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

Diagnosis: Tooth Decay
Treatment: Crowns on Teeth 6, 7, 10 and 11
The insurer denied: Crowns on Teeth 6, 7, 10 and 11
The denial is upheld

The patient is an adult female. The request is for porcelain crowns on teeth #s 6, 7, 10 and 11. The health plan denied coverage of the request as not medically necessary. The denial is being appealed.

The requested Crowns on Teeth 6, 7, 10 and 11 are not medically necessary.

Based on the records, images and documents provided for review, decay is not evident in the four teeth in question. The teeth are not missing any walls. No prior root canal treatments have been performed on any of these teeth that would necessitate crowns. No decay, in any tooth, severe or 
otherwise, is seen in the photo or x-rays provided. No large fillings (taking up half of the tooth) are seen in any of these teeth. No need for crowns has been demonstrated. Crowns for teeth 6, 7, 10 and 11 are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient is an adult that presented to the hospital requesting a stent for chest pain. The patient first presented for chest pain several days prior to admission and work up was negative. The patient presented several days later with similar complaints and Computed Tomography (CT) angiogram was performed, however the patient signed out against medical advice. The patient returned several days later complaining of constant chest pain radiating to the left arm and constant left upper body numbness radiating to the left abdomen. On arrival to the hospital, vital signs were stable (blood pressure 157/100, pulse 77). Physical examination revealed chest tenderness with palpation. 12 lead electrocardiogram (ECG) revealed sinus rhythm with no evidence of ischemic ST (interval on ECG) or T (interval on ECG) wave abnormalities. Serum troponin levels were not elevated (less than 0.01) and CT angiogram performed during the first presentation revealed coronary artery disease (CAD) with an Agatston Calcium score of 34, a non-obstructive mid left anterior descending artery plaque and a severe stenosis in the second diagonal artery. Given the atypical nature of chest pain, exercise stress testing was performed and revealed no evidence of ischemia. The patient was discharged the following day without further intervention.

The patient's pretest probability of CAD was low, and CT scan revealed no evidence of large vessel occlusion (1). Utilizing the HEART (history, ECG, age, risk factors, initial troponin) score, the patient was considered low risk (2). Utilizing the thrombolysis in myocardial infarction (TIMI) risk score, the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days (3). Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati, et al (3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all-cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, this patient could have been treated at a lower level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite
Treatment: D8080 Braces and D8670 Monthly visits
The insurer denied coverage for D8080 braces and D8670 monthly visits.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified maxillary spacing and mandibular crowding, and anterior crossbite (mandibular left canine). The orthodontist has completed the HLD (Handicapping Labio-Lingual Deviation) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the requirements of the HLD index, attaining 15 points by internal reviewers when 26 points are required for approval. The dentist is appealing on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review), 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 HLD index report (HLD, New York State Medicaid program) modeled after the HLD 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 
cross bite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. The medical necessity for D8080 braces and D8670 monthly visits services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This case involves an adult patient who presented to the emergency department with right upper molar tooth abscess associated with cellulitis of the face and a witnessed seizure. She reported pain across the upper teeth with significant right side facial swelling that had been occurring for 2 days.  She denied fevers or chills and had a history of seizures for which she was taking Keppra and Tegretol. The patient was a current every-day smoker and had poor dentition. Vital signs noted elevated blood pressure at 143/93 and an elevated pulse rate of 103. The emergency department progress note stated the patient had a witnessed seizure that resolved spontaneously with no fall and no trauma. The patient claimed that she had not missed any seizure medications recently but her current seizure occurred in the setting of noxious paint fumes in the home. The patient was admitted to inpatient care and given 2 grams of Keppra and was started on vancomycin. A Computed tomography (CT) was obtained and showed no displaced fracture or traumatic listhesis. The patient was taken to the dental clinic for abscess management and had a witnessed seizure, which resolved spontaneously with no fall and no trauma. She was brought back to the emergency department and was responsive, mildly postictal, and protecting her airway. She was hemodynamically stable with no evidence of incontinence. The plan was to load the patient with Keppra and admit her to the stepdown unit. The patient refused to stay and complete the plan of care developed by the attending physician and oral surgeon and signed out against medical advice. 

