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

Diagnosis: deep impinging overbite

Treatment is braces and monthly visits

The insurer denied coverage for braces and monthly visits
 
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the HLD (Handicapping Labio-Lingual Deviation) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical. 

Upon review of the submitted documentation, (study models were not provided for review), 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, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and 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 with a total of 14 points (6 points overjet, 5 points overbite, 3 points labiolingual spread).

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. 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 upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for braces and monthly visits services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Periodontal disease. 
Treatment: Buildup (D2950) and crown (D2740) on tooth number 19. 

The insurer denied coverage for buildup (D2950) and crown (D2740) on tooth number 19.  The denial is upheld. 

Upon review of the documentation provided, which includes copies of one undated bitewing, one undated periapical radiograph, narrative letter from the dental office, and insurer correspondence, it appears that this patient presented to the dentist with pain and sensitivity for care involving tooth #19.  The treating dentist recommended a buildup and full coverage crown for #19. The Insurer has denied these services stating the there is no clinical/ radiographic evidence, such as traumatic injury or decay, or evidence of periodontal health provided to support the necessity of his service. The documentation is insufficient to approve treatment and therefore the service does not meet medical necessity criteria. 

The objective documentation provided for review is a copy of one bitewing and one periapical radiograph. There are no other dental treatment records provided for review. It appears that there is no evidence of fracture or other pathology specifically affecting #19 based on the images provided for review. There does not appear to be any radiographic evidence of caries. The radiographs do not substantiate the requested dental services as enumerated above and therefore the crown is deemed not medically necessary. 

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

The insurer's denial of coverage for the buildup (D2950) and crown (D2740) on tooth number 19, is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: Home health care
The insurer denied Personal Care Aide (PCA) Services, Level 2: 5 Hours per Day, 7 Days per Week - Total of 35 Hours per Week. 
The denial is overturned.

The patient is a male with past medical history of osteoarthritis, coronary artery disease, dementia, and urinary incontinence who had been assigned PCA (personal care aide) services based on telephonic assessment performed assessing patient at maximum assistance with tasks of meal preparation and ordinary housework while extensive assistance with task of shopping. The patient was assessed at limited assistance with tasks of stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, and toilet use while supervision with task of managing medication. The patient was assessed at set up with tasks of managing finances and phone use while independent with tasks of bed mobility and eating.

Personal Care Aide (PCA) Services, Level 2: 5 Hours per Day, 7 Days per Week - Total of 35 Hours per Week are medically necessary for this patient.
There is documentation from the patient's son of the patient's worsened cognitive and functional status which led to placement in a Skilled Nursing Facility (SNF) facility; however, the patient's condition improved with plan for the patient to return to home. In order to return home, the patient required assistance with activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient requires total assistance with managing medication and as the son noted the patient has medication management assistance needs throughout the day. In addition, the patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs when the patient did not have informal help. Furthermore, the plan assumed the patient had informal help from his ex-wife which was not the case. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 5 hours/day, 7 days/week, to total 35 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral palsy (CP) and semi-lobar holoprosencephaly

Treatment is (E1399) Recaro Monza Nova 2 car seat

The insurer denied coverage for (E1399) Recaro Monza Nova 2 car seat
 
The denial is overturned

The is a patient with semi-lobar holoprosencephaly, gastrostomy (GT) tube dependence, gastroesophageal reflux, diabetes insipidus, and cerebral palsy (CP). Off the shelf car seats and the adaptive Spirit Car Seat by Drive were trialed and failed. Under review is the medical necessity for a requested (E1399) Recaro Monza Nova 2 car seat. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested Recaro Monza Nova 2 car seat is medically necessary for this patient. This physician agrees with the patient's physical therapist, regarding the medical necessity of the requested Recaro Monza Nova 2 specialized adaptive car seat. The insurer's approved car seats place the child at increased risk of severe injury in the event of a motor vehicle accident. The patient's diagnoses include semi-lobar holoprosencephaly and cerebral palsy with associated developmental deformities. She requires full support of her head and trunk. The requested car seat is the most appropriate given the patient's asymmetric posture, hypotonic core and associated muscle weakness; rendering other seating systems unsafe (which have been trialed and failed). 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the requested for (E1399) Recaro Monza Nova 2 car seat is medically necessary. 

