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

Diagnosis: shortness of breath
Treatment: inpatient stay
the insurer denied the inpatient stay
the health plan's determination is upheld. 

The patient is a female with a significant medical history of hypertension, asthma and chronic obstructive pulmonary disease (COPD) of unknown severity who was admitted for an acute COPD/asthma exacerbation with symptoms of shortness of breath, cough, and wheezing. She was treated with acetaminophen, Duoneb nebulizers, steroids (Decadron), Singulair and Symbicort with an improvement in her condition within 24-hours.

Inpatient Hospital Admission was not medically necessary for this patient. Although the patient had mild wheezing only in the right lower lobe, she remained afebrile, hemodynamically stable, had a respiratory rate of 20 breaths per minute and oxygen saturation of 95% on room air. Throughout the hospitalization, she was alert, awake and oriented, and did not have evidence on arterial blood gas for hypercapnia or hypoxemia from baseline. She had no reported cyanosis or increased work of breathing after observation, and she did not have any cardiac dysrhythmias. Therefore, the Inpatient Hospital Admission was not medically necessary for this patient and the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Blood Disorder
Inpatient Hospital Stay

Diagnosis: Idiopathic thrombocytopenia (ITP), Pregnancy
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the emergency department with a history of idiopathic thrombocytopenia (ITP) at 16 weeks gestation. The patient had labs being trended as an outpatient and was noted to have a platelet drop with a slight rise in her liver functions and a glucose initially in the 50s on labs. The patient denied any vaginal bleeding and reported intermittent abdominal pain throughout the pregnancy that have been unchanged.  The patient was given a diagnosis of thrombocytopenia with elevated liver enzymes. She was planned for admission by obstetrics for evaluation of the laboratory abnormality. She had no acute bleeding at presentation. The patient was transferred to labor and delivery from the emergency room (ER). The patient was discussed with the maternal-fetal medicine service and a plan was made. The patient was noted to have possible transaminitis due to liver injury from supplements and the patient was going to discontinue the use at that time. The patient had no complications during the hospitalization. At issue is the medical necessity of an inpatient hospital admission.

Based upon an evaluation of the medical records in this case and the peer-reviewed literature and standard of care for management of immune thrombocytopenic purpura (ITP) at 16 weeks of pregnancy, the admission to acute inpatient level of care would not be medically necessary for a patient who was stable, without bleeding, and without any acute complications of ITP. In this case, the patient was noted to be at 16 weeks gestation without any complications other than lab abnormalities. The patient was noted to have mildly elevated liver functions that were thought to be due to a supplement she was taking and a plan was made to discontinue this supplement. There was no intervention on behalf of the fetus at 16 weeks gestation as this is previable for fetal intervention considerations. The patient was noted to have normal liver imaging and no abnormality on physical exam.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Comprehensive Orthodontic Treatment of the Adolescent Dentition and Periodic Orthodontic Treatment Visits.
The insurer denied Comprehensive Orthodontic Treatment of the Adolescent Dentition and Periodic Orthodontic Treatment Visits.
The determination is overturned.

This is a female patient with Class I with minor spacing in the maxillary and mandibular arches. She has a bilateral posterior crossbite. She is treatment planned for 24-36 months of orthodontics with rapid palatal expansion (RPE). At issue is the medical necessity of Comprehensive Orthodontic Treatment of the Adolescent Dentition and Periodic Orthodontic Treatment Visits.
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This patient presents with a bilateral posterior crossbite and mandibular spacing. She is an excellent candidate for rapid maxillary expansion to assist with orthodontic correction. If she is allowed to reach skeletal maturity before the expansion is initiated the only option to achieve orthopedic expansion will be to perform RPE in conjunction with a surgical procedure (2), which would greatly increase the morbidity to the patient. It is imperative to start treatment as soon as possible to hopefully alleviate the need for future surgical procedures about dentition. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned


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

The patient is a male who presented to the emergency department (ED) with syncope while driving. Two days before admission, he noted weakness and exertional dyspnea with lightheadedness while on the treadmill. He had to stop and lie down until his symptoms resolved.
One day before admission, the patient was at a stop at a red light and suffered syncope. Then he woke up but felt foggy. The patient spoke to his PCP (primary care provider) and was referred to the ED.

Inpatient Level of Care was medically necessary for this patient. The patient met criteria for inpatient admission. The patient had episodes of second-degree atrioventricular (AV) block with dizziness, pre-syncope, and syncope, which was not readily reversible and required permanent pacemaker implantation.
The presence or absence of symptoms is a major determinant of whether permanent pacing will be required in the setting of bradycardia associated with atrioventricular block. In addition to symptoms, 3 additional clinical issues must be considered when deciding on the use of permanent pacing in patients with atrioventricular block. First, the site of atrioventricular block is critical because patients with intranodal disease who then later develop complete heart block will be dependent on unreliable ventricular escape rhythms. Second, significant amounts of right ventricular pacing are potentially deleterious. Finally, patients with atrioventricular block may have an associated systemic disease that leads to progressive atrioventricular block or has an additional risk for ventricular arrhythmias.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied Intraosseous Basivertebral Nerve Ablation (64628).
The denial is overturned.

