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

Diagnosis: Shortness of Breath and Chest Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This adult male patient was hospitalized for shortness of breath and chest pain. He presented to the emergency department for evaluation of substernal, exertional chest pain. His past medical history was significant for protein C/S deficiency, splenic vein thrombosis, prior deep vein thrombosis (DVT) on Xarelto and active tobacco and cocaine use. There was one millimeter ST-elevation (STE) in the inferior leads and a ST-elevation myocardial infarction (STEMI) protocol was initiated. However, cardiac catheterization with coronary angiography showed mild coronary artery disease (CAD) only and the patient was treated medically. His troponin was not elevated. There were no significant procedural complications documented and the patient was observed overnight and deemed stable for discharge to home by the next day. 
The request for coverage for inpatient hospitalization has been denied by the patient's medical policy and the patient is appealing the decision.

The proposed treatment is not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay, because the severity of this patient's illness did not meet the
intensity of service for inpatient hospital stay. Per the Milliman Care Guidelines (MCG) criteria for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. 
In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, including urgent cardiac catheterization with transient bradycardia like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the
current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath and Chest Pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This adult male patient was hospitalized for shortness of breath and chest pain. He presented to the emergency department for evaluation of substernal, exertional chest pain. His past medical history was significant for protein C/S deficiency, splenic vein thrombosis, prior deep vein thrombosis (DVT) on Xarelto and active tobacco and cocaine use. There was one millimeter ST-elevation (STE) in the inferior leads and a ST-elevation myocardial infarction (STEMI) protocol was initiated. However, cardiac catheterization with coronary angiography showed mild coronary artery disease (CAD) only and the patient was treated medically. His troponin was not elevated. There were no significant procedural complications documented and the patient was observed overnight and deemed stable for discharge to home by the next day. The request for coverage for inpatient hospitalization has been denied by the patient's medical 
policy, and the patient is appealing the decision.

The proposed treatment is not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the requested acute inpatient hospital stay, because the severity of this patient's illness did not meet the 
intensity of service for an inpatient hospital stay. Per the Milliman Care Guidelines (MCG) criteria for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which inpatient hospitalization is considered appropriate. 
In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care the patient received, including urgent cardiac catheterization with transient bradycardia like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the 
current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: 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 impacted permanent anterior teeth among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated (right maxillary canine). The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 7 points on review by internal reviewers.

Upon review of the submitted documentation 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 impacted permanent anteriors where extraction is not indicated. This automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care using this criterion. Concur with the findings of the insurer of attaining 7 points on the HLD index (4 points overjet, 1 points overbite, 2 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 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Problems/Other/Dental Issues.
Treatment:  Braces.

The health plan denied the braces.  The denial is upheld.

The patient is a male with a Class II malocclusion, mild maxillary crowding, mild mandibular crowding, moderate overjet and severe overbite.  The subject to be determined is if the requested health service/treatment of braces is medically necessary.

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

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 17 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 millimeter (mm) or greater and underbite 3.5 mm (millimeters) 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, the requested health service/treatment for braces is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of asthma and admissions for asthma flares. Her presenting complaint was shortness of breath. On arrival to the emergency department, the patient's vital signs were a blood pressure of 126/82, heart rate 101, respiratory rate 24, with an oxygen saturation of 92 percent (%) on room air. The physical exam was notable for bilateral wheezing, poor air entry, and able to speak only in short sentences. Lab results were unremarkable. Radiology was unremarkable. In the emergency department (ED), she was given steroids and nebulizer therapy. She was also briefly started on bi-level positive airway pressure (BiPAP) which she did not tolerate well. Her symptoms improved to the point where she was having only mild tachypnea, and she was admitted to an inpatient level of care.
At issue is the medical necessity of an inpatient stay.

