (SL) nitroglycerin. She admitted to noncompliance with medical therapy and fluid restriction. She also presented with right lower extremity (LE) discharge coming from the wounds. Notable labs showed a brain (or B-type) natriuretic peptide (BNP) of 3300 and hyperkalemia, with a potassium of 6. Examination revealed 3 plus (+) lower extremity (LE) edema. A chest x-ray (CXR) showed pulmonary edema. The patient was admitted to the telemetry service for evaluation and management of acute on chronic systolic heart failure with volume overload associated with hypoxemia. The patient left against medical advice (AMA) the same day. At issue is the medical necessity of an inpatient stay.

The inpatient stay was medically necessary. The patient presented with acute decompensated heart failure with significant volume overload and hypoxia. She had worsening shortness of breath, chest pain, respiratory distress and hypoxia due to acute on chronic systolic heart failure with significant volume overload. She required aggressive intravenous (IV) diuresis, telemetry monitoring, supplemental oxygen for treatment of hypoxia and relief of symptoms. Her brain (or B-type) natriuretic peptide (BNP) was significantly elevated indicative of marked volume overload and a marker of adverse cardiac events. Based on the patient's significant volume overload demonstrated by high BNP, pulmonary edema, and severe leg edema, it was anticipated that aggressive IV diuresis would be required beyond observation. For these reasons, inpatient level of care was medically necessary, appropriate and in the best interest for the safety of the patient to achieve optimal patient outcomes supported by expert consensus guidelines on acute heart failure management (1-3).

The health plan's determination is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I malocclusion
Treatment: Braces
The insurer denied braces. 
The health plan's determination is upheld. 

The patient in question is a female with a diagnosis of Class I malocclusion, appropriate 5 millimeter (mm) overjet and 1 mm overbite. The upper arch has minor spacing, and the lower arch has minor crowding. The provider states that the patient has a 2mm anterior open bite and for this reason Braces are being requested. 

Braces are not medically necessary. The patient has appropriate overbite and overjet. There is minor lower crowding but that alone does not rise to the threshold of medically necessary. The photographs do not support a diagnosis of an anterior open bite or an anterior crossbite. This patient has a Class I occlusion and masticatory efficiency is highest in patients with a Class I occlusion. If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. For these reasons, braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient hospital stay. 

The insurer denied the inpatient hospital stay. 
The health plan's determination is upheld. 

The patient is a woman with hyperlipidemia and previous deep vein thrombosis (DVT) who presented to the emergency room with chest pain which began four days prior to admission. The pain was constant, squeezing in nature and associated with shortness of breath. Her blood pressure was 117/46, pulse 78 and respiratory rate 16. She was afebrile. Oxygen saturation was 100% on room air. The electrocardiogram (EKG) shows normal sinus rhythm at 79 beats per minute (bpm). 

The patient presented with chest pain for a few days prior to admission but had no objective evidence for an acute coronary syndrome. She did not have objective signs or symptoms to indicate an alternative potentially life-threatening cardiac or pulmonary diagnosis (such as aortic dissection, pulmonary embolus, or pneumonia). An inpatient hospitalization is not indicated. The inpatient stay is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of chronic type 1 diabetes, coronary artery disease, dementia, hypertension, congestive heart failure, hypothyroidism, aortic valve replacement, Paget's disease, macular degeneration, Bell's palsy, osteoarthritis, hearing loss, history of bowel resection, and urinary incontinence who had been assigned PCA (personal care aid) services.

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week are medically necessary for this patient. 
There is documentation from the medical provider and healthcare advocate of the patient's worsening cognitive and physical functioning. The patient had a surgery with hospitalization which resulted in an increased need of assistance with activities of daily living (ADL) and Instrumental activities of daily living (IADL). Specifically, the assessment noted that the patient required an increase in assistance with tasks of ordinary housework, stairs, transportation, bathing, dressing lower body, and toilet use when comparing the assessment to her previous assessment. The patient's medical provider also documented the need to have assistance with meals 3 times a day due to the patient's significant weight loss and the current PCA hours would not accommodate this. The patient requires extensive assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan assumed the patient had informal help outside of the currently assigned PCA service hours which is not the case. Lastly, the patient's medical provider documented the medical necessity of increased PCA services. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces and monthly visits
The health plan denied the braces and monthly visits.
 The health plan's determination is overturned. 