The patient is an adult male with a history of chronic low back pain due to degenerative disc disease (DDD) that has resulted in development of vertebrogenic pain identified by degenerative endplate changes on magnetic resonance imaging. The patient has pain and has failed treatment for greater than six months. Prior treatment included heat, ice, home exercise, medication, physical therapy, and transforaminal epidural steroid injection.

The health plan should cover the requested health service.

Based on the documentation provided, the requested procedure is recommended in this case. The patient has a history of chronic low back pain, and despite prior conservative treatments, the patient continues to be symptomatic with findings on exam as well as on CT (computed tomography) imaging. The CT (computed tomography) imaging provided does demonstrate Modic type changes at the (lumbar) L3 and L4 level. It was noted that the patient has multitouch changes noted on magnetic resonance imaging, for which the requested procedure is supported by the 
Food and Drug Administration (FDA).
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied Intraosseous Basivertebral Nerve Ablation (64628).
The denial is upheld.

The patient is an adult male with low back and leg pain that began more than 10 weeks ago. His past treatments include activity modification, ice/heat, home exercise, physical therapy, transforaminal epidural steroid injections, Tylenol, and ibuprofen. His pain is rated an 8/10. Magnetic resonance imaging (MRI) of the lumbar spine from last year shows developmentally small spinal canal, degenerative disc disease, disc bulges/herniations, and chronic Schmorl's nodes. The request for Intracept was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the requested health service.

Review of literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time, there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer-reviewed literature and data regarding the long-term outcomes of the 
procedure. As such, the health plan should not cover the requested health service.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Intraosseous Basivertebral Nerve Ablation (64628)
The insurer denied Intraosseous Basivertebral Nerve Ablation (64628).
The denial is upheld.

The patient is an adult male with chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, and home exercises. The patient has failed multiple medications including non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. No magnetic resonance imaging (MRI) is available. Computed tomography (CT) scan shows degenerative endplate changes. Physical exam does not reveal any neurological injury.

The health plan should not cover the requested health service.

The requested Intracept procedure is not medically appropriate. The requested health service or procedure is not likely to be more beneficial than standard treatments. The patient is an adult male with chronic low back pain. An Intracept procedure has been requested. The procedure was denied coverage by the health plan as experimental/investigational. The patient has failed conservative treatment in the form of physical therapy, epidural steroid injections, and home exercises. The patient has failed multiple medications including non-steroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. No magnetic resonance imaging (MRI) is available. Computed tomography (CT) scan shows degenerative endplate changes. Physical exam does not reveal any neurological injury. The Intracept procedure (interosseous basivertebral nerve ablation) is not an intradiscal procedure. It is a new Food and Drug Administration (FDA) approved intraosseous nerve ablation for the treatment of chronic low back pain in the treatment of vertebrogenic related chronic low back pain. It has been shown effective in randomized controlled trials with five-year results. It is typically used in patients with significant Modic type 1 or type 2 vertebral endplate changes, typically in situations where conventional and typical options have been exhausted. However, the patient has not failed or attempted facet joint interventions, or sacroiliac (SI) joint interventions, which are common treatments of axial low back pain. Furthermore, no magnetic resonance imaging is available to determine if true Modic changes are present. The Intracept 
procedure should be employed after all conventional and evidence-proven alternatives have failed. The literature has not shown superiority over conventional, less invasive treatments, which is the basis to the denial. Given that the alternative sacroiliac injections do show favorable outcomes in the literature and have lower risk and morbidity, the requested Intracept procedure is not medically appropriate and should not be covered by the health plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces, Monthly Visit and Retainer
The insurer denied: Braces, Monthly Visit and Retainer
The denial is overturned.

The patient is a teenage male. The request is for orthodontic benefits with monthly visits and retainer. The patient has a Class III skeletal malocclusion with mild upper and severe lower crowding. The health plan denied coverage of the request due to the patient having a score of 12 points on the handicapping index scale. The denial is being appealed.

The requested Braces, Monthly Visit and Retainer are medically necessary.

The patient has a crossbite of a permanent anterior tooth (#25) with attachment loss and gingival recession. This is an automatic qualifier according to the handicapping index scale. This case has medical necessity, and orthodontic treatment is needed to correct this problem. The monthly visits are to make sure the treatment progresses properly, and the retainer is needed at the end of treatment to prevent relapse. Therefore, the requested service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal
Treatment: Inpatient Hospital stay

Diagnosis: Orthopedic/Musculoskeletal- Bone Fracture/Break-Sternal Fracture
Treatment: Inpatient Hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan's determination.

