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

Diagnosis: Substance use disorder

Treatment: Inpatient substance abuse services

The insurer denied coverage for inpatient substance abuse services. The denial was reversed.

This patient is a female who was admitted to this inpatient hospital for detoxification treatment due to alcohol abuse. She had withdrawal symptoms including nausea, vomiting, diarrhea, fatigue, malaise, nervousness and anxiety, shakes, headache, and she had a CIWA of 13. She was drinking daily, using several hundred dollars' worth of crack/cocaine daily, and smoking a few blunts of cannabis per day. She started alcohol and cannabis use at an early age. She had multiple past detoxification treatments. She reportedly lacked sober supports and could not maintain abstinence on her own. She was unemployed. She was put on a Librium taper. She also has medical conditions of hypertension and asthma. She was discharged.

The insurer denied coverage for inpatient hospital detoxification treatment as not medically necessary treatment.

This reviewer disagrees with the decision to deny coverage for inpatient hospital detoxification treatment. The chart notes provided enough specific evidence to support that she required this treatment. The APA Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that failure to achieve abstinence or patients who relapse frequently, or failure to be cooperative with or benefit from outpatient detoxification, current abuse of other substances, very heavy use or tolerance putting one at high risk for complicated withdrawal are candidates for inpatient detoxification treatment. In this case this patient had a history of use of multiple substances including crack/cocaine and cannabis in addition to alcohol.

According to the LOCADTR she did require 24 hour treatment as she could not safely and effectively be treated for detoxification in a less restrictive setting as she continued to use alcohol and substances despite multiple past inpatient detoxification treatments, needed detoxification medication as she took Librium to modify withdrawal from alcohol and prevent more severe, complicated, or life threatening withdrawal, and she needed 24 hour treatment then as she was at risk for worsened withdrawal symptoms including possible life threatening withdrawal such as delirium tremens. 

She lacked a sober support system and could not stop drinking alcohol or stop using crack/cocaine daily and cannabis outside of a 24 hour setting as she likely would have relapsed again as evidenced by relapsing after past treatments.

As a result, the determination is to reverse the previous decision and approve coverage for inpatient hospital detoxification treatment as she was discharged. It did not appear that the health care plan acted reasonably or in the best interests of the patient.

Based on the above, the medical necessity for the inpatient substance abuse services from is not substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is a female child. She presented with two-day history of right-sided abdominal pain, fever to 101, vomiting, and decreased appetite. She had one episode of diarrhea, and no dysuria or cold symptoms. 

Acute abdominal pain is a common complaint in children and adolescents, but it presents a diagnostic dilemma because of the many potential causes, some of which are life-threatening. Abdominal pain can be divided into visceral, somatoparietal, and referred, depending on the pain receptors involved. Most abdominal pain is visceral. Causes can be categorized as follows: gastrointestinal, hepatobiliary/splenic/pancreatic, genitourinary, cardiac, pulmonary, hematologic, metabolic, neurologic, toxins/drugs, and a miscellaneous category that includes functional abdominal pain and infantile colic. Gastrointestinal causes include appendicitis, intussusception, volvulus, inflammatory bowel disease, gastroenteritis, constipation, peritonitis, peptic ulcer, and mesenteric adenitis. 

Acute gastroenteritis is a major problem worldwide, representing one of the leading causes of morbidity and mortality in children. There are an estimated 2.5 million deaths each year attributable to gastroenteritis in children under the age of five years. Most cases are caused by viruses, are self-limited, and require supportive treatment. According to the World Health Organization, oral rehydration therapy is the treatment of choice, particularly where diarrhea is the prominent feature and dehydration is mild to moderate. Intravenous rehydration is indicated when oral rehydration fails or when output is excessive. Vomiting limits the success of oral rehydration, prompting use of anti-emetic medications.