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 (E1399) Recaro Monza Nova 2 car seat services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

The patient was having intermittent epigastric pains for months. He was not compliant with his medications. He was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. An abdominal ultrasound showed gallbladder sludge. An endoscopy revealed gastritis. He was treated with a PPI (proton pump inhibitor). 

Clinical indications for admission for Undiagnosed Abdominal Pain (MCG (Milliman Care Guidelines) M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

Clinical indications for admission for Gastritis (MCG M-560) include hemodynamic instability, gastric outlet obstruction, peritoneal signs, severe vomiting, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient had epigastric pain and required a workup including endoscopy. However, IV (intravenous) hydration and PPI therapy could have been given in the ER (emergency room) as an outpatient. He was stable to have had the endoscopy performed on an ambulatory basis. He did not meet MCG criteria for admission for either Undiagnosed Abdominal Pain or Gastritis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

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 in Part

Diagnosis: Congestive heart failure and Parkinson's disease
Treatment is 24 hours per day - split shift - personal care aide (PCA) services
The insurer denied coverage for 24 hours per day - split shift - personal care aide (PCA) services
The denial is overturned in part

This is a patient with chronic medical problems including congestive heart failure and Parkinson's disease.  She was hospitalized due to cardiac arrest and for sepsis. She lives alone in a private residence. The patient is approved by the insurer for 70 hours/week of PCA services and is requesting an increase to 24 hours/day - split shift.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired." She requires maximal assistance for bathing, lower body dressing and toilet transfer/use.  She is frequently incontinent of bowel and bladder. Extensive assistance is required for personal hygiene, upper body dressing and ambulation (uses a walker for short distances). Bed mobility requires limited assistance. Her functional ability for performing activities of daily living is much the same as was documented in the UAS report. However, since the more recent UAS assessment, the patient has been hospitalized and treated for cardiac and infectious disease conditions, which could contribute to a further functional decline. The combination of the patient's cognitive deficits and functional impairments support the medical necessity of increasing PCA to 84 hours/week. Her condition and functional needs are not at a level or unpredictable as to require the requested PCA 24 hours/day, 7 days a week - split shift. This physician would agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing PCA services to 84 hours/week.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  

From a physical medicine and rehabilitation perspective, the requested 24 hours/day - split shift - PCA services, is not medically necessary. However, increasing PCA 84 hours/week is medically necessary.  

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 24 hours per day - split shift - personal care aide (PCA) services is not substantiated. However, increasing PCA hours to 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: BRUE (Brief Resolved Unexplained Event)
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is overturned

This patient presented via EMS (emergency medical services) from home after an episode of choking and cyanosis. According to her mother, following a feeding around midnight, she and the infant's grandmother heard the infant coughing in another room. When they entered the room, they found she had vomited, was choking, and had "turned blue in the face". They picked her up and delivered back blows and bulb suctioning with a return to baseline within one minute. On examination, the only significant finding was previously identified ectrodactyly/syndactyly of the left foot. In addition to the acute presentation, the infant's mother gave a history of an episode of choking/emesis within hours after birth that was assessed as "choking on some amniotic fluid".  After initial Emergency Department assessment, the infant was admitted to the NICU (neonatal intensive care unit) with a diagnosis of Brief Resolved Unexplained Event and placed on continuous cardiorespiraotry monitoring, including pulse oximetry. Following admission, there was no untoward event prior to discharge.  At discharge, diagnoses included BRUE and Gastroesophageal Reflux. In addition to monitoring, care included teaching the infant's mother and grandmother how to avoid reflux and what to do if there was another event. 

The insurer denied coverage of an in-patient admission citing MCG (Milliman Care Guidelines) : P-12, Apparent Life-Threatening event (BRUE). According to this guideline, Admission is indicated for ALL of the following:

Diagnosis of apparent life-threatening event (brief resolved unexplained event) appropriate, as indicated by ALL of the following:
Infant younger than 1 year of age
Event is reported (eg, by observer) as having included 1 or more of the following:
Cyanosis or pallor
Absent, decreased, or irregular breathing
Marked change in tone (eg, hypertonia, hypotonia)
Altered level of responsiveness (eg, loss of consciousness, lethargy)
Infant recovered fully to baseline state of health after event (eg, normal appearance, vital signs)
Event remains unexplained after history and physical examination. 

