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

Diagnosis: Knee pain
Treatment: Knee surgery (procedure codes 27331 and 27334) rendered
The insurer denied coverage for knee surgery (procedure codes 27331 and 27334) rendered
The denial is overturned

This is a patient with a history of left knee pain. The patient's magnetic resonance imaging (MRI) of the left knee demonstrated lobulated fatty lesion with peripheral hypointense rim within the Hoffa's fat pad; synovial lipoma and osteochondral body were considered, minimal joint effusion and trace popliteal cyst.

In the insurer's Final Adverse Determination letter, they write that they have approved procedure code 27331 but have upheld the denial on procedure code 27334. The knee surgery (procedure codes 27331 and 27334) rendered is considered medically necessary for this patient.

The medical record was consistent to substantiate the procedure. Surgery is indicated when there is a defined pain generator. A course of conservative treatment should first be provided and there should be functional limitation. 

The records show a mass was present in the fat pad. There were reports of problems kneeling and bending the knee. There was a report of Physical Therapy (PT) and other conservative treatment not being effective. The size of the mass likely would result in mechanical limitations. It was almost 2 centimeters (cm) which would prevent normal knee motion. The patient was found to have lost the last 5 degrees of extension. This would be likely as the mass would prevent full knee mobilization. 

Additional conservative treatment would not provide resolution. The most appropriate step would be surgical excision.

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 knee surgery (procedure codes 27331 and 27334) rendered is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: D8080 braces; D8670 monthly visit x 12

The insurer denied coverage for D8080 braces; D8670 monthly visit x 12

The denial is overturned

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radio graph) montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence) it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite, and anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report attaining 28 total points. 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 attaining only 19 points on the HLD index by internal reviewers.

Upon review of the submitted documentation it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation. Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation lndex. 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 second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care. 
Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 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; D8670 monthly visit x 12 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain/vomiting. 
Treatment: Inpatient Stay. 

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

The case involves a woman with a history of cannabis use who presented to the hospital with mid-epigastric pain and vomiting for three days. She experienced palpitations and dizziness. She continued to use cannabis frequently before hospitalization. Psychosocial stressors were present related to work. 

The requested inpatient hospital admission is medically necessary for this patient. The patient has been severely dehydrated due to hyperemesis for three days. The patient has developed a multitude of electrolyte derangements, unstable vital signs, and generally poor clinical appearance. The symptoms did not rapidly improve in the observation timeframe, with persistent acidosis, inability to tolerate food and liquids, and ongoing need for intravenous (IV) fluid resuscitation. To ensure no further deterioration, the patient required frequent monitoring of labs, correction of electrolytes, and telemetry monitoring.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Kidney Stone
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned

The patient is an adult female with a history of bilateral renal calculi. The patient had successful lithotripsy of right renal calculus but developed sudden left flank pain and vomiting. The patient was seen on where notes indicate left renal colic, flank pain and vomiting with the patient placed on Percocet, ondansetron, urocit k, cephalexin and levofloxacin. Records indicate that the previously noted seven millimeter left renal stone was now in the proximal ureter along with residual two left renal stones. The patient was to proceed with another extracorporeal shock wave lithotripsy (ESWL), continue Flomax, pain medications and antibiotics in the interim. Serum creatinine was 1.37. 

The patient presented to emergency department with complaint of left flank pain ongoing for four to five days associated with multiple episodes of vomiting. Serum creatinine was 1.12, white blood cell count was 8.96, urinalysis had three white blood cells, seven red blood cells, and was positive for bacteria. Computed tomography demonstrated mild to moderate left hydroureteronephrosis secondary to a seven-millimeter stone in the distal third of the ureter. The patient was admitted due to pain, nausea, vomiting and acute kidney injury. The admission was denied as not meeting criteria for medical necessity.

The proposed inpatient hospital admission was medically necessary.

This patient was identified to have a symptomatic left ureteral calculus. The patient had persistent nausea, vomiting and pain prompting despite pain medication and ondansetron use to treat the nausea and vomiting, and Flomax. Her creatinine was noted to be elevated at 1.37. Due to increased pain, nausea and vomiting present, the patient presented to the emergency department where an obstructing stone was noted, urinalysis was suspicious for urinary tract infection and creatinine was elevated at 1.12. Given the failure to achieve pain control and management of the nausea and vomiting at the admission, inpatient admission is considered consistent with generally accepted standards of care as is urgent treatment of obstructing stones in the presence of a suspected urinary tract infection. The 
Canadian Urological Association (CUA) guidelines note "Spontaneous passage of stones less than 5 mm in size in the distal ureter have a >(greater then) 90%(percent) chance of spontaneous passage within 40 days and are appropriate for an attempt at conservative management provided there are no infectious symptoms, intolerable patient symptoms or a threat to renal function." An obstructing ureteral stone in the setting of infection constitutes a requirement for urgent urologic treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain and Knee Pain (Sickle Cell Crisis). 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient in this case is an adult male with sickle cell anemia. He presented to the emergency department with the complaint of back pain and bilateral knee pain. He had been seen in the emergency department the prior night with the same complaint and he noted that the pain continued. 
The patient's exam was notable for tenderness of both knees and tenderness of the lumbar spine. His symptoms were felt to be less likely due to pain crisis and more likely due to opioid dependence. He was admitted to the hospital and treated with narcotic pain medications, including subcutaneous Dilaudid. Records note that the patient had persistent pain despite two doses of Dilaudid in the emergency department. Intravenous access could not be obtained. Labs were notable for a hemoglobin of 6.1 grams per deciliter (g/dl). The patient was treated with pain medication and fluids and was not transfused. Vital signs were unremarkable. The patient was discharged 3 days later. He asked to leave as he had plans to celebrate with his family. 