According to the Milliman Care Guidelines, the inpatient admission was appropriate as it pertains to cellulitis given that the information indicated the patient needed abscess drainage, which is a supported treatment on an inpatient basis. Additionally, given that the patient had recurrent seizure activity while in the hospital, it would have been appropriate for the patient to remain on an inpatient status for further work-up and care. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cervical stenosis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned in part.

According to the medical records, the patient with cervical stenosis was admitted and underwent posterior cervical decompression and fusion cervical (C) 3-6 without complications. Post operatively, the patient remained hemodynamically and neurologically stable, with no infection, bleeding, or infusions noted, and no further surgery needed.

"Conclusions: Posterior cervical fusion with decompression resulted in significant clinical improvement, as indicated by the changes in patient-reported outcomes. Additionally, high fusion rates and low rates of revision and of complications and adverse events were found." (Youssef, J. A., et al, 2019)

There is no indication for inpatient stay pre-operatively as the surgery could have been done electively, with admission on the day of surgery. Also, inpatient stays are allowable for up to 3 days after fusion to make sure no hardware failure and no bleeding. 

Based on the above, the insurer's denial must be overturned in part. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for full inpatient hospital admission is partially substantiated. Inpatient hospital admission for only three days are medically necessary; however, four days are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cognitive decline, hyperlipidemia, abnormal gait, and osteoarthritis

Treatment: Home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in)

The denial is modified.

 
This is an elderly patient with hypertension, osteoarthritis and dementia. She lives alone in a 2-bedroom apartment. The insurer approved home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 44 hours per week and the request is for 24 hours per day (live in) due to cognitive decline.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. She is totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing and lower body dressing. Extensive assistance is needed for personal hygiene, upper body dressing and toilet transfer/use. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. Limited assistance is needed for locomotion/ambulation. She requires supervision for bed mobility and eating. There have been no reported falls over the prior 90 days. Her functional ability has declined compared to the prior UAS. 

The patient's medical condition and functional ability are not at the level or unpredictable as to require the requested PCA 24 hours/day live-in. However, her functional impairments support an increase to 12 hours/day, 7 days/week (total 84 hours). The patient may require additional monitoring; particularly due to her cognitive decline. However, safety monitoring under personal care services / home health care(PCS/HHC) does not include monitoring an individual (with dementia) when no other Level I or Level II personal care service tasks are being provided.  Based on the records reviewed, attention to the patient's functional needs are more appropriately provided and maintained by increasing PCS / HHC to 12 hours/day, 7 days/week (total 84 hours).

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (live in) services is not substantiated. 

However, increasing home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 12 hours per day, 7 days/week (total 84 hours) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Unstable angina
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female for which an inpatient hospitalization is under review. She presented with two days of chest pain. The BP (blood pressure) was elevated. Other vital signs and the oxygen saturation were normal. There was history of hypertension, hyperlipidemia, and type II diabetes. Troponins were negative. The ECG (electrocardiogram) was not acute. Chest x-ray was unremarkable. She remained chest pain free. 
Cardiac catheterization was negative for obstructive CAD (coronary artery disease). She remained stable and was discharged.

The requested Inpatient Hospital Admission is not medically necessary.

This patient presented with chest pain and remained stable. There was no CHF (congestive heart failure), respiratory distress, ongoing symptoms suggestive of treatment refractory angina or angina equivalent, severe arrhythmia, hemodynamic instability, another serious cause for chest pain, such as a PE (pulmonary embolism) or aortic dissection, need for prolonged IV (intravenous) medications or oxygen support, introduction of high -risk medications requiring ongoing in-hospital monitoring, severe catheterization related complication (i.e. severe bleeding, CVA [cerebrovascular accident]), need for invasive hemodynamic monitoring, need for vasopressor or mechanical cardiac support, or supporting evidence for an acute coronary syndrome such as elevated cardiac biomarkers or an abnormal ECG (electrocardiogram). In the setting of this case an acute inpatient level hospitalization, compared to a lower level of care, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atherosclerotic heart disease, dependence on supplemental oxygen, malignant melanoma of skin, generalized osteoarthritis, urinary incontinence, and type 2 diabetes mellitus.

Treatment: Personal care worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person: 168 hours per week.

The insurer denied coverage for personal care worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person: 168 hours per week.

The denial is overturned.