The inpatient stay was not medically necessary.
The patient presented with signs and symptoms of a moderate asthma exacerbation: respiratory rate less than 30, oxygen saturation greater than (>) 90 percent (%), and moderate distress. She improved with the initial therapy delivered by Emergency Medical Services (EMS) and in the emergency department. A lower level of care would have been an appropriate venue to monitor the patient for continued improvement, continue to provide therapies such as nebulizer therapy and steroids, and coordinate outpatient follow-up. An inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, hypothyroidism, and glaucoma
Treatment: Personal Care Services, Level 2
The insurer denied coverage for Personal Care Services, Level 2
The denial is upheld

This is an adult with diagnoses that include hypertension, hypothyroidism, and glaucoma. The patient lives with their spouse, sister-in-law, and niece in a private residence. The patient is on medical leave from their job. The patient has a benign brain tumor that is affecting their vision. The patient is requesting Personal Care Services (PCS) Level 2, which is currently under review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are documented as independent. Much of the patient's Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and managing medications are at the independent to supervision level of care. Activities of Daily Living (ADL) tasks such as bathing, dressing, bed mobility and toilet transfer/use are independent. Only supervision is needed for mobility (such as locomotion and ambulation) due to vision impairment. The patient is completely continent of bowel and bladder. The patient may benefit from safety monitoring, particular for ambulation due to vision impairment. However, safety monitoring under PCS does not include monitoring an individual when no other Level 1 or Level 2 personal care service task is being provided. 

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 Personal Care Services, Level 2 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves an adult patient with a history of hypertension and diabetes mellitus that presented to the hospital with complaints of chest pain, palpitations, and dyspnea. The patient was noted to have a heart rate of 140-170 while visiting the endocrinologist. The patient was sent by ambulance to the hospital. The patient denied nausea/vomiting. On arrival, vital signs were stable (blood pressure 111/71, Pulse 86). Physical examination revealed no abnormal findings. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm without ST (interval on an ECG) or T (interval on an ECG) wave abnormalities. Serum blood testing was significant for sodium (Na) 159, carbon dioxide (CO2) 47, chloride (Cl) 85, blood urea nitrogen/Creatinine 12/0.63. Point of care testing (POTC) glucose was 157. Urine toxicology revealed cannabinoids. Exercise stress testing, performed one week prior to admission, revealed no evidence of ischemia and the echocardiogram revealed normal left ventricular ejection fraction. The patient was admitted to the hospital for observation and treatment. Following treatment for presumed dehydration with intravenous half normal sodium, labs showed Na 137, CO2 23, Cl 106 and a glucose of 89. Troponin and B-type natriuretic peptide (BNP) were both normal. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. This patient presented with palpitations, dyspnea, and hypernatremia. On arrival the vitals were normal. While the patient had electrolyte abnormalities, these corrected rapidly with fluid within hours. The patient could have been observed and when there were no acute findings and electrolytes corrected, the patient could have been discharged. 

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Occlusion; crowding
Treatment: D8080 Braces, D8670 Monthly Visits
The insurer denied: D8080 Braces, D8670 Monthly Visits
The denial is overturned.

The patient is an adolescent female. The request is for orthodontic treatment and monthly follow up visits. She has Skeletal Class I occlusion with moderate upper and lower crowding. She has a deep bite and anterior crossbite of tooth #(number) 22. The health plan's prior denial of coverage was due to handicapping scale score of 6.

The braces and monthly visits are medically necessary.

The patient has an anterior crossbite of the lower left permanent canine (#22). There is attachment (gum) loss and recession present. This is an automatic qualifier according to the handicapping index scale.

The health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis of Knee, Bilateral
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission
The denial is upheld

This is an adult with a history of osteoarthritis of the knees, coronary artery disease (CAD), hyperlipidemia, and hypertension. The patient presented to the hospital for a scheduled right total knee replacement (TKR). The procedure was performed. The patient progressed from sitting at the bedside, weight bearing as tolerated (WBAT) with a walker, and WBAT and with assistance. The patient was medicated as ordered. Use of an incentive spirometer was encouraged. The patient was seen by physical therapy (PT), occupational therapy (OT), and rehabilitation services. The patient was discharged.   

The medical record demonstrates a non-complicated post arthroplasty course. The procedure was of limited duration (Operative time approximately 1 1/2 hours). There was limited blood loss reported. No drain was required. Anesthesia handoff and Post Anesthesia Care Unit (PACU) were satisfactory. 