This female child presented with signs and symptoms initially suggestive of appendicitis vs gastroenteritis, unremarkable lab evaluation, and radiographic studies that were somewhat equivocal (fat stranding, possible early tip appendicitis). She was admitted for observation and serial abdominal examinations. However, she was overall hemodynamically stable, with no signs or symptoms of sepsis, no worsening pain, no significant dehydration, and no persistent vomiting/diarrhea. She did not require acute inpatient admission. She could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rule out pulmonary embolism (PE)

Treatment: Inpatient admission

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

This patient is a female with a past medical history notable for gastric sleeve surgery 3 years prior and recent liposuction 8 days prior. She presented to the ER with complaints of chest pain, shortness of breath, and pleurisy. She had an elevated WBC of 14.9 K. The electrocardiogram (EKG) and troponins were unremarkable. The physical examination was unrevealing. She was admitted to the hospital. She ruled out for myocardial infarction with serial negative cardiac enzymes. She had a computer tomogram (CT) of the chest which was negative for pulmonary embolism and a lower extremity duplex ultrasound which was negative for deep venous thrombosis. She was hemodynamically stable throughout her stay and was discharged home for outpatient follow-up.  

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

The patient presented with chest pain. The initial evaluation in the ER was unremarkable, including a non-diagnostic EKG and cardiac biomarkers. The Inpatient admission was not medically necessary for this patient. The patient did not meet InterQual Guidelines for Acute Coronary Syndrome or MCG Guideline Angina RRG: M-40-RRG (ISC) guidelines. The patient's care could have been provided in the Observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission criteria was not met. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

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

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a female with a Class I occlusion with appropriate overjet and overbite deep bite. The maxillary arch has some crowding and teeth 6 and 11 are high. The mandibular arch has mild crowding, and primary teeth K and T remain and 20 and 29 are unerupted. She is treatment planned for 24 months of orthodontics to correct her malocclusion. This is the subject of this review.

The health plan's determination is upheld. Braces/monthly visits are not medically necessary for this patient. 
There is no medical reason to correct her mild crowding with braces. Starting orthodontic treatment now to bring the canines down would simply be for esthetics. The patient has some mild crowding but a solid Class I occlusal relationship. She has an appropriate overbite and overjet. There is documentation from the physician that the patient has pain in her gums when she brushes her teeth. The photos are not of the highest quality, but it is apparent the patient has gingival swelling at the gingival margins. This indicates the patient has gingivitis. Gingivitis can easily cause pain when brushing and would not be resolved by orthodontics - only proper oral hygiene.
Additionally, the fact that the patient has a lisp in the absence of a severe orthodontic deformity could mean there is a myofunctional problem that would be better treated with speech therapy rather than orthodontics. The cephalometric radiograph clearly indicates that the incisors appropriate overbite and overjet. The patient's mother states she cannot chew food. It should be investigated if there is another reason why the patient cannot chew food properly. The patient does have incomplete eruption of the maxillary canines. However, she still has primary teeth and incomplete eruption of permanent teeth. At the patient's age this is not unusual. Standard of care would be to allow for more time for the permanent teeth to erupt before deciding that the canines will not erupt further.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Issue under review: Right - Neurolysis facet nerve

Determination:
The Right - Neurolysis facet nerve is not medically necessary.

The patient is an adult male with chronic low back pain who has had multiple radiofrequency ablation zones over the years.  He does not typically achieve six months of relief.  Per the documentation, he typically achieves three to four months of relief.  In addition, with the last radiofrequency ablation, there was only 20% relief.  Most notably, this procedure is being requested to be done despite having been done less than six months ago.  Typical guidelines do not recommend repeating radiofrequency ablation more frequently than twice per year, as it is a neuro-destructive procedure. This means six months between ablations.  This is consistent with the literature and with pain management Society recommendations.  

Given that the patient has not had at least six months between the procedures, and he has had less than 50% improvement, the requested radiofrequency ablation is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with chronic arthritis, chronic pain syndrome. Status post bilateral total knee replacements (TKRs), obesity and seizure disorder.
This review is for the medical necessity of an increase in consumer directed personal assistance service (CDPAS) hours. The patient is currently receiving 56 hours per week. The patient is requesting 84 hours a week. This was denied by the health plan based upon medical necessity.
The subject under review is the medical necessity for additional CDPAS hours.

The health plan's determination is upheld. 