The patient in question is a female. She has a Class II malocclusion with minor crowding and protrusive maxillary incisors. She has approximately 6-millimeter (mm) overjet and -2 mm overbite (anterior open bite). She is treatment planned for 24-30 months of orthodontics to correct the crowding and protrusion.

At issue is the medical necessity for the requested braces and monthly visits.

I overturn, in whole, the health plan's determination of medical necessity.

The health plan has not acted in the best interest of this particular patient. Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma.

There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. [1] Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6+ mm overjets, which this patient has. [2] For these reasons, orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Anemia.
Treatment: Inpatient Admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient is a male with a past medical history significant for multiple myeloma on chemotherapy who presented to the emergency department with complaints of fatigue, recurrent fever, and difficulty breathing for a week. The patient was also referred to receive a blood transfusion. Vitals on presentation included the following: Temperature 38.2 C (Celsius), blood pressure (BP) 137/73, Pulse 118, Respiratory Rate 20, oxygen (O2) saturation 100% (percent) on room air. Laboratory results showed: white blood cells (WBC) 8.5, hemoglobin (Hgb) 6.3, hematocrit (Hct) 21.7, creatinine 0.77, glucose 114. Chest x-ray (CXR) was negative. The patient was admitted for fever and anemia. He was empirically started on broad-spectrum antibiotics (vancomycin and cefepime), which he refused. Cultures were obtained but remained negative. The patient improved clinically and remained hemodynamically stable. He signed out against medical advice (AMA).

According to medical records, the patient presented with fevers (38.3 C) and tachycardia. Laboratory results revealed severe anemia (Hgb 6.3).  Based on the above findings, the patient presented with possible infection and symptomatic anemia requiring supportive intravenous fluids and blood transfusions. In a high-risk patient with immunosuppression due to underlying malignancy (multiple myeloma), hospital admission was medically necessary.

Prior determination of denial of hospital admission is overturned. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient is overturned. Medical Necessity for admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations and chest pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld.

This is a patient that was presented to the hospital complaining of chest pain and palpitations. Symptoms were of sudden onset while the patient was at rest. The patient was evaluated for similar symptoms one month prior to presentation. At that time echocardiogram revealed a structurally normal heart with a preserved left ventricular ejection fraction. Subsequent recommendations by a cardiologist were for cardiac monitoring. Upon arrival to the hospital vital signs were stable [blood pressure (BP) 145/88 millimeters of mercury (mmHg) and pulse of 96 beats per minute]. Physical examination revealed no significant abnormality. Serum blood testing revealed mildly decreased white blood cell count and potassium. 12 lead electrocardiogram (ECG) revealed no evidence of pre-excitation. Incomplete right bundle branch block was present. The patient was admitted to the hospital and cardiac telemetry revealed no significant arrhythmia. The patient was discharged with a thirty-day cardiac monitor and a follow up appointment with cardiac electrophysiology.

This patient presented with palpitations and chest pain of sudden onset. Evaluation for similar symptoms had already transpired prior to presentation. There were no significant abnormal findings on physical examination or subsequent ECG to warrant acute inpatient hospital admission. Most patients with palpitations can be evaluated in the outpatient setting. (Reference 1-2) In conclusion, acute inpatient admission was not medically necessary in this case.

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

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

Diagnosis: Dental issues.
Treatment: D8080 Braces, D8670 Periodic Orthodontic Treatment Visit times 12.
The insurer denied: D8080 Braces, D8670 Periodic Orthodontic Treatment Visit times 12.
The denial is overturned.

The patient is an adolescent male. The request is for orthodontic benefits. The prior denial was due to a handicapping index scale score being remarked as nine.

The proposed treatment is medically necessary.

The patient has crossbites of several anterior teeth. Teeth numbers 7 and 10 are behind the lower teeth, which is reverse of what it should be. There is also clinical loss of gingival attachment seen in the photos. Each one of these is an "automatic qualifier' according to the handicapping index scale.  In addition, the patient's upper left and right canines are "blocked" out of the arch, meaning they cannot erupt properly due to there not being enough room in the dental arch. Without the canines being in their correct positions, there can be no "canine guidance". This means that during the chewing cycle, the upper and lower teeth grind into each other in an uncoordinated fashion. This can cause trauma and tooth breakage over time. Orthodontic treatment is needed to correct this. This case has medical necessity.