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

Diagnosis: Anemia.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with heavy menses who had fatigue and dizziness. She had a hemoglobin of 6.1 and hematocrit was 23. Her heart rate was 107, blood pressure (BP) was 102/64 and oxygenation (O2) was 98%. She had a low mean corpuscular volume (MCV) and was diagnosed with iron deficiency anemia. The patient was admitted to the hospital and received one unit of red blood cells and was started on oral iron therapy.

No, the proposed inpatient admission was not medically necessary.
The patient did not require inpatient hospitalization. Her vital signs were not severe enough to warrant hospitalization. She was not febrile and had a normal blood pressure. She had mild tachycardia which was not severe enough to require inpatient management.  She had a hemoglobin of 6.1. She had heavy menses but was not having hemorrhage. The blood transfusion could have been safely administered at a lower level of care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The patient did not require inpatient hospitalization; the blood transfusion could have been safely administered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Adenovirus and Enterovirus. 
Treatment: Hospital Admission. 

The insurer denied coverage for hospital admission. 
The denial is upheld. 

This infant male with no significant past medical history. He presented to the emergency room (ER) with complaints of shortness of breath (SOB) and a cough. In the ER, temperature and heart rate were elevated. The physical examination was significant for subcostal retractions, course lung sounds, and expiratory wheezing. Intravenous (IV) fluids were given, and labs were collected. White blood cell (WBC) count was elevated. The chest x-ray (CXR) revealed no significant findings. The rapid viral panel (RVP) revealed adenovirus and enterovirus. He was given Ceftriaxone, steroids, and nebulizers. The patient was admitted to the pediatric intensive care unit (PICU) for acute respiratory failure. Albuterol was given and weaned. The patient was initially placed on high flow oxygen and then weaned to nasal cannula. He was transferred to the floor. Albuterol weaning continued and steroids were given. The patient's condition improved, and he was discharged. 

The patient could have been managed at a lower level. There was no need for repeated Magsulfate, no need for continuous nebulizers for prolonged time, no need for terbutaline drip or continuous steroids. The patient's saturation was 90 percent at its' lowest. If one were to assess the asthma severity such as Pediatric Asthma Severity Score or Pediatric Respiratory Assessment Score (PRAM), the score would indicate that patient needed only at lower level of care such as observational status or outpatient. Furthermore, the chest x-ray revealed was normal which is expected. Also, there was no underlying medical conditions such as chronic lung disease or congenital heart disease. There was also no need for BiPAP (Bilevel Positive Airway Pressure). There was no need for pressors and no need for positive pressure ventilation. The Pediatric early warning score (PEWS) documented by the nursing was always 0 which is perfect score and predicted uneventful course. If one were the examine the PRISM (Pediatric Risk of Mortality) score, that would be low and desirable too; the PRISM score incorporates, various clinical parameters and lab parameters (systolic BP (blood pressure), acid base values etc.) to synthesize a score system used in Pediatric ICU [intensive care units] to control for severity of illness or injury when comparing patients within and between ICUs. The Hospital course was suggestive of rapidly improving clinical picture.
Due to all the above reasons, the reviewer deems it that the patient only required observational status care. 

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

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

Diagnosis: s/p (status post) Induction Of Labor For Termination Of Pregnancy
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female having had three pregnancies, one term infant, zero preterm infants, one abortion and one living child (G3P1011) who presented to the hospital for termination of pregnancy due to fetal anomalies at 22 weeks five days.  A potassium chloride (KCl) injection had been performed for feticide prior to admission to the hospital.  Induction of labor was performed with Cytotec, fentanyl, and epidural.  Fetus and placenta were delivered, and postpartum care given without incident.  

The facility contends that the admission was medically necessary for fetal demise and cites Milliman Care Guidelines (MCG) Vaginal Delivery.  The health plan contends that the inpatient admission was not medically necessary because the patient did not meet clinical criteria of complications including hemodynamic, pulmonary, neurological, or metabolic for admission following an ambulatory procedure.  

Yes, the proposed inpatient admission was medically necessary. 

Mid trimester termination of pregnancy by induction of labor cannot be performed as an outpatient procedure.  It is an induction of labor with the same risks and need for high level of nursing, anesthesia, and physician or midwife support and attention as an induction of labor at a later gestational age, regardless of whether the fetus is alive or demised.  The risks of labor, even with a fetal demise, can be life threatening including hemorrhage, aspiration, shock, sepsis, amniotic fluid embolus, uterine rupture, trauma to the genital tract at all levels, shoulder dystocia, retained products of conception, uterine inversion, pulmonary edema, preeclampsia, and death.  It is not possible to adequately monitor nor perform necessary and emergent interventions for these risks at a lower level of care than hospital admission.  Therefore, the admission was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post brain tumor resection and visual loss. 
Treatment: Install Stair Lift Inside The Home, Pre-service. 

