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

Diagnosis: Missing teeth.
Treatment: Oral Surgery (occlusal orthotic device).
The insurer denied the Oral Surgery (occlusal orthotic device).
The denial is upheld. 

The patient is a female who is edentulous on the upper and has multiple missing teeth on the lower. The provider is planning to place the implants, which have been denied. This is the review for an occlusal orthotic device.

No, the Oral Surgery (occlusal orthotic device) is not medically necessary.

This code, in the plan language that was utilized, requires that a report be submitted. There was no report submitted and there is no clinical information to show what the purpose of this device is. The description of this code states that this should be used to report an occlusal orthotic device used to treat disorders of the temporomandibular joint (TMJ) only.  Therefore, based on the available information, the treatment is not medically necessary.

The typical signs and symptoms of temporomandibular joint disorders (TMD's) are pain in the joint (preauricular region), headaches behind and around the eyes, and pain radiating from the joint to the temple, ears, side of neck and upper shoulder. The pain is typically aggravated by wide opening, chewing or other joint activities, such as clenching and bruxism. There often is clicking, popping or "locking" because of disc interference, which results in reflex masticatory muscle spasm. Incisal opening, protrusion, and contra-lateral movements are decreased and may interfere with mastication. The joint, muscles of mastication, sternocleidomastoid muscle and trapezius muscle are often tender to palpation. None of the above is documented.

There is no documentation that the patient has temporomandibular joint (TMJ) dysfunction nor any mention of an occlusal orthotic device in the records.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain.
Treatment: Outpatient procedure- pain management injections (CPT 62323).
The insurer denied outpatient procedure- pain management injections (CPT 62323).
The determination is overturned.

The patient has low back pain radiating into the right lower extremity. A lumbar magnetic resonance imaging (MRI) scan by report, describes degenerative changes which resulted in nerve root impingement on the right. A lumbar epidural steroid injection (ESI) was performed. A repeat epidural steroid injection was proposed. The original request was denied as criteria was not met, specifically documentation of 50% pain relief for 2 months from the injection. A progress note dated  reported that the prior epidural steroid injection provided 65% pain relief for one month and 50% for the second month. 
The repeat epidural steroid injection is under review for medical necessity.
Based on the submitted records, the proposed repeat epidural steroid injection is considered medically necessary. The progress note dated the previous epidural steroid injection provided 65% pain relief for one month and 50% for the second month, thus meeting criteria to establish medical necessity for another injection.
Guidelines issued by the American Society of Interventional Pain Physicians state (in part) "In the therapeutic phase (after the diagnostic phase is completed), the suggested frequency of interventional techniques should be 2 months or longer between each injection, provided that greater than (>) 50% relief is obtained for 2 months....In the treatment or therapeutic phase, the epidural injections should be repeated only as necessary according to medical necessity criteria, and it is suggested that these be limited to a maximum of 4 times per year" [1].
Guidelines issued by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine state (in part) "Epidural steroid injections with or without local anesthetics may be used as part of a multimodal treatment regimen to provide pain relief in selected patients with radicular pain or radiculopathy" [2].
Guideline issued by the North American Spine Society state (in part) "Interlaminar ESIs may be considered in the treatment of patients with lumbar disc herniation with radiculopathy" [3].
In this case, the medical necessity criteria was met for another injection and is supported by peer-reviewed guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer; Diabetes; Osteoporosis.

Treatment: personal care/consumer directed personal assistance services, 56 hours per week.

The insurer is denied coverage for personal care/consumer directed personal assistance services, 56 hours per week

The denial is upheld. 

This female patient has a history of osteoporosis, recurrent effusion, pancreatic cancer and type 1 diabetes. Per the physician's order for personal care/consumer directed personal assistance services. The patient is frail following hospitalization for recurrent effusion and pneumonia. The patient requires oxygen, and has urinary incontinence. The Uniform Assessment System (UAS) - New York Comprehensive Community Assessment Report and UAS - ATSP (Aide Task Service Plan). Summary of Hours Recommended is submitted for review. The patient needs assistance with multiple functions.

As per the New York Codes Rules and Regulations, Title: Section 505.14 Personal care services: 

(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

In this case, the patient needs assistance due to multiple medical problems. The patient takes insulin and uses oxygen at home. Tasking tools were done 6 months ago. There is no documentation provided that indicates that there has been a change in the patient's condition since then. There is no documentation provided that would support a change in the plan's assessment of this patient's needs.  

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

The carrier's denial of coverage for the personal care/consumer directed personal assistance services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical spondylosis without myelopathy and cervicogenic headaches.
Treatment: Cooled radiofrequency ablation.
The insurer denied Cooled radiofrequency ablation.
The determination is upheld.

