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

Diagnosis: Dental Disorder.
Treatment: Adjustment of braces, insertion of braces, and retainer.
The insurer denied Adjustment of braces, insertion of braces, and retainer.
The determination is overturned.

The patient is a male with a Class I malocclusion and anterior crossbite of number (#)7. Tooth #26 is showing some recession. He is treatment planned for orthodontics to correct his malocclusion. At issue is the medical necessity of adjustment of braces, insertion of braces, and retainer.
The patient has significant maxillary anterior crowding with #7 in crossbite. This tooth has a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time (4), which will make treating this occlusion at a later time more difficult. Tooth #26 already has slight recession, and further movement of #26 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diverticulitis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The patient has a history of diverticulitis and presented with abdominal pain and loose bowels. The patient was given outpatient antibiotics but remained with symptoms. There was a previous history of a diverticular abscess. In the hospital the patient was afebrile, and the vital signs were stable. On examination there was tenderness in the left lower quadrant (LLQ) but no rebound or guarding. The white blood cell count (WBC) count was 11.3k. A computed tomography (CT) scan showed a long segment of diverticulitis, but no abscess was found. A branching colo-enteric fistula was present. The patient was now treated with IV Ceftriaxone and Metronidazole and placed on a clear liquid diet. There was a plan for an outpatient evaluation to consider a colon resection. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-150 for Acute Diverticulitis. Clinical indications for admission include having a significant abnormality on an imaging study. A fistula is considered to be a significant abnormality warranting admission. 

This patient has recurrent diverticulitis and has failed outpatient oral antibiotic therapy. The CT scan showed a long segment of diverticulitis including having a fistula. Since there was a fistula present, this met MCG guidelines for admission. The patient was treated with intravenous (IV) antibiotics. 

Based on the above, the insurer's denial must be reversed. 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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Dental issues
Dental/orthodontic

Diagnosis: Dental issues
Treatment: Surgical Extraction of Teeth 21 and 28 and Placement of Intra-Socket Dressing for Teeth 12, 21, 28 and 5
The insurer denied Surgical Extraction of Teeth 21 and 28 and Placement of Intra-Socket Dressing for Teeth 12, 21, 28 and 5
The health plan's determination is overturned in part. 

The patient is a young female with dental issues who has been denied Surgical Extraction of Teeth 21 and 28 and Placement of Intra-Socket Dressing for Teeth 12, 21, 28 and 5.

The Surgical Extraction of Teeth 21 and 28 is medically necessary for this patient. The patient is having braces and needs extractions. When there is inadequate space in the arch for all the teeth, extractions are needed to provide the available room to align the teeth. Orthodontic treatments commonly involve premolar extractions for providing space and are known as therapeutic extractions. Surgical Extraction of Teeth 21 and 28 is medically necessary.
The Placement of Intra-Socket Dressing for Teeth 12, 21, 28 and 5 is not medically necessary. A dressing in a socket is done to aid in hemostasis. There is no medical history and no justification from the provider that dressings are needed to provide additional hemostasis for this patient.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Skilled Nursing Facility

Diagnosis: Hip fracture
Treatment: Skilled Nursing facility stay
The insurer denied a skilled nursing facility stay.
The health plan's determination is upheld. 

This is a female patient with a history of atherosclerotic heart disease, hypertension, dementia, Parkinsonism, tremor, bladder and bowel incontinence, and acute traumatic transcervical right hip fracture. She previously lived alone in an apartment. The patient underwent a right hip closed reduction percutaneous pinning for a fracture after a fall at home. She was readmitted to the hospital for failing hip hardware and subsequently underwent a right hip hemiarthroplasty. She was admitted to a skilled nursing facility for rehabilitation. 