The insurer denied the Install Stair Lift Inside The Home, Pre-service. 
The denial is overturned. 

The member is a male with history of general debility and weakness, difficulty in walking, dizziness, giddiness, epilepsy, full incontinences of bladder and bowel, hemiplegia after brain tumor resection, visual loss, etc.. 
He lives alone on the second floor. He is unable to stay on the first floor because there are no bathroom facilities on that floor. 
At the moment, he is able to ambulate within the house, transfer and use the toilet with assistance and uses wheelchair for community ambulation.
The health plan also approved Personal Care Assistant (PCA) services 7 days a week, 24 hours per day as live in services and are able to assist him with all Activities of Daily Living and also call for help in emergencies. In addition, he gets home physical therapy.
The request by member's PCP (primary care physician) is for a stair lift to be fitted in the house as he lives upstairs where his bedroom is located in the house. 

Yes, the requested stair-lift is medically necessary in this patient who is visually impaired, hemiplegic, incontinent of bladder and bowel along with multiple medical issues. 
Although he has a Patient Care Assistance service 7 days a week and 24 hours a day, along with the fact that he requires moderate assistance, it will be difficult for a single person to be responsible for tasking him up and down the stairs in view of all of the above. 

The reason given by the health plan for denial is therefore not tenable in this regard. 

The medical necessity for a stair lift in this instance is because it is: 
1. Provided for the relief of a health condition, illness, injury or disease, as stated above... 
2. Necessary for and appropriate to the diagnosis, treatment, cure, or relief of a health condition, illness, injury, disease or its symptoms as stated above. 
3. Within generally accepted standards of medical care in the community, in patient with similar condition and circumstance, and, 
4. Not solely for the convenience of the insured, the insured's family or the provider. 

No. The health plan has not acted reasonably in this instance and its decision lacks sound medical judgment, which was not in the best interest of the patient based on the above rationale because the patient is an hemiplegic with multiple medical issues and also visually impaired and a very high risk of fall navigating stairs and requiring moderate assistance (50% support) that can only be provided by a single live-in patient care assistance that will not be adequate to prevent a fall.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea/Vomiting. 
Treatment: Inpatient Stay. 

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

The patient is a female who initially presented to the emergency department with concerns for nausea, vomiting, and diarrhea. Pertinent history included complex migraine and aseptic meningitis with residual left sided weakness. Initial vital signs revealed a temperature of 99.3, heart rate (HR) 105, blood pressure (BP) 117/66, respiratory rate (RR) 20, and peripheral capillary oxygen saturation (SpO2) 94% on room air. Initial examination did not reveal acute peritoneal signs. Initial laboratory testing revealed a white blood cell count (WBC) 28.1, Hemoglobin (HGB) 12.8, platelets (Plt) 230, Na (sodium) 140, K (potassium) 5.1, blood urea nitrogen (BUN) 8, Creatinine 0.6, and Lactate 2.05. A computed tomography (CT) abdomen/pelvis revealed findings suggestive of proctocolitis. Intravenous fluids and empiric antibiotics were administered. The patient was placed in the hospital thereafter with an impression of sepsis secondary to intra-abdominal infection, likely proctocolitis. 

The inpatient hospital admission was medically necessary. 

In this particular situation, the patient met the criteria to prompt the suspicion for a dysregulated systemic response. The patient presented with abdominal pain, nausea, and vomiting believed to be due to an intra-abdominal infection. Initial evaluation was concerning for tachycardia, leukocytosis, and radiographic findings suggestive of proctocolitis. Treatment included fluid resuscitation, cultures, and empiric antibiotics. Following observation care, the patient continued to be tachycardic with a leukocytosis. The patient decided to leave against medical advice thereafter. However, the clinical indications for admission to inpatient care were met. The patient had tachycardia that persisted beyond the observation time frame despite fluid resuscitation and empiric antibiotic therapy directed at the presumed source. In addition, it was reasonable to implement parenteral antimicrobial regimen only on an inpatient basis in this setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Palpitations. 
Treatment: Inpatient Stay. 

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

The patient is a male with history of hypertension, hyperlipidemia, coronary disease, and diabetes. The patient was admitted for palpitations and dyspnea in the setting of heavy lifting. Troponins were minimally elevated in the setting of a hypertensive emergency with a systolic blood pressure (BP) over 200. An Echocardiography demonstrated a normal left ventricular ejection fraction (LVEF). A computed tomography (CT) angiography demonstrated non-obstructive coronary disease. There was an abnormal FFR (fractional flow reserve) in the left anterior descending (LAD) and left circumflex. He underwent atherectomy and stenting of the LAD and circumflex. There were no complications. His BP was reported as well-controlled. His heart rate was in the normal range. On admission, he was on amlodipine, aspirin, and a statin. He was also on an ace inhibitor and metformin. 