 
This is the case of a patient with a history of atherosclerotic heart disease, dependence on supplemental oxygen, bilateral dry eye syndrome, hypertension, malignant melanoma of skin, bilateral knee pain, generalized osteoarthritis, urinary incontinence, and type 2 diabetes mellitus. The patient's recent Uniform Assessment System for New York (UAS-NY) showed that the patient lives alone and assistance is needed in instrumental activities of daily living (IADLs) and ADLs (activities of daily living), such as bathing, dressing upper and lower body, toilet transfer, and toilet use. The patient is frequently bladder incontinent and is bed-bound. The patient's overall self-sufficiency has deteriorated since the last assessment. The patient scored a 28 on the Mini-Mental State Examination (MMSE).

The clinical record shows continued deterioration of the patient's medical status. The facts are she is not independent with ambulation. There will be no improvement. She cannot perform her activities of daily living. She requires oxygen which must be monitored. She is incontinent, essentially bedbound and unable to reach a bathroom or change herself. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for an increase in personal care worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental decay. 
Treatment: Crowns on teeth #s(numbers) 8 and 9. 

The insurer denied coverage for crowns on teeth #s 8 and 9. 

The denial is overturned. 

Based on the submitted documentation which includes copies of pretreatment full mouth series and periapical radiographs, insurer correspondence and coverage booklet, it appears that this patient presented to the dentist for comprehensive dental care. Endodontic therapy was recommended and completed on tooth #9. The recommendation is for full coverage crown restoration on tooth #8 and #9. The insurer has denied the full coverage crowns stating that the service is not medically necessary as the documentation did not demonstrate medical need to support the treatment. The patient is appealing the decision. 

Upon review of radiographs, it supports the recommended treatment. Review of pretreatment radiograph indicates a completed endodontic therapy #9. There is ample coronal structure remaining after the endodontic therapy. This tooth will have adequate residual coronal structure for support of crown and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of the crown on an endodontically treated tooth which would have an excellent long-term prognosis with the recommended treatment. 

Recommendation is to overturn the denial and approve coverage for dental crowns for teeth #8 and #9 as medically necessary. The radiographic documentation supports this service, and this service would be a standard of care in general dental practice. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for crowns on teeth #s 8 and 9 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular/Cognitive decline 
Treatment: Increase in consumer directed personal assistance services (CDPAS) to 7 days per week, 6 hours per day; 42 hours per week.
The insurer denied increase in consumer directed personal assistance services (CDPAS) to 7 days per week, 6 hours per day; 42 hours per week.
The health plan's determination is upheld.

This is a male patient with a medical history notable for cognitive decline and gait difficulty. The patient is approved for 5 hours per day, 7 days per week (35 hours per week) of consumer directed personal assistance services (CDPAS). The patient and his care team requested an increase to 6 hours per day, 7 days per week (42 hours per week) and this request was denied by the health plan. There were no office visit notes, letters of medical necessity, or letters of support provided as part of this appeal.
A uniform assessment system (UAS) was completed and was available for review. The assessment was conducted in person. The patient's cognition was found to be minimally impaired with supervision necessary if decisions become poor or unsafe. Mini-mental status examination (MMSE) score was 19. From a functional standpoint, he requires total dependence for housework. The patient requires maximal assistance for meal preparation and shopping. He requires extensive assistance for finances, stairs, and transportation. For his activities of daily living (ADLs), he requires extensive assistance for bathing and dressing lower body. The patient requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet use, and eating. He is independent for toilet transfer and bed mobility. He is infrequently incontinent of urine and is continent of stool. A task tool associated with the assessment recommended 28.3 hours per week to address his personal care needs. Compared with a prior UAS, his functional status did not change significantly.
At issue is the medical necessity of an increase in consumer directed personal assistance services (CDPAS) to 7 days per week, 6 hours per day; 42 hours per week.

The health plan's determination of medical necessity is upheld, in whole.

The requested health service/treatment of an increase in consumer directed personal assistance services (CDPAS) to 7 days per week, 6 hours per day; 42 hours per week has not been demonstrated to be medically necessary for this patient.
There are no clearly demonstrated personal care needs that are not being addressed at the patient's current level of 35 hours per week. This is greater than the amount which is recommended by the tasking tool (28 hours per week). According to the assessment, the patient has not had a significant functional decline over the past year. At this time, there is no documented justification for the medical necessity for an increase in hours.