No, the requested service CDPAS 84 hours is not medically necessary for this patient. The services currently provided are adequate to meet the patient's need in the allotted time. Additional hours are not medically necessary.
The Uniform Assessment System - New York Comprehensive Community Assessment report was used to evaluate the patient's needs. It was noted that the patient is alert and oriented to person place and time. The patient can walk with a cane. She currently lives with her son. The patient has a diagnosis of seizures. The personal assistant services the patient has include help with cooking, shopping, housekeeping, bathing and personal hygiene. Safety monitoring, supervision and cognitive prompting are not by themselves independent or standalone instrumental activities of daily living (IADLs), activities of daily living (ADLs) or tasks. That means the plan does not allow more hours for supervision purposes alone.
The services provided her adequate to meet her needs. The patient is noted to be cognitively impaired but minimally. She has intermittent seizures. Most of her personal care including IADLs and ADLs are secondary to her immobility and chronic pain issues. These include assistance with almost all ADLs i.e. housekeeping and meal preparation. Patient is able to walk into her apartment with the help of her son was 17 steps up to her apartment. She does need assistance to help her prevent falling. She is able to walk inside her apartment using a cane for assistance with a steady gait. She is able to transfer on and off the toilet using grab bars and cane for support. She is able to perform normal hygiene when items are placed close to her. There is noted urinary incontinence. The patient may have up to 6 episodes a day, she does use pads. According to the Uniform Assessment System (UAS) these needs have been met adequately.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with chronic medical problems including lower back symptoms and pain, bilateral lower extremity pain and radiculopathy, and anxiety disorder.  The patient currently receives 5.5 hours a day  7 days a week for total of 38.5 hours week.  At issue is the medical necessity of personal care level 2 aide hours 7 hours per day  7 days a week for a total of 49 hours per week.
The health plan's determination is upheld.  An appeal letter states that the patient should receive increased services secondary to urinary incontinence and need for weightbearing support while ambulating and toilet transferring.
A recent evaluation showed that the patient's abilities to perform physical function were stable or improved since prior assessment.  The patient requested an increase in personal care hours secondary to weakness and forgetfulness to assist with activities of daily living (ADLs).
The following was noted on assessment.  Patient is able to walk with assistance of cane.  Patient is able to dress herself with some assistance.  Patient is able to feed herself once meals are prepared by the personal care aide.  Patient is able to self-direct her own care.  Patient is able to transfer on and off the toilet and take care of her toileting needs with assistance.  Patient can take care of her personal hygiene with some assistance.
The patient requested additional hours secondary to arthritis and back pain and forgetfulness.  There was no mention of urinary disorder.
A Personal-care assessment was performed.
The patient was noted to perform personal hygiene and body dressing with some oversight.  She was observed to ambulate and transfer with some weightbearing assistance from personal care assistant (PCA).
The patient reports that she has not used the stairs in 3 days; however, she requires minimal involvement from the caregiver.  The patient requires guidance with toilet use and oversight with bed mobility due to dizziness.  She wears liners for occasional urinary incontinence.
The patient reported a fall when she was ambulating in the hallway.  She states she slipped on an area of the floor with water on it.  No significant injury was noted.  Incontinence care is noted to take a total of 20 minutes per day. 
Physician reports note that the patient is mainly seen for chronic lower back pain, however, does have frequent urinary tract infections.  There is no evidence of a complicated urinary infection or skin breakdown in the perineal area.  There is no need for frequent turning and repositioning.
The provided hours appeared reasonable to meet her needs.  There are no noted extenuating circumstances which would necessitate additional hours.
Appeal type: Experimental/Investigational
Decision: Overturned

Pregnancy
Genetic Testing

The patient is a female who is seeking fertility care with in vitro fertilization (IVF). Her partner is an autosomal dominant carrier of hypertrophic cardiomyopathy (HCM). At issue is whether the method of karyomapping testing for preimplantation genetic testing for a genetic disease is indicated.

The health plan's determination is overturned. The Genetic Testing of Embryos is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Karyomapping provides reliable results for preimplantation genetic testing for monogenetic diseases and provides simultaneous information about embryo aneuploidy from amplified material without a priori probe development in a manner not previously possible with classic methods. Research clearly demonstrates the efficacy of the genetic testing in this case.
Appeal type: Experimental/Investigational
Decision: Overturned

Pregnancy
Genetic Testing

The patient is a female who presented after 6 months of attempting pregnancy. During this time, her husband's mother was diagnosed with hypertrophic cardiomyopathy which was found to have a genetic cause. This was found to be an autosomal dominant disorder. Further testing revealed that the patient's husband is a carrier for the autosomal dominant gene that would cause hypertrophic cardiomyopathy. Since it is a dominant disorder, the risk of passing on the gene is 50%. If the offspring receive this gene, then the offspring like their father is at increased risk for this disorder.