The inpatient hospital admission was not medically necessary. 

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization has not been established as the standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Pharmacy/prescription drugs. 

The insurer denied Dupixent. 
The health plan's determination is upheld. 

This is a male patient with Rhinosinusitis. The request is for Dupixent. The patient has tried fluticasone and Claritin D. He has had polyp surgery. 

Dupixent is not medically necessary. In this case, the patient has not tried and failed first line therapies for CRS(Chronic rhinosinusitis) with NP(nasal polyp). Thus, Dupixent is not medically necessary for this patient. 

The formulary alternatives include flunisolide 0.025% nasal spray, triamcinolone acetonide nasal spray over-the-counter (OTC), mometasone furoate nasal spray and Rhinocort Allergy nasal spray OTC. The patient has only tried fluticasone. There are no head to head studies to show that the alternatives are less effective and a trial would be reasonable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite, rotation and midline shift. 
Treatment: D8080 braces and D8670 monthly visits. 

The insurer denied coverage for D8080 braces and D8670 monthly visits. 

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including Class I malocclusion, anterior crossbite, rotation and midline shift and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 5 total points to support orthodontic care. 

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, a 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 does not claim an automatic qualifying condition
and completes the second portion of the index arriving at 5 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining at total of 5 points on the HLD index which is below the threshold of 26 points to support orthodontic care. Of note in this case, is that the patient's own orthodontist does not attain 26 points on the HLD index as required for orthodontic approval. 

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 referenced below. 

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. 

In this case the patient's own orthodontist completed HLD index total score of 5 points remains below the threshold of 26 points to justify orthodontic care. 

D8080 braces and D8670 monthly visits is not considered medically necessary for this patient. 

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visits is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is upheld. 

This case involves a female with seizures, maintained on Keppra, anxiety and panic attacks, on chronic benzodiazepine therapy, who presented to the emergency department due to a witnessed seizure. The seizure was described as generalized shaking of the body, without tongue biting, with no loss of bowel or bladder function. There was no injury. The symptoms lasted for a few seconds, and then the patient returned to baseline. Upon checking her blood pressures, she was hypotensive, and they referred the patient to the emergency department. The patient was reportedly anxious before the onset of the seizure. Before this episode, the last seizure event was approximately 8 or 9 years ago. After admission, the neurology team assessed the patient and performed a detailed neurologic exam, which appeared fairly unremarkable. They also ordered a Keppra level for the following morning, a brain magnetic resonance imaging (MRI) and an electroencephalogram (EEG). The EEG was performed and showed no evidence of epileptiform activity. The neurology team adjusted the patient's dose to 500 milligrams (mg) twice daily. The Keppra level was 26.5, considered in the therapeutic range. The sodium also improved to 136, and the potassium was in the normal range at 3.9 by the following day. 

The health plan's determination is upheld. 

The requested inpatient stay is not medically necessary for this patient. Isolated breakthrough seizures can be managed under a lower level of care without the need for inpatient hospitalization. The patient has a known seizure disorder, has been compliant with antiepileptic medication for many years, and is currently experiencing a breakthrough episode. Imaging was unremarkable, and EEG did not reveal evidence of seizure activity. There were no additional seizure events that could not be managed under a lower level of care. As a result, admission to an inpatient level of care is not indicated. 
It was reasonable to admit the patient to the hospital for monitoring and dose adjustment of the antiepileptic medications. The patient had no evidence of recurrent seizures or status epilepticus and did not require any additional antiepileptic medications for uncontrolled seizure activity. Based on medical necessity, the patient could have been managed at a lower level of care for this type of presentation.
Appeal type: Medical necessity
Decision: Overturned

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

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, ectopic eruption, and anterior crowding and posterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 28 total points. 

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 the use of an orthodontic Index: The Handicapping Labiolingual 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.  The treating orthodontist completed the second portion of the index arriving at 28 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support 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 referenced below.

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.

Overturn denial as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems/Other/ Class I Occlusion
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested dental treatment plan. 
The health plan's determination is upheld.

The patient is a female with a Class I occlusion. She has severe mandibular crowding and moderate maxillary crowding, moderate overjet, and moderate overbite. The subject to be determined is the medical necessity for braces and monthly visits.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, braces and monthly visits are not medically necessary for this case.