Continued Room and Board in a Skilled Nursing Facility is not medically necessary.
Although the patient has ongoing care needs and requires assistance with most activities of daily living, she does not meet requirements for ongoing care in a skilled nursing facility. She has been discharged by physical therapy and occupational therapy. Per physical therapy notes, the highest practical level of function has been achieved. She does not have any other medical needs that require care from trained medical or paramedical staff. The current level of care she is receiving is consistent with care typically received in the home setting with a personal care aide or in the setting of a nursing home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Patent foramen ovale

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult with a history of right posterior cerebral artery stroke and patent foramen ovale.  He presented to the hospital for elective transcatheter patent foramen ovale closure.  On arrival, vital signs were stable and physical examination revealed no abnormality. Electrocardiogram (ECG) demonstrated normal sinus rhythm without ST or T wave abnormality.  The patient underwent successful patent foramen ovale closure with an Amplatzer device under fluoroscopic and transesophageal echo guidance.  There were no perioperative complications. The patient remained hemodynamically stable. Transthoracic echocardiogram performed the following day, demonstrated a preserved left ventricular ejection fraction (LVEF) and an Amplatzer occlusion device positioned along the interatrial septum. The patient was discharged the day after presentation.

This patient underwent uncomplicated transcatheter closure of a patent foramen ovale. In a meta-analysis of 5 randomized clinical trials including over 1800 patients, patent foramen ovale closure reduced recurrent stroke or transient ischemic attacks (TIA) compared with medical therapy. In a more recent trial of 476 patients undergoing Patent Foramen Ovale Closure, more than 97% of patients were discharged on the day of their procedure. Full hospital inpatient admission was not medically necessary for this patient. The patient could have been managed at a lower level of care.

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

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) 24 Hours (split shift) Per Day 7Days Per Week
The insurer denied: Personal Care Aide (PCA) 24 Hours (split shift) Per Day 7Days Per Week
The denial is overturned.

The patient is an elderly male with a history of general debility due to dementia. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 24 hours per day live-in, 7 days per week to 24 hours per day split shift, 7 days per week based on Uniform Assessment System (UAS) of some months ago. The health plan denied the request because the patient is alert, oriented, and self-directing his care, with his need for assistance with toilet use, bathing, personal hygiene, and dressing remaining unchanged from the previous Uniform Assessment System. The additional hours requested are because of the patient's chronic medical conditions, and to help with his activities of daily living (ADLs) as he requires extensive assistance with most activities of daily living. A review of the records showed that the patient has multiple chronic medical conditions including dementia, coronary artery disease (CAD) status post angioplasty, colon cancer status post colon resection, peripheral vascular disease (PVD), hypertension, ischemic cardiomyopathy, hyperlipidemia, pain due to lumbar disease, kyphosis and traumatic left shoulder osteoarthritis, postural instability, blindness in one eye, bladder/bowel incontinence, and history of falls with high risk for falls. Uniform Assessment System - New York (UAS-NY) evaluation of some months ago showed that the patient is moderately cognitively impaired, with decisions consistently poor to unsafe at all times, required extensive assistance with phone use, personal hygiene, upper body dressing, bed mobility, eating, maximal assistance for managing medications, transportation, bathing, lower body dressing, walking, locomotion, toilet transfer, toilet use, and totally dependent for meal preparation, housework, managing finances, shopping, locomotion, toilet use, etc. The patient lives alone in a one-bedroom apartment.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 24 hours per day live-in, 7 days per week to 24 hours per day split shift, 7 days per week is medically necessary.

The requested hours are medically necessary because the patient is moderately cognitively impaired, with decisions consistently poor to unsafe at all times, and requires extensive assistance with phone use, personal hygiene, upper body dressing, bed mobility, eating, maximal assistance for managing medications, transportation, bathing, lower body dressing, walking, locomotion, toilet transfer, toilet use, and totally dependent for meal preparation, housework, managing finances, shopping, locomotion, and toilet use. The reason for denial by the health plan as stated in the clinical information above, does not align with the patient's disability features as stated in the Uniform Assessment System (UAS) of several months ago.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Liver disease.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient has a history of alcohol and intravenous (IV) drug abuse, squamous cell carcinoma of the leg, and diabetes. The patient presented with weakness. The patient was recently started on cemiplimab for the carcinoma. The cemiplimab had been stopped due to elevated liver enzymes. The patient was afebrile, and the vital signs were stable. The liver enzymes were elevated. Hepatitis C serology was positive, and the viral load was elevated. The hepatitis B core antibody was positive, although the Hepatitis B viral deoxyribonucleic acid (DNA) was not detected. The patient was treated with IV steroids for the possibility of immune mediated hepatitis. The patient was subsequently switched to oral steroids. A liver biopsy was performed. The bilirubin was 4.2, and the international normalized ratio (INR) was 1.23. The diabetes was treated. It was felt that the hepatitis was likely multifactorial, due to Hepatitis C, Hepatitis B reactivation, and immune checkpoint inhibitor autoimmune hepatitis. There was improvement in the liver enzymes and a plan to treat Hepatitis C with Epclusa. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-570 for Liver Disease. Clinical indications for admission include having acute liver failure with an INR over 1.5 and hepatic encephalopathy, moderate to severe hepatic encephalopathy, cirrhosis with an acute exacerbation, infected ascites, hepatorenal syndrome, portal or splenic vein thrombosis, and the need for a drainage procedure of the liver. The patient did not have these conditions. 