The proposed inpatient hospital admission was not medically necessary. 

This patient was admitted for pain. He did not have hemodynamic instability and there was no sign of sepsis, acute kidney injury or any other acute process. He did not have hypoxia, chest pain or acute chest syndrome. He was treated with pain medications and asked to leave after three days. He did not require acute care inpatient admission. He could have been treated with pain medication at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with complaints of abdominal pain. She also had nausea and vomiting. A computed tomography (CT) scan of the abdomen in the emergency room (ER) showed a hemoperitoneum from a likely ruptured right ovarian cyst. The patient's hemoglobin was 6.8 and she was transfused 2 units of packed red blood cells (PRBCs). She had a laparoscopic procedure and the estimated blood loss was 650 cubic centimeters (ccs). She had a postoperative complication of noncardiogenic pulmonary edema requiring continuous positive airway pressure (CPAP) and Lasix. She was discharged in stable condition. At issue is the medical necessity of an inpatient admission.

The requested health service/treatment of inpatient stay is medically necessary for this patient.
The patient had a rupture ovarian cyst and required surgery. Normally this would be an outpatient procedure with discharge home in less than 24 hours, however, this particular patient required additional oxygen and diuretics secondary to a diagnosis of pulmonary edema. Pulmonary edema is a life-threatening condition requiring acute, inpatient monitoring and a complication of her condition. She also was hemodynamically unstable with a hemorrhage and a hemoglobin of 6.8. She required a transfusion and acute inpatient monitoring with this. Based on her tachycardia, cardiogenic issues and pulmonary complications, acute inpatient monitoring was standard of care, although she rapidly improved and was discharged the following day. Inpatient admission was necessary and reasonable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Early-stage prostate cancer
Treatment: Genetic Testing of Prostate Tissue with Oncotype DX
The insurer denied: Genetic Testing of Prostate Tissue with Oncotype DX
The denial is upheld

The patient in this case is an adult male diagnosed with early-stage prostate cancer. PSA (prostate specific antigen) was less than 10, and Gleason Sum was 3+(plus)4=(equal) 7. An Oncotype DX Prostate Cancer test was done.

The Genetic Testing of Prostate Tissue with Oncotype DX was not medically necessary.

Oncotype DX Prostate Cancer is a gene expression assay performed to assess the likelihood of finding high-risk pathology at the time of radical prostatectomy. There is no evidence showing that this test can improve health outcomes in men diagnosed with early-stage prostate cancer. It is not currently considered a routine standard of care test in men diagnosed with early-stage prostate cancer. Given these considerations, this test was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld.

This adult female was hospitalized for chest pain. Her past medical history is significant for known mild coronary artery disease (CAD) by prior cardiac catheterization with coronary angiography demonstrating luminal irregularities and gastroesophageal reflux disease (GERD). The patient's vital signs were stable. There are no documented troponin or cardiac arrhythmias. The clinical impression was possible microvascular angina. Cardiac magnetic resonance image (MRI) was recommended, but by the next day, the patient left against medical advice (AMA). The request for coverage for acute inpatient hospitalization has been denied, 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) guidelines 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 a rule out acute coronary syndrome (ACS) / acute myocardial infarction (AMI) protocol and recommendation to have a cardiac magnetic resonance image to assess for 
possible microvascular angina 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:  Cholecystitis.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

This is a female patient who presented to the emergency department with right upper quadrant (RUQ) pain. She had 3 previous episodes of biliary colic. She reported that the pain was 10/10. She had no nausea or vomiting. The examination demonstrated a positive Murphy's sign. Lab results demonstrated a white blood cell count (WBC) of 14.3. An ultrasound of the right upper quadrant demonstrated a distended gallbladder with layering stones. The patient was made nothing by mouth (NPO) and started on intravenous (IV) fluids. She was given 2 grams of cefoxitin. The patient was scheduled for surgery and underwent a laparoscopic cholecystectomy without complications the day after admission. The patient was discharged home later that day. The pathology demonstrated chronic cholecystitis and cholelithiasis. At issue is the medical necessity of an inpatient stay.

