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

Diagnosis: Substance Detoxification 
 
Treatment: Inpatient substance detoxification

The insurer denied the Inpatient Hospitalization. The denial was reversed.

This is a male patient who was admitted to treatment in early 2019 for alcohol and Xanax.  He reportedly had withdrawal symptoms including nausea, tremors, dry heaves, yawning, lethargy, sweats, anxiety, irritable mood, headache, and agitation.  His blood pressure initially was elevated at 152/98.  He had a history of depression.  He was reportedly drinking 2 pints and beer per day and using 4 mg of Xanax per day.  He lacked coping skills to stay sober.  He was placed on a 5-day Librium protocol.  He also received PRN (as needed) Clonidine, Vistaril, Benadryl, and had Trazodone.  He was discharged with a referral for substance and alcohol rehabilitation treatment.
The insurer denied coverage for continued inpatient substance detoxification treatment in this hospital as not medical necessary treatment.  They stated that during this admission his Clinical Institute Withdrawal Assessment of Alcohol (CIWA) scores were low at 1 and vital signs were stable and he had no history of withdrawal seizures or delirium tremens and that he did not require 24 hour inpatient hospital treatment and they recommended a less restrictive level of care.

This reviewer disagrees with the decision to deny coverage for continued inpatient substance detoxification treatment in this hospital.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report 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 been drinking alcohol and using large amounts of Xanax daily and was at high risk for severe, complicated, and life threatening withdrawal symptoms and was at risk for delirium tremens, delirium tremens can occur 3-4 days after alcohol and benzodiazepine use.  

Based on the above, the medical necessity for the inpatient hospital services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depressive symptoms, depressed mood, suicidal ideation
 
Treatment: Inpatient mental health treatment

The insurer denied the continued inpatient stay. The denial was upheld.

This patient was admitted to inpatient mental health treatment due to depressive symptoms including depressed mood and suicidal ideation with a plan to hang himself. He reportedly had multiple past psychiatric hospitalizations including 4 in the past year.  He had a family history of depression. He reportedly tried multiple past medications including Paxil, Zoloft, Wellbutrin, Nortriptiline, Rexulti, and Seroquel. 

The insurer denied coverage for continued inpatient mental health treatment in this hospital, starting Day #7, as not medically necessary treatment. They stated that he had no acute behavioral or self-care conditions requiring 24 hour hospital treatment then. They recommended a less restrictive level of care. 

As of Day #7 there were no notes stating that patient still had suicidal ideation, plan, or intent, or severe depressive symptoms. He had reports of severe depressive symptoms on admission including depressed mood, suicidal ideation with a plan to hang himself with his belt, low energy, anhedonia, concentration problems, and decreased appetite but there were no reports of suicidal ideation, plan, intent, or severe depressive symptoms in the medical records provided. The note on Day #10 reported that his mood was good, he had improved energy, concentration, interest, and appetite, was more engaged in self-care, and denied suicidal ideation, intent, homicidal ideation, or hallucinations and that his active suicidal ideation resolved. 

Continued inpatient mental health treatment in this hospital from Day #7 through discharge was not medically necessary. 


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

This is a patient with a diagnosis of pain in the right knee. The patient is noted to have a history of knee problems. Case notes indicate the patient has four authorizations on file for physical therapy due to knee related problems. Three authorizations were approved for a total of 12 visits. Additional physical therapy was denied based on a lack of medical necessity.The health plan's determination is upheld. The patient has a diagnosis of pain in the right knee and standard of care treatment for this diagnosis would be 9 visits of therapy over 8 weeks. The patient had completed 12 sessions of therapy that were approved previously. Multiple handwritten physical therapy notes were provided. The physical therapy notes provided were handwritten and mostly illegible with no documentation of significant progression with objective gains and no indication that the patient would not be able to transition into an independent home exercise program to continue managing symptoms.
Appeal type: Medical necessity
Decision: Upheld

The patient has  a history of an ear infection, tinnitus, and diminished hearing, which was diagnosed as Meniere's disease and treated with prednisone. About 4 days prior to presentation the patient  was prescribed diuretics. The patient  presented to urgent care complaining of lightheadedness, palpitations, leg cramps, and malaise. Tachycardia was noted and the patient  was sent to the hospital emergency room. The health plans determination of medical necessity is upheld . There was no objective evidence on physical examination, laboratory evaluations, imaging, or electrocardiogram (EKG) of an imminently life-threatening cause of the patient's complaints that required acute inpatient care.Therefore, the hospital stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental overbite with severe soft tissue damage
 
Treatment: Braces, comprehensive orthodontics 

The insurer denied coverage of orthodontics treatment. The denial was upheld.

This is a child who sought orthodontic services.  According to the documentation submitted, the child had lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, copies of peer reviewed literature,  as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, moderate maxillary and severe mandibular crowding, excessive overjet and deep impinging overbite.

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 not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 20 points (4 points overjet, 5 points overbite, 3 points ectopic eruption, 5 points anterior crowding and 3 points labiolingual spread).