Infant at increased risk for recurrence, serious underlying disorder, or unsafe discharge, as indicated by 1 or more of the following:
Infant age younger than 60 days
Infant born at less than 32 weeks' gestation and now at less than 45 weeks' postconceptional age
Cardiopulmonary resuscitation (CPR) administered by medical personnel during or after event
Duration of event is 1 minute or longer.
Infant history of prior event (ie, current event not the first such event)
History, physical examination, or other evaluation identifies abnormality requiring inpatient care (eg, Hypoxemia, infection, suspected abuse).

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis
Treatment: Inpatient Hospital Services
The insurer denied the Inpatient Hospital Services as not medically necessary.
The health plan's determination is overturned.

At the time of his admission, the patient was previously healthy and brought to the emergency department with a skin infection. The patient believes he was hit in the shin and noticed a bump and skin redness. He went to urgent care and was given Mupirocin. The redness spread, so he went to his primary care provider who started him on Clindamycin orally, which he took, as prescribed. The patient presented to the emergency department (ED) for continued redness. The patient's vital signs were normal. He appeared well and had a normal examination except for inflammation of the left lower extremity "from 4-5 centimeters (cm) below knee to distal shin, crossing ankle along medial malleolus to proximal dorsum of foot." The patient had full range of motion at the ankle and some point tenderness along the medial malleolus. It hurt to walk and with weight bearing. Both an x-ray and ultrasound were unremarkable. The patient's blood work was normal. Infectious disease was consulted. The patient was given intravenous (IV) Vancomycin and Cefazolin in the ED and he was admitted for further evaluation and treatment. An magnetic resonance imaging (MRI) scan showed focal T2 signal within several bones of the ankle, suggesting possible acute or chronic multifocal osteomyelitis. The patient was continued on IV antibiotics and infectious disease was re-consulted. The consultant saw the patient and noted the downtrending c-reactive protein and the lack of pain corresponding to possible areas of osteomyelitis. The consultant recommended "discharge home with at least two weeks of Keflex, infectious disease (ID) follow up in clinic and repeat imaging of foot and blood work as outpatient." The patient was discharged home.
At issue is the medical necessity of Inpatient Hospital Services.

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

Yes, the requested health service/treatment of Inpatient Hospital Services was medically necessary for this patient.
The patient had worsening lower extremity cellulitis despite appropriate outpatient oral antibiotics. He was admitted to start intravenous antibiotics, which is the appropriate treatment when outpatient oral antibiotics have failed. An MRI that was done suggesting possible osteomyelitis, so IV antibiotics were continued, and an infectious disease specialist was consulted. This specialist saw the patient and questioned whether acute or chronic osteomyelitis was the actual diagnosis. The doctor opined that either way, since the patient was now doing well, was non-toxic and afebrile, with normal inflammatory markers, it would be safe to discharge the patient home on oral antibiotics for a planned prolonged course with close outpatient follow up. This patient's hospitalization was medically necessary for IV antibiotics.
Therefore, the requested health service/treatment of Inpatient Hospital Services was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abdominal pain.
treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a woman who presented with abdominal pain and nausea. At the time of presentation, the patient was without fever and vital signs were normal. She was tender in the right upper quadrant. The white blood cell (WBC) count was normal. The complete metabolic panel identified elevated liver enzymes and elevated bilirubin. An Ultrasound showed gallstones and a normal caliber common duct. She was admitted to the hospital and initially treated with intravenous (IV) fluid and antiemetics. 

The inpatient hospital admission was medically necessary for this patient. This patient presented to the hospital with cholelithiasis and choledocholithiasis (elevated total bilirubin and image confirmation of common bile duct (CBD) stones). Based on the presenting lab and imaging data, it was reasonably anticipated that the medically necessary care would span a period of greater that 48-hours. The patient was appropriately started on IV antibiotics and was appropriately evaluated by the surgical and gastroenterology services. Lab data confirmed persistently elevated liver enzymes and bilirubin. The magnetic resonance cholangiopancreatography (MRCP) was appropriately performed that confirmed filling defects (stones) within the common bile duct (CBD). It was recommended that the patient be treated for this condition (choledocholithiasis) with endoscopic retrograde cholangiopancreatography (ERCP) and stone extraction followed by surgical treatment with laparoscopic cholecystectomy). This patient was evaluated and treated in an expeditious and efficient manner. The intensity of service, the coordination of multiple medical services (gastroenterology and surgery), the diagnosis of choledocholithiasis, and the anticipated need for multiple interventional procedures support the medical necessity of an inpatient designation.