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

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

This is an adult female who presented to the hospital with complaints of dizziness, beginning the previous day with trouble walking. It was noted dizziness was worse with laying down or turning over and could last several minutes before resolving. The patient denied ear pain, hearing loss, or ear trauma. Dizziness had resolved at the time the patient was seen by Otolaryngology. The patient complained of associated nausea and headaches. Examination on presentation revealed normal general, eye, ear, nose, and throat, cardiovascular, respiratory, musculoskeletal, abdominal, genitourinary, extremity, cranial nerve, motor, sensory, and cerebellar examinations. A head computed tomography (CT) scan performed on presentation revealed a nonspecific subtle mild linear hypodensity in the right frontal lobe, similar compared with the prior CT scan. A CT angiography revealed no large vessel stenosis or occlusion. Troponins were normal. The patient was seen by Neurology and Otolaryngology services. 

This patient presented with headache, vertigo, and gait and headache, vertigo, and ataxia. Stroke and other acute intracranial processes required exclusion, as did myocardial infarction. Myocardial infarction was ruled out with troponins. A head computed tomography (CT) scan and CT angiography ruled out vascular occlusion and a large intracranial mass. A brain magnetic resonance imaging (MRI) was also performed and did not reveal any acute pathology. Once an acute intracranial abnormality and myocardial infarction were ruled out, the patient could have been discharged with plans for further evaluation that may include an echocardiogram, as an outpatient. There was no evidence of hypertension or hypotension requiring intensive pharmacological management. There was no need for hemodynamic monitoring. The patient underwent cardiac telemetry which was negative. This could have been performed in the emergency department or observation setting.

By the time of presentation, the patient did not require any frequent neurochecks. There is no need for any longer-term cardiac monitoring. There is no need for any pulmonary monitoring. The head CT (computed tomography) scan and CT angiography, the rule out of myocardial infarction and the brain MRI (magnetic resonance imaging) could have been performed in the emergency department or observation setting, and there were no acute inpatient hospital needs. There is therefore no medical necessity for acute inpatient hospitalization.

"This concise review of the epidemiology, pathophysiology, evaluation, acute management, and prevention of ischemic stroke targets internists, family practitioners, and emergency physicians who manage patient with stroke."(Feske S. K., et al.)

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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth Fracture

Treatment: Crown (D2740) for teeth numbers 2 and 15

The insurer denied coverage for crown (D2740) for teeth numbers 2 and 15

The denial is upheld 

The insurer has denied coverage for a crown (D2740) for teeth numbers 2 and 15. In their Final Adverse Determination letter, they write that the patient tooth is fractured, and they do not want an extraction. To approve this service the patient must have very few teeth in the back. They need to have less than 8 teeth in the back (upper and lower) that touch when they bite or chew. The patient has 8 molars, bicuspids, and or partial denture teeth that touch when biting down and when chewing (upper and lower teeth).  

The patient is appealing. 

Upon review of the documentation provided which includes copies of periapical and bitewing radiographs, dental charting and insurer correspondence, it appears that this patient presented to the dentist for comprehensive care. The treating dentist recommended crowns for teeth #2 and 15. The insurer has denied these services stating the clinical findings do not support the recommended treatment and therefore the services do not meet medical necessity criteria. The patient is appealing.

The objective documentation provided for review is periapical and bitewing radiographs. It appears that there is no evidence of fracture or other pathology specifically affecting #2 or 15 based on the images provided for review. There does not appear to be any radiographic evidence of caries. There does not appear to be any structural or pathologic issue associated with the existing crowns on #2 or 15. The radiographs do not substantiate the requested dental services as enumerated above and therefore they are not medically necessary.

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 a crown (D2740) for teeth numbers 2 and 15 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness. 
Treatment: Inpatient stay admission. 
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a woman with known Bell's palsy, affecting her left side, undergoing Botox treatments. She was seen in the emergency department for generalized weakness to left upper and left lower extremities. Additional symptoms included mild intermittent dizziness for three days, waxing and waning. She denied headaches, trauma, fevers, or chills. No other past medical history was reported. Examination showed no acute distress, 4 out of 5 strength in the left upper extremity and left lower extremity, and 5 out of 5 in the right upper extremity. The emergency department (ED) documented pronator drift. The stroke team was called to assess the patient and ordered a brain computed tomography (CT) angiogram of the neck, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and labs. 