This patient presented to the emergency department (ED) following a fall at home. There was no loss of consciousness. Comorbid health conditions included human immunodeficiency virus (HIV) positivity, hypertension, hyperlipidemia, and osteoporosis. At presentation, she had normal vital signs and a Glascow coma score of 15. She complained of sternal pain and head pain. Her evaluation included x-ray and computed tomography (CT) imaging in addition to physical examination. She was evaluated by the ED physician and by the trauma service. The imaging studies did identify a displaced sternal fracture at the inferior aspect of the sternum. She was also noted to have pre-existing thoracic spine compression fractures for which no acute intervention was advised. The physical therapy note states that the patient was ambulatory with minimal assistance. She had normal vital signs.
The patient remained clinically stable from the time of presentation until discharge.

An inpatient level of care was not medically necessary.
The records support that the health plan has acted reasonably in its determination of medical necessity. A lower level of care would have permitted evaluation, imaging, pain management, and arrangement of outpatient follow up as was performed in this case. This patient was hemodynamically stable at the time of presentation. She had an isolated minimally-moderately displaced fracture of the lower aspect of the sternal body. She remained clinically stable during overnight monitoring and the physical therapy note states that she was ambulatory with minimal assistance.
This patient presented to the ED following a fall at home. Her evaluation and clinical work up identified a displaced sternal fracture. There were no acute intracranial or abdominal injuries. There were no hemodynamic aberrations. The patient was stable at the time of presentation and did not require acute surgical intervention. In this case the care and treatment provided could have safely been rendered with a lower level of care rather than an inpatient level of care. This would allow for provision of intravenous (IV) fluid, IV pain medication, and overnight monitoring, in addition to ED, trauma service, and physical therapy evaluations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Mounjaro 7.5 mg (milligrams)/0.5 ml (milliliters) Pen Injector
The insurer denied: Mounjaro 7.5 mg (milligrams)/0.5 ml milliliters) Pen Injector
The denial is upheld.

The patient is an adult female with a history of obesity and a body mass index (BMI) of 33. The provider is requesting continuation of Mounjaro (tirzepatide). The patient reports a weight loss of 50 pounds since being on Mounjaro. She states that multiple family members have diabetes mellitus. The patient, however, does not have diabetes mellitus type 2.

The treatment with Mounjaro is not medically necessary.

Mounjaro is indicated as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes. This patient does not have documentation of type 2 diabetes. Therefore, Mounjaro is not indicated. The requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult male with diabetes. He presented to the hospital with fatigue, weakness and loose stools. The patient was noted to have elevated creatinine. The patient was treated with fluids, and his creatinine trended down from peak of 1.6. The patient was seen by hematology/oncology for leukopenia and noted chronic groin lymph node. The patient was subsequently discharged to home with outpatient follow up.

The inpatient admission was not medically necessary.

The patient could have been safely and effectively managed at a lower level of care. The requested inpatient admission was therefore not medically necessary. Based on available documentation, there was no report of hemodynamic instability, vomiting that is severe or persistent, altered mental status that is severe or persistent, persistence or worsening of clinical findings despite observation care treatment, parenteral antibiotics needed 
beyond observation care treatment, documentation regarding need for continuous infusion of insulin. There was no documentation of suspected infection of a prosthetic device, renal failure, acute kidney injury, or need for IV (intravenous) hydration beyond lower level of care or other condition, treatment, or monitoring requiring inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Egg Count (infertility)
Treatment: Artificial Insemination (embryo transfer)
The insurer denied: Artificial Insemination (embryo transfer)
The denial is upheld.

The patient is an adult female. She has a diagnosis of infertility due to diminished ovarian reserve. The patient underwent and failed three intrauterine inseminations. She underwent a fourth intrauterine insemination that was not covered by her health plan, as this process is not indicated beyond three cycles. This is being appealed.

The requested health service is not medically necessary.

The patient has a diagnosis of diminished ovarian reserve and unexplained infertility. She has already undergone three cycles of insemination. According to the American Society for Reproductive Medicine (1), "It is recommended that IUI [intrauterine insemination] treatment be considered as a regimen for couples with unexplained infertility. There is compelling evidence that a strategy of 3 cycles of IUI [intrauterine insemination] for unexplained infertility and if it fails, the next step is to be followed immediately by IVF [In Vitro Fertilization]."
Note that following three cycles of intrauterine insemination (IUI) and with the patient's diagnosis of diminished ovarian reserve as shown by low anti-mullerian hormone (AMH), antral follicle count (AFC), and elevated day #3 estradiol, additional intrauterine insemination cycles are considered futile and not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces and monthly visits

The insurer denied coverage for braces and monthly visits

The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, photographic images of study models, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (#7, 10) when clinical attachment loss and recession of the gingival margin are present, 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 23 points on review by internal reviewers. The orthodontist is appealing on behalf of the patient.	

Upon review of the submitted documentation, it is evident that the patient exhibits a 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 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 not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labio-Lingual 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. 

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 braces and monthly visits services is not substantiated.