The patient's admission was not medically necessary at the inpatient level of care for the entire admission. The patient underwent a laparoscopic cholecystectomy without complications. Per the Milliman Care Guidelines (MCG), inpatient admission is indicated for acute cholangitis, acute cholecystitis when cholecystectomy is not anticipated, and for calculous or obstruction of the gallbladder with certain complications. The patient does not meet criteria for acute cholangitis, as this requires systemic signs of inflammation and evidence of common bile duct disease. The patient does not meet criteria for acute cholecystitis with signs of systemic inflammation or where cholecystectomy is not anticipated. The patient did not have a fever, C-reactive protein elevation or white blood cell count elevation. The patient does not meet criteria for calculous or obstruction of the gallbladder or bile duct with hemodynamic instability, common bile duct obstruction, vomiting that is severe or persistent, severe pain requiring acute inpatient management, bacteremia. The patient also does not meet MCG criteria for undiagnosed abdominal pain which requires hemodynamic instability, severe pain, peritoneal signs, identification of an etiology that requires inpatient care, NPO status greater than (>) 24 hours requiring significant IV fluid support, suspected toxic megacolon, bacteremia, procedure that cannot be performed on ambulatory basis, parenteral nutrition. The documentation does not suggest that the patient's care could not have been performed at a lower-level care. There is no evidence that additional complex testing or therapy other than the procedure was performed. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. While the patient appears to have chronic cholecystitis, she does not appear to have utilized hospital services at the inpatient level of care. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose Veins
Treatment: Endovascular Embolization (36465)
The insurer denied: Endovascular Embolization (36465)
The denial is upheld.

The patient is an elderly female. The patient presented with bilateral symptomatic varicose vein disease. She had failed a trial of compression stockings. Her symptoms were severe enough to interfere with normal function. Reflux testing showed bilateral great saphenous vein (GSV) and short saphenous vein (SSV) enlargement and incompetence. The right anterior accessory vein also had reflux.

The patient underwent right anterior accessory Varithena closure. Coverage of this procedure was denied by the health plan. The medical records do not show that any other vein intervention was done. The denial is being appealed.

The Endovascular Embolization (36465) was not medically necessary.

The standard of care for a patient such as this would indicate GSV (great saphenous vein) closure in the right leg because of symptoms that can be reasonably attributed to varicose vein disease and the symptoms adversely affected normal function; failed a trial of compression stockings; and duplex-proven reflux of the GSV (great saphenous vein).

However, rather than treat the GSV (great saphenous vein), the provider treated only the anterior accessory vein. It is not appropriate to treat the anterior accessory vein in an isolated fashion when the patient has severe GSV (great saphenous vein) reflux. Appropriate strategies when patients have reflux in both GSV (great saphenous vein) and anterior accessory vein are: (a) ablate the GSV (great saphenous vein) and later treat the accessory vein if the patient has residual symptoms; or (b) ablate both GSV (great saphenous vein) and accessory vein at the same setting.

Because the provider performed isolated anterior accessory closure, the procedure was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: HIV (human immunodeficiency virus), opioid dependence gait disorder, hepatitis C, polyneuropathy, and anxiety disorder
Treatment: Continued Long Term Custodial Care
The insurer denied the Continued Long Term Custodial Care
The denial is upheld.

The patient is an adult female with HIV (human immunodeficiency virus), opioid dependence gait disorder, hepatitis C, polyneuropathy, and anxiety disorder. The request is for continued Long Term Custodial Care Service. A Patient Review Instrument (PRI) notes that the patient requires intermittent supervision/minimal physical assistance with eating; wheels with no supervision or assistance; requires one person to assist with transfers but can participate; is continent of bowel and bladder and requires supervision for toileting. Physical therapy notes the need for minimal to contact guard assistance for toilet transfer. Notes indicate that she can propel 75 feet in her wheelchair. Documentation from psychiatry indicates "no profound depression" with insight and judgement at baseline. The patient was discharged to the community.

The health plan approved coverage of the request for Long Term Custodial Care for 5 weeks but denied coverage of continued Long Term Custodial Care onward, noting that the patient could perform many activities of daily living and direct their care. The denial notes that the patient will have personal care services and equipment to meet their needs in the community.

The denial was appealed, and the plan upheld the denial of the Long-Term Custodial Care onward, noting that the patient's needs could adequately be managed at a different level of care such as outpatient or home care program.

An appeal letter notes that the patient is wheelchair bound and has limited support in the community and requires extensive 24/7 assistance with activities of daily living. The letter notes that she is a fall risk and has a history of depression.

The Continued Long Term Custodial Care was not medically necessary.

The documentation does not reflect clinical findings that support the need for Long Term Custodial Care onward. While the appeal documentation argues that the patient requires 24/7 care, the documentation notes that the patient is able to accomplish many of her activities of daily living with minimal assistance, including toileting, eating and dressing. She is able to transfer with assistance. The psychiatry documentation does not reveal any severe behavioral concerns. Based on the documentation, the patient's needs could be met with personal care services, safety equipment, and physical therapy in the community setting. The medical literature does not suggest a significant difference in outcomes between long-term custodial care and community care with appropriate services (Denham 2018). Thus, Long Term Custodial Care after the initially approved 5 weeks was not medically necessary.