Based on the provided documentation, inpatient admission was not medically necessary. The patient was ruled out for an acute stroke and diagnosed with a complex migraine headache that resolved with migraine cocktail treatment within 24 hours of presentation. This type of presentation can be managed at a lower level of care.
Although the patient has some findings concerning a stroke, the imaging studies disproved the presence of a stroke. There was no hemodynamic instability, and the patient is at relatively low risk for stroke suspicion, given the lack of past medical history of hypertension, diabetes, cardiovascular disease, and peripheral vascular disease. Therefore, in the absence of radiographically diagnosed stroke, a rapid resolution of the symptoms after administration of a migraine cocktail, the presentation favors a non-stroke diagnosis, and therefore an inpatient admission is not indicated. The final diagnosis is complex migraine, which based on the documentation, cannot be construed as intractable to require inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who had a spontaneous abortion and was treated also for a urinary tract infection (UTI). She said she took medications for 3 days but lost the bottle. She presented to the emergency room (ER)  with complaints of a headache, fever, body aches and abdominal pain.  On exam, she was noted to have bilateral costovertebral angle tenderness and rest of exam was normal. The diagnosis was made of systemic inflammatory response syndrome (SIRS) due to a urinary tract infection (UTI) versus (vs) endometritis vs upper respiratory infection (URI). She was started on Cefepime and Flagyl as well as intravenous fluids (IVF). Cultures were drawn and she was subsequently admitted. She was reviewed by gynecology, a transvaginal ultrasound (US), showed absence of the previously intrauterine saclike structure seen on a previous ultrasound (US) consistent with complete abortion. A gynecologist felt that the patient likely had pyelonephritis and not sepsis secondary to recent abortion, By the following day, the patient was afebrile and hemodynamically stable. She was subsequently discharged on oral antibiotics. The plan denied hospitalization at an inpatient level care. At issue is the medical necessity of an inpatient admission.
An inpatient admission was not medically necessary. A review of records shows that the member was initially seen after a spontaneous abortion and treated for a urinary tract infection (UTI) but lost her prescription after taking the medications for a few days. Except for tachycardia, her vital signs were stable and she had no hemodynamic instability. She had a normal white blood cell count (WBC), no acute kidney injury (AKI), had no vomiting or diarrhea or altered mentation. She was started on appropriate antibiotics and seen by gynecology (GYN) who concluded that she had no evidence of sepsis related to the abortion. She did not require any invasive procedure and was improved during the observation period and subsequently discharged. As a result of the above, care and management could have been safely and appropriately rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visit x (times) 12
The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.
The denial is overturned.

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 impacted canine and premolar among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the Handicapping Labio-Lingual Deviations (HLD) index. 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 Handicapping Labio-Lingual Deviations (HLD) index by internal reviewers attaining a score of 4 points. 

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 completes the Handicapping Labio-Lingual Deviations (HLD) index, choosing the impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance as documented meets this criterion for approval of 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. 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 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 D8080 braces and D8670 monthly visit x (times) 12 services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Complex eyelid and orbit defect. 
Treatment: Inpatient stay. 
The insurer denied coverage for the inpatient stay. 
The denial is overturned.  

The patient underwent sentinel lymph node biopsy and reconstruction of a complex eyelid and orbit defect.  Although there were no documented complications from the surgery, the patient's history and surgery are complex, and thus the inpatient admission was medically necessary to monitor post-operative status given extensive surgical procedure and patient's comorbid conditions. 

The patient meets the Milliman Care Guidelines (MCG) criteria for ambulatory surgery exception because the patient required a complex surgical approach and that situation indicated by unusually a difficult procedure because of previous operation for invasive sebaceous carcinoma and extensive reconstruction, and the procedure indicated a need for longer than usual postoperative care and monitoring. 

The inpatient admission is considered medically necessary for this patient. The patient has a complex history of sebaceous carcinoma of the left eyelid with lymphovascular invasion, necessitating a complex procedure of lymph node biopsy and reconstruction of a complex eyelid and orbit defect. Because of extensive procedure required for the reconstruction, which includes grafting, this is considered a complex surgery that requires a longer recovery after surgery than usually expected for a same-day ambulatory procedure. Thus, the inpatient admission is medically necessary for this patient.

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult female who presented to the hospital with periumbilical abdominal pain, fever, chills, general body aches. She was found to have a urinary tract infection. Patient's computed tomography scan revealed edematous left kidney and ureter possibly related to a recently passed ureteral stone vs pyelonephritis. She improved, her white blood cell count came down, had no fever spikes. She was stable for discharge home on a course of oral antibiotics. The insurer has denied the acute inpatient hospital admission as not medically necessary. The appeal by the hospital is noted and read in detail. Per Milliman Care Guidelines (MCG) Health (26th) Urinary Tract Infection (UTI) RRG, patient fails to meet clinical indications for admission to inpatient care. These include hemodynamic instability, altered mental status that is severe or persistent, persistence worsening of clinical findings despite observation care, etc., ureteral  obstruction, renal or perinephric abscess, significantly immunocompromised status, etc.

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



Diagnosis: dental issues
Treatment: Porcelain Crown (Tooth 19) 
The insurer denied Porcelain Crown (Tooth 19). 
The health plan's determination is overturned. 

The patient is a female who presents for the treatment of tooth # (number) 19 with (D2740) porcelain crown. Provided for review are health plan language, clinical notes, clinical images, radiographic images, and claim forms for review. 