The patient was diagnosed with cervical spondylosis without myelopathy and cervicogenic headaches. She reportedly has more than two years history of chronic neck and right shoulder pain that is worse with activities. She had undergone cooled radiofrequency ablation at the right cervical C 2- C-3 and C3- C4 with a reported six months of 100% pain relief. The patient had a return of symptoms and had decreased range of motion with tenderness to palpation at the right-sided cervical facet joints as well as mild tenderness to palpation at the right muscles of the neck and shoulder. She was recommended to undergo repeat cooled radiofrequency ablation to the cervical spine at the right C3- C4 and C4-C5. Records provided indicate that a request for cooled radiofrequency ablation to the cervical spine was denied by the health plan.
According to a "to whom it may concern" letter from the treating provider, it was stated that the patient has been under their care for neck pain and headaches and has previously undergone multiple right-sided C3, C4, C5 cooled radiofrequency ablation for which she got 100% relief of her pain for six months and 100% amelioration of her migraines. The provider states that cooled radiofrequency ablation of her cervical facets is the only therapy that has resulted her migraines for at least 10 months and has allowed her to have a normal quality of life. The provider stated that this procedure is the most effective treatment for neck pain secondary to facet mediated pain and is currently accepted and preferred method for radiofrequency ablation. At issue is the medical necessity of the requested procedure.
The requested health service/treatment of cooled radiofrequency neuroablation is not medically necessary for this patient.
The patient has cervical spondylosis without myelopathy and cervicogenic headaches.  Per Walega et al, "Radiofrequency ablation of medial branch nerves is considered a safe and effective treatment for chronic facet joint pain in the cervical, thoracic, and lumbosacral spine. Cooled radiofrequency ablation (C-RFA) is gaining popularity over conventional thermal radiofrequency ablation (RFA) in pain management. However, complications of C-RFA have not been reported in the literature." Although standard radiofrequency ablation can be recommended for carefully selected patients with proven cervical facet joint pain following a diagnostic medial branch block, there is a lack of evidence found in the peer-reviewed medical literature supporting the safety or efficacy of cooled radiofrequency ablation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Back Pain
Treatment: Inpatient Hospital
The health plan denied the requested inpatient hospital stay due to the lack of medical necessity. 
The health plan's determination is overturned.

At the time of service, the patient was a female with a history of chronic lower back pain and a recent new injury that resulted in severe left leg radicular pain. She was seen in the emergency department (ED) and reported a fall a week previously and was seen in the ED at that time and released. She then returned to the ED for escalating left leg pain - apparently, she had also been seen the day before and was scheduled for an outpatient magnetic resonance imaging (MRI), but the pain was so severe she returned to the ED. In the ED, she was noted to have no focal neurological deficits. An MRI of the lumbar spine reported a large left paracentral disc herniation on the left at (lumbar) L4-5. She was admitted as an inpatient for pain control and placed on a Dilaudid patient-controlled analgesia (PCA) pump as well as intravenous corticosteroids. This apparently gave her initial relief but the next morning, she reported intractable severe pain again. A neurosurgical note from that morning documented 4-/5 weakness of the left extensor hallucis longis (EHL) and foot dorsiflexors with numbness from the left knee distally. Given the intractable pain despite the PCA and the apparently new neurological deficits, the decision was made to take the patient to the operating room (OR) that day, where she underwent a left L4-5 decompression and removal of a large subligamentous herniated disc. The procedure was uncomplicated according to the operative report. The next day she reported significant relief of the severe left leg pain and was discharged home after having been evaluated and cleared by the rehabilitation team.

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

Yes, due to the need for a PCA utilizing Dilaudid for pain control, the inpatient stay was medically necessary and appropriate for this patient.
Once it was decided by the medical staff that the patient's pain was severe enough to require a PCA with Dilaudid to try and control her pain, the inpatient admission was the only appropriate status for this patient. While it is possible to administer the intravenous corticosteroids and as needed (prn)prn intravenous pain medications, as well as perform every 4-hour neurological checks at the observational level of care, a PCA requires much closer monitoring of the patient's hemodynamic and respiratory status and is not appropriate at an observational acuity of care. Even with the close monitoring provided in an inpatient setting, adverse complications such as respiratory suppression and dosing errors can still occur.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: vaginal bleeding.
Treatment: inpatient admission.
The insurer is denied coverage for inpatient admission
The denial is upheld. 

This female patient has a history of diabetes mellitus, hypertension, hyperlipidemia, obesity, fibroids, polyps, and abdominal myomectomy currently taking iron pills for a consistently low blood count. A recent transvaginal ultrasound was positive for 2 centimeters (cm) and 3 cm fibroids. She presented to the Emergency Room (ER) with complaints of vaginal bleeding for the prior 2-4 days. The patient reported that due to her fibroids, her periods normally lasted 10 days and were heavy, but not to this extent. She was prescribed norethindrone 2 weeks prior but stopped taking it 4 days prior to presentation. She was scheduled to see her Gynecologist that morning but felt dizzy, had palpitations and her Gynecologist instructed her to go to the ER. Examination revealed normal vital signs and gross blood pooling in the vaginal vault with small clots. Review of prior lab results showed a hemoglobin result in the 11-12 range. A hematocrit (HCT) done in the ER was 26.9 and a repeat HCT was 23.6. The patient was admitted and received two units of packed red blood cells. Eight hours post transfusion her HCT was 27.4, bleeding was minimal, and she was discharged.