Uphold denial as the clinical circumstance as presented does not substantiate the medical/dental necessity of orthodontic care. The insurer acted reasonably, with sound medical judgement, and in the patient's best interest.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class II Malocclusion, Retruded Mandible, Maxillary and Mandibular Crowding and Incisor Protrusion, Traumatic Bite and Excessive Overjet.
 
Treatment: Orthodontic Treatment of the Adolescent Dentition.

The insurer denied the Orthodontic Treatment of the Adolescent Dentition. 
The denial was reversed. 


This is an adolescent female per Orthodontic Treatment Program from late 2018 had skeletal class ll-retruded mandible, normal vertical growth pattern, permanent dentition, mild maxillary crowding, mild mandibular crowding, traumatic deep bite, moderate maxillary incisor protrusion, moderate mandibular incisor protrusion, and severely excessive overjet. Overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties was indicated on the Handicapping Labio-Lingual Deviation (HLD) Index Report.  The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of overjet greater than 9 mm with incompetent lips.to support orthodontic necessity. It is evident that the patient exhibits a significant malocclusion.

For this patient, the treating orthodontist claims an automatic qualifying condition of overjet greater than 9mm with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. The clinical circumstance does meet insurer and plan criteria to justify 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. 

Based on the above, the medical necessity for the Comprehensive Orthodontic Treatment of the Adolescent Dentition is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion and deep impinging overbite
 
Treatment: Orthodontic care

The insurer denied the orthodontic care. The denial was reversed.

This patient presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I malocclusion, mild maxillary and mandibular crowding, excessive overjet and deep impinging overbite.  The orthodontist completed the Handicapping Labiolingual Deviation (HLD) index as required.  The insurer has denied coverage for orthodontic treatment as not medically necessary.

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, a Handicapping Labiolingual Deviation Index is utilized. 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. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.  

The carrier's denial of coverage for braces (comprehensive orthodontic treatment) and adjustments for braces (periodic orthodontic treatment visit) is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior open bite
Issue under review: Braces

Determination:
The braces are medically necessary.

The patient has an anterior open bite. This means that her front teeth do not touch each other (i.e. the front upper teeth do not touch the front lower teeth). During the patient's chewing cycle, there can be no "anterior guidance or canine guidance."  This means that since her front teeth do not touch, all her back teeth will grind together, since there is no "disoccluding" or disconnecting of her back teeth when she chews. Over time, this will definitely cause severe wearing down of all of her back teeth. This disconnection of her front teeth will most probably contribute to future TMJ (temporomandibular jaw) problems due to the increased stresses placed on her joints. This patient has a medical necessity for orthodontic treatment to close her anterior open bite.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Carious Tooth #26
 
Treatment:  Root Canal, Post, Core and Crown for Tooth #26

The insurer denied the Root Canal, Post, Core and Crown for Tooth #26.  The denial was upheld.

This patient presented for dental treatment of a carious tooth #26 associated with pain.
Based on the clinical and radiographic findings, endodontic therapy with post and core and subsequent full coverage crown restoration for tooth #26 was recommended.

Based on the patient information, particularly the radiographic examination, Tooth #26 exhibits significant decay/caries markedly undermining and compromising tooth integrity and tooth structure, and involving the root structure.  This decay radiographically extends below the alveolar bone height. Effectively, this tooth will remain a retained root tip.  The extent of coronal destruction and caries renders this tooth a poor support for full coverage restoration despite the recommended endodontic therapy.  Additional definitive treatment after caries removal in the attempt to maintain this tooth in the arch would require periodontal crown lengthening surgery, further compromising crown and root ratios, leaving less tooth structure than currently exists as support of a fixed crown.  As this tooth would be prosthetically poor support for a crown restoration, it is determined that the services as recommended are not medically necessary and contraindicated.  
Based on the above, the medical necessity for root canal, post, core and crown for tooth #26 is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a stress test. Ischemia was ruled out by stress testing. Echocardiogram revealed no evidence of structural heart disease or pericardial effusion. There was no evidence of acute myocardial infarction, ACS, decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. 

The standard of care for patients presenting with chest discomfort and in whom the diagnosis of acute coronary syndrome is unclear, is observation in ED or chest pain unit with serial cardiomarker measurements to rule out an acute myocardial infarction, followed by a non-invasive ischemic workup (stress test, CT angiogram). This standard of care is in concert with ACC/AHA clinical guidelines. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tonsillectomy and adenoidectomy
 
Treatment: Inpatient admission, post-operative monitoring

The insurer denied the inpatient admission. The denial was upheld.

This case involves a male child who presented for an elective tonsillectomy and adenoidectomy.  The patient had sleep apnea, per a sleep study.  The patient was an American Society of Anesthesiologists (ASA) class 2.  He underwent the tonsillectomy and adenoidectomy without complication and was admitted postoperatively for monitoring.  The patient was stable at the time of admission and was discharged the following day.