After the procedure, vital signs were stable with no evidence of bleeding. There were no problems with the wound. There were no delays in mobilization. There were no reported complications secondary to underlying medical conditions. Past medical history such as immunocompromised status, hypertension, psychiatric history, heart disease and elevated body mass index (BMI) were taken into account. 

The medical consultant made no recommendations for changes in drugs nor suggested additional testing. She was able to tolerate oral pain medications. The social worker reported that there was no problem with placement. 

There were no extenuating circumstances to substantiate the admission and length of stay at level provided.

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

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

Diagnosis: Hypertension
Treatment: Inpatient Hospital admission
The insurer denied the inpatient hospital admission.
The determination is overturned.

This is a patient with a history of hypertension, hyperlipidemia, obesity, who presented to the emergency department (ED) for evaluation of high blood pressure and a left sided headache. The patient's initial blood pressure was severely elevated at 190/100. A high sensitivity (HS) cardiac troponin was found to be elevated at 49.3 nanograms per liter (ng/l), peaking to 53 ng/l. An electrocardiogram (ECG) demonstrated sinus rhythm without ischemic changes. A chest x-ray was normal. A head computed tomography (CT) scan was normal without acute changes. The patient was admitted for evaluation and management of a hypertensive emergency. The patient was monitored on telemetry, given hydralazine 10 milligrams (mg) intravenous (IV), and the oral nifedipine dose was increased to 60 milligrams (mg) daily. The patient's symptoms improved, the blood pressure became controlled, and she was ruled out for acute coronary syndrome (ACS). The patient was discharged home the following day. At issue is the medical necessity of an inpatient stay.

An inpatient level of care was medically necessary and appropriate for evaluation and treatment of a hypertensive emergency and rule out acute coronary syndrome (ACS) given the patient's high cardiac troponin as recommended by the 2017 American College of Cardiology (ACC)/ American Heart Association (AHA) guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. Evaluation and treatment of this patient's hypertensive emergency under a lower level of care would not have been medically appropriate or safe in this case.
The patient presented with a symptomatic, severely elevated blood pressure with associated high cardiac troponin consistent with acute myocardial injury and evidence of target organ damage. Given the concerning presentation of a severe headache and high cardiac troponin, inpatient level of care was medically appropriate and necessary for telemetry monitoring, aggressive blood pressure management, and comprehensive evaluation for manifestations of target organ damage. Inpatient level of care was necessary to rule out acute coronary syndrome (ACS) with serial cardiac troponins as well as investigate for other manifestations of target organ damage as recommended by the 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults (1).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystic Fibrosis (CF)
Treatment: Airway clearance device (vest)
The insurer denied coverage for airway clearance device (vest)
The denial is overturned.

This is a child diagnosed with Cystic Fibrosis. The child is homozygous for the delta 508 mutation which is the most common mutation resulting in pancreatic insufficient CF. The child has been on treatment with pancreatic enzymes, famotidine (H2 blocker), pulmozyme and pancreatic enzymes. On a recent physical examination, the child was diagnosed with a pulmonary exacerbation of Cystic Fibrosis when noted to have audible rhonchi upon chest examination. The child has been cared for by her maternal grandparents who are foster care parents because her parents have been determined to be unable to provide adequate daily care for this medical illness.

The medical team has prescribed the Vest airway clearance system to provide daily chest physical therapy. Based on the experience, the medical record indicates that the child tolerates the treatments with the Vest and has benefitted from daily usage. 

The child has a history of Cystic Fibrosis which is a disease which places him at risk for chronic lung disease and bronchiectasis. Patients with Cystic Fibrosis have a shortened lifespan related to chronic infection and airway inflammation resulting from increased mucus accumulation in his airways. Airway clearance is an essential treatment that improves the quality of life and long-term outcome for children with CF. 

The Vest airway clearance device is considered an appropriate treatment for administering chest physical therapy in the home and it is known to be an effective therapy to improve health outcomes for children with Cystic Fibrosis. In addition, the Vest airway clearance device has been in widespread use throughout the United States by CF patients and is recognized as a standard of care for patients with Cystic fibrosis. The medical record does support the need for ongoing daily treatment with the Vest high frequency airway clearance device.

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 airway clearance device (vest) is overturned. Medical Necessity is substantiated.