The health plan's determination is overturned. The genetic testing of embryos is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Please note that the CPT codes listed are incorrect for the procedure that was performed. However, the use of Preimplantation Genetic testing for a single gene defect (PGT-M). PGT-M has been shown to be effective in finding which embryos carry the gene mutation in question that would lead to the life threatening condition. In this case, 50% of the embryos or 50% of their children would be affected. The use of PGT-M would virtually eliminate the risk to their offspring and therefore is more beneficial than doing no testing or achieving pregnancy on their own.
Appeal type: Experimental/Investigational
Decision: Overturned

Pregnancy
Genetic Testing

The patient is a female who is seeking fertility care with in vitro fertilization (IVF). Her partner is an autosomal dominant carrier of hypertrophic cardiomyopathy (HCM). Being a carrier of an autosomal dominant condition means patients are affected with that condition. This also means there is a 50% chance the mutation could be passed on to children. There is a possibility for this to be a fatal event where patients can die suddenly from cardiac failure. Genetic counseling and PGD were offered to this patient given the risk to future offspring.

The health plan's determination is overturned. Genetic Testing of Embryos is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient's partner is a carrier of an autosomal dominant genetic mutation for Hypertrophic Cardiomyopathy. Being a carrier of an autosomal dominant condition means patients are affected with that condition. This also means there is a 50% chance the mutation could be passed on to his children. There is a possibility for this to be a fatal event where patients can die suddenly from cardiac failure. The genetic testing is indicated in this case.
Appeal type: Medical necessity
Decision: Upheld

The patient is a female with a Class II occlusion and slightly high overjet and overbite.  The maxillary arch has some spacing, and the mandibular arch has some crowding.  She is treatment planned for 24 months of orthodontics to correct her malocclusion, which was denied by her health plan on the basis of medical necessity.  The subject under review is the medical necessity for the treatment of braces.

The health plan has acted in the best interest of this patient.
The patient has some mild spacing in the maxillary and mild crowding in the mandible.  Her bite is slightly deep, but there is no indication of damage to the incisors or the palate in the photographs, and her cephalometric radiograph show the lower incisors are contacting the maxillary teeth in occlusion, not the palate.  There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient.

There is no medical reason to correct her malocclusion with braces.  The patient does have a 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 strong evidence that one treatment is not better than another (1).  Furthermore, deep bites may be corrected in adulthood (2), so it is not as if she will lose the ability to correct her malocclusion should she choose to do so as an adult.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces

The proposed treatment with braces is medically necessary. The patient has a malocclusion that causes a deep impinging overbite, with damage to the soft tissues of the palate.  This is an "automatic qualifying" condition on the handicapping index scale. The patient needs orthodontic treatment to correct this. It is a medically necessary situation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal class ll- retruded mandible, normal vertical growth pattern, permanent dentition, mild maxillary crowding, mild mandibular crowding, slightly excessive overjet, deep impinging overbite with severe soft tissue damage, and deep impinging overbite with severe soft tissue. 
 
Treatment: D8080 Braces

The insurer denied the D8080 Braces. The denial was reversed.

This is a young male patient who consulted an orthodontist for an evaluation for orthodontic care.  The patient underwent a lateral cephalometric radiograph, panoramic radiograph, extraoral and intraoral clinical images. A handicapping Labio-Lingual Deviation (HLD) index was performed which resulted 20 points. This result was used to qualify the patient for orthodontic treatment.

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an Orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care, a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach.  This is confirmed by several studies. Each of the consulted 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. 
 
Reverse denial and approve coverage for braces as the clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.The healthcare plan did not act reasonably or with sound medical judgment or in the best interest of the patient.  D8080 braces are considered medically necessary for this patient.

The carrier's denial of coverage for D8080 Braces is reversed.  The medical necessity is substantiated.