The medical literature indicates that inpatient admission may be indicated for pediatric patients if there is evidence of hemodynamic instability, hypertension, cardiac arrhythmias of immediate concern, severe heart failure, respiratory, neurologic, or abdominal abnormalities, reduced urine output, acute renal failure, significant uremic complications, high fever, or other high-risk infection, severe electrolyte, or metabolic abnormality, acute blood loss causing significant abnormality or severe pain requiring inpatient management.  The patient underwent a tonsillectomy and adenoidectomy.  The records failed to support the patient had complications following the procedure, as the patient was noted to be stable.  The documentation indicated the patient was to stay overnight due to sleep apnea.  However, the records failed to support the patient could not have undergone an observational level of care post-operatively.  

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

Diagnosis: Substance abuse
Treatment: Inpatient detoxification
The inpatient detoxification was not medically necessary.

The patient in this case was using opioids and alcohol on a continuous daily basis. The patient presented as cooperative in the absence of severe symptoms of alcohol or opioid withdrawal. Mental status examination was free of severe symptoms, and the patient was noted to deny suicidal ideation at the time of admission. There were no co-morbid general medical problems or co-occurring psychiatric disorders that would have required inpatient level services. Moreover, the withdrawal symptoms were not reported to be severe, and the patient's clinical presentation was not serious enough to warrant inpatient level treatment or monitoring. Thus, the detoxification treatment (and referral for rehabilitation services) could have been effectively provided at a lower level of care.

Medical necessity is not met in this case for the time interval under review, consistent with prevailing standards of professional practice, published practice guidelines, the American Society of Addiction Medicine (ASAM) Criteria, and the scientific literature, referenced below. This answer is consistent with New York State instruction for medical necessity reviews and with New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines, referenced below.

The substance use disorder inpatient admission with detoxification services and withdrawal management could have been safely and effectively provided at a lower level of care in this case scenario. Thus, the requested service of Substance use disorder inpatient admission for detoxification and other medical services is not reasonable in this case scenario. The patient's presentation and clinical features of substance use disorder did not warrant the intensity of inpatient services or inpatient level structure or monitoring in keeping with New York State Level of Care for Alcohol and Drug Treatment Referral Guidelines, referenced below and with ASAM Criteria, also referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spinal cord injusry
Treatment: ReWalk lower body robotic exoskeleton
the proposed ReWalk Lower Body Robotic Exoskeleton (ReWalk) is not medically necessary because the patient sustained a complete AIS spinal cord injury at T11 level making him paraplegic with associated muscle atrophy wallerian degeneration of some of the peripheral nerves. 
Clinical data from systematic review with meta-analysis, randomized-controlled or cohort studies in peer-reviewed medical literature did not show any concrete evidence that already atrophied muscles could be improved as in this instance. In terms of improved endurance and cardiovascular status, there is no study that showed that this is better than other available exercisers including ergometric hand bicycles. Most of the studies showed investigator bias, a high degree of performance variability across participants, etc. Powered Robotic Exoskeletons while having the potential to revolutionize rehabilitation following spinal cord injury, it is stated that it is still premature to make solid recommendation about their clinical use in spinal cord Injury.
The requested ReWalk is unlikely to be more beneficial than any other standard treatment for paraplegic with complete spinal cord injury and therefore not medically necessary.  Also, withholding the procedure in whole or in part is not reasonably likely expected to affect the patient's health as all other options for the treatment of paraplegia with spinal cord injury have not been documented to have been exhausted.
Appeal type: Medical necessity
Decision: Overturned

The patient is a pre-pubertal child with no chronic medical problems, who has idiopathic short stature and poor growth velocity.  Height is tracking along a channel that is 3 SDs below the mean for age and gender.  Body mass index (BMI) is at the 42nd percentile.  Mid-parental target height is 67.5 +/- 2 inches.  Prior evaluation revealed normal thyroid function, negative SHOX deoxyribonucleic acid (DNA) mutations, normal prolactin, normal androgen levels in the setting of hypertrichosis.  IGF-1 level was 42 ng/mL, and IGFBP-3 was 2.85 mg/L.  Bone age was delayed, with phalanges being 4 6/12 years at a chronological age of 6 5/12 years, and even more delay in the carpal bones at 2 years. Provocative growth hormone (GH) testing revealed a peak GH response of 10.6 ng/mL.  Magnetic resonance imaging (MRI) of the brain was normal.  A complete blood count (CBC), chemistry panel, celiac screen, and ESR were normal.  GH therapy is being requested for treatment of idiopathic short stature with poor adult height prediction.  GH therapy is medically necessary for this patient.  The patient's height is 3 SDs below the mean for age and gender, patient has poor growth velocity, and bone age is delayed more than 2 SDs compared to chronological age.  All other causes of short stature have been ruled out.  Although the patient passed provocative GH testing, patient meets auxological criteria for a trial of GH, as the patient most likely has a defect in the GH/IGF-1 axis.  GH therapy is medically necessary to achieve a normal adult stature.

According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria:  (1) height more than 2.25 standard deviations below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency.  This patient meets most of the above criteria.