The Porcelain Crown (Tooth 19) is medically necessary for this patient. As the tooth currently has a failed restoration which already covers 3/4 of the tooth, a direct restoration is no longer possible as the tooth requires cuspal coverage. With the need for cuspal coverage, only an indirect lab fabricated prosthesis such as a porcelain crown can be used to restore the tooth. Hence, the porcelain crown for tooth #19 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System.
Skilled Nursing Facility.

Diagnosis: cerebral vascular accident.
Treatment: Skilled Nursing Facility.
The insurer denied continued Skilled Nursing Facility stay. 
The health plan's determination is overturned. 

This is a female with congestive heart failure (CHF), coronary artery disease (CAD), cardiogenic shock, implantable cardioverter defibrillator (ICD), diabetes mellitus (DM), and cerebrovascular accident (CVA) left hemiplegia who was admitted for Skilled Nursing Facility (SNF) level care. 

Skilled Nursing Facility (SNF) Subacute Rehabilitation Level 1 is medically necessary for this patient.
The patient has left hemiplegia with multiple comorbidities and functional deficits. She is making slow progress in therapy. She completed speech therapy, and it is discontinued. In physical and occupational therapy, she is making functional progress. Her transfers are modA (moderate assistance) and ambulation modA. She can progress to a minA (minimum assistance) level with continued therapy. Her activities of daily living (ADL) are mostly modA with maxA (maximum assistance) toileting. She can progress to a minA level with ADL's with continued therapy. The patient is motivated and cooperative in therapy. Continued SNF is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism

Treatment: Personal Care Assistance services for a total of 25 hours per week

The insurer denied coverage for Personal Care Assistance services for a total of 25 hours per week

The denial is upheld

 
The patient has been diagnosed with autism, and mixed expressive and receptive language deficits. It is noted the patient is currently taking medications for behavioral issues. It is noted that due to these issues, the patient requires home health aide. It is noted the patient can gesture to express needs and lives with a parent and sibling.

An assessment indicated the patient has no difficulty in normal conversation or social interaction and the patient was able to express herself and understand questions appropriately without difficulty. The most recent Uniform Assessment System (UAS) stated the patient is able to walk at least 150 - 299 feet without assistance. The patient did not cooperate with the Mini mental state exam. According to a recent physician progress note the patient attends school, and has an occasional manageable outburst related to autism.  She is employed outside of the home.

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

Personal Care Assistance services for a total of 25 hours per week is not considered medically necessary for this patient.

There is no clear need, or objective deficits that would justify this level of care above supervision and care, which can be provided by the family. As such, the request is denied.

"When friends and family are unavailable or unable to care for homebound loved ones, primary care often deploys Home and Community Based Services, including home health aides. For these homebound older adults, home health aides are essential to help preserve an independent life at home and avoid nursing home care" (D'Cruz, L., et al. 2022).

To ensure optimal outcomes, decisions on and the delivery of health care services must focus on the child and family; be individualized to meet the child's needs; and cut across fragmented settings and service sectors to improve the child's health, functioning, and quality of life." (National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Care Services; Committee on Improving Health Outcomes for Children with Disabilities. 2018).                                                         

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 Assistance services for a total of 25 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal uterine bleeding.
Treatment: Hysterectomy (surgery to remove the uterus and the ovaries and/or fallopian tubes, procedure code 58571).

The insurer denied coverage for hysterectomy (surgery to remove the uterus and the ovaries and/or fallopian tubes, procedure code 58571).  The denial is upheld. 

The patient is an adult with a history of abnormal uterine bleeding (AUB). The patient reported that periods typically last from 4-8 days. The patient reported experiencing clotting during menstruation and cramps. Coverage was requested for a hysterectomy.

The patient had an ultrasound that did not show any anomaly. 

The provider reported that the patient is complaining of menopausal symptoms and recommended hormonal pellets (Testosterone and estrogen). Her laboratory evaluation was not consistent with menopause.

Endometrial biopsy was normal. Pap smear was normal. Hematocrit was 42.1.

It is not clear that this patient has any issue with bleeding. Her hematocrit was excellent (42.1). Ultrasound did not show any thick or abnormal endometrium. The biopsy was benign. The patient was said to be menopausal and was placed on estrogen pellets even though her laboratory evaluation did not show any evidence of menopause. It is unclear why the patient is on testosterone.

In addition, bleeding could be due to the estrogen pellets this patient is receiving.  Note that this patient bleeding has not been addressed. There is no evidence that the patient has undergone any treatment for her heavy bleeding: hormonal treatments, Progestins, Levonorgestrel intrauterine device (IUD), Tranexamic acid, endometrial ablation. 

Based on the submitted information, there is no indication for a hysterectomy.

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 hysterectomy (surgery to remove the uterus and the ovaries and/or fallopian tubes, procedure code 58571) is not substantiated.