The patient presented to the ER with complaints of vaginal bleeding and dizziness. Her medical history was significant for anemia and uterine fibroids. On admission to the ER the patient had normal vital signs with a normal blood pressure and pulse. She exhibited no signs of dizziness or syncope. Her abdominal and pelvic examinations were normal except for a 16 week sized uterus on palpation, and documentation of evidence of moderate active vaginal bleeding. There was no evidence of hemodynamic instability. The patient was noted to be alert, awake and oriented during admission and inpatient care. The patient was appropriately observed and given IV(intravenous) fluids in the ER with resolution of reported dizziness. Her condition was stable on presentation and during admission. She had no significant underlying medical conditions increasing her risk for complications to indicate inpatient admission. She did not require IV or narcotic pain medication. There was no evidence of significant infection or acute/ongoing hemorrhage which could have indicated inpatient admission. Therefore, there is no evidence in the medical records that the patient required inpatient admission. The patient's condition could have been managed in an outpatient setting, including administration of packed red cells. She could have been observed and given the supportive care she received in the ER or in an intermediate care unit. Follow up care could then be performed as was planned at her discharge. Therefore, the inpatient admission was not medically necessary.


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

The carrier's denial of coverage for the inpatient hospital admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial Cellulitis

Treatment: Inpatient Admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient is a male with past medical history significant for hypertension, hyperlipidemia, and depression who presented to the Emergency Department with complaints of swelling to left side of his face. Vitals on presentation included: Temperature-98.1 Fahrenheit, Blood Pressure-135/80, Pulse-84, Respiratory Rate-16, Oxygen Saturation - 98% on Room Air. Laboratory values were notable for the following: White blood cell count-10.4, hemoglobin - 13.3, hematocrit - 40.8, glucose-83, and creatinine-1.4.  The patient was empirically started on intravenous antibiotics (vancomycin and Zosyn) for facial cellulitis secondary to odontogenic infection. Maxillofacial computed tomography scan showed no acute osseous abnormalities but maxillofacial soft tissue swelling. Infectious Diseases consulted and adjusted antibiotic coverage. The patient remained afebrile, hemodynamically stable, and clinically improved. He was discharged to continue oral antibiotics and follow-up with a dentist as an outpatient. 

According to documentation, the patient presented with a left side facial swelling secondary to dental caries. Otherwise, he was afebrile, stable hemodynamically with normal white blood cell counts. The patient had no evidence for respiratory compromise or disseminated infection; moreover, he was able to tolerate oral intake. No surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management. Documentation does not support need for acute inpatient hospitalization. 

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

The prior determination of denial of coverage for inpatient hospital admission is upheld.

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

Diagnosis: Dental Problems/Other-brace and monthly visits.
Treatment: Dental/Orthodontic Procedure.
The health plan denied the request for braces as not medically necessary.
The health plan's determination is overturned.

The patient in question is a female with an anterior crossbite on teeth 7 and 10. She presents with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 24-30 months of orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.
At issue is the medical necessity of the requested health service/treatment of braces.

I overturn, in whole, the health plan's denial of medical necessity.

This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.[1,2,3]
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, COPD (chronic obstructive pulmonary disease)
Treatment: An increase in Consumer Directed Personal Assistance Services (CDPAS) from 40 hours per week to 24 hours per day (Live-In).
The insurer denied the An increase in Consumer Directed Personal Assistance Services (CDPAS) from 40 hours per week to 24 hours per day (Live-In).
The denial is overturned.

The patient is a male with a history of dementia, COPD (chronic obstructive pulmonary disease), cancer and coronary artery disease. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Appeal review requested for potential approval of Consumer Directed Personal Assistance Services (CDPAS) from 40 hours per week to 24 hours per day (Live-In).

The proposed Consumer Directed Personal Assistance Services (CDPAS) from 40 hours per week to 24 hours per day (Live-In) is deemed medically necessary.

This is a male with a history of dementia, COPD (chronic obstructive pulmonary disease), cancer and coronary artery disease. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). 

Recent correspondence from the patient's physician indicates that due to progressively worsening functional and cognitive decline, the currently approved plan of 40 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment Consumer Directed Personal Assistance Services (CDPAS) from 40 hours per week to 24 hours per day (Live-In) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, vertical growth pattern, Class II canines, maxillary and mandibular crowding, open bite and anterior crossbite with gingival attachment loss (mandibular left canine)). 

Treatment: D8080 braces and D8670 monthly visit. 

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

The denial is upheld. 

This is a female patient who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, Class II canines, maxillary and mandibular crowding, open bite and anterior crossbite with gingival attachment loss (mandibular left canine). The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 21 points on review by their internal reviewers. 

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, an HLD index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 21 points (6 overjet, 8 anterior open bite, 5 anterior crowding, 2 labiolingual spread).

The healthcare plan did act reasonably and with sound medical judgment is the best interest of the patient.

The coverage for D8080 braces and D8670 monthly visit is not considered medically necessary for this patient.

The insurer's denial of coverage for D8080 braces and D8670 monthly visit is upheld. The medical necessity is not substantiated.