This patient developed hepatitis and was found to have an elevated viral load for Hepatitis C. There was also a concern that the patient had an autoimmune component of the hepatitis from being on cemiplimab. However, the patient was not in acute liver failure. The INR remained under 1.5, and the patient did not have encephalopathy. The patient underwent an extensive workup including a liver biopsy, but this could have been done on an outpatient basis. The hepatitis C treatment with Epclusa will be done as an outpatient, and she could have been given outpatient steroids. The patient did not meet MCG (Milliman Care Guidelines) criteria for admission for Liver Disease. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was 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 hospital admission 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 is the case of a patient who presented to the hospital complaining of chest pain and lightheadedness on exertion. The patient presented with symptoms like those assessed at another hospital three days earlier. The work-up included a stress test (ST) that revealed a perfusion abnormality. On arrival at the hospital, vital signs were stable (blood pressure [BP] 168/87, heart rate [HR] 60). Physical examination revealed no significant abnormality. The 12-lead electrocardiogram (ECG) demonstrated normal sinus rhythm with T wave inversions in the inferior leads and precordial leads V4-V6. Serum blood testing did demonstrate mild transaminase elevations (aspartate transferase [AST] 70, alanine aminotransferase [ALT] 80) and no elevation in troponin. The hospital admitted the patient for medical treatment. The echocardiogram demonstrated normal left ventricular ejection fraction (LVEF) without wall motion abnormalities. Cardiac catheterization was performed due to recurrent chest pain and a positive stress test, and non-obstructive coronary artery disease was noted. The patient received medical therapy.

The health plan acted reasonably and with sound medical judgment in the patient's best interest. This patient presented with chest pain and lightheadedness with exertion. Attempts to treat symptoms with medical therapy following a positive stress test were not successful. The patient's pretest probability of coronary artery disease is intermediate (1) Utilizing the History, ECG, Age, Risk Factors, Troponin (HEART) score, the patient was considered intermediate risk. (2) Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (3) Using the HEART score risk stratification schema; this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation. Cardiac catheterization was warranted and could have transpired within 24 hours of presentation. In conclusion, admission to the hospital was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. 

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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This adult male was hospitalized for chest pain. He presented to the emergency department for evaluation following abrupt onset of back pain with radiation anteriorly to his left chest. His past medical history included known coronary artery disease by
cardiac catheterization showing borderline instantaneous wave-free ratio (iFR) lesion in the mid left anterior descending (LAD). The patient's vitals were stable. Other than a heart rate of 52, troponin panel was negative, electrocardiogram (EKG) showed sinus bradycardia, chest film was unremarkable, and a chest computed tomography angiogram (CTA) was negative for acute aortic dissection. The clinical impression was noncardiac chest pain and musculoskeletal related. The requested coverage for Inpatient Hospital Admission was denied according to Plan policy and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer reviewed medical literature, including 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 for musculoskeletal (MSK) chest pain like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the standard of care, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental malocclusion,

Treatment: D8080 braces/comprehensive orthodontic treatment of the adolescent dentition.

The insurer denied coverage for D8080 braces/comprehensive orthodontic treatment of the adolescent dentition.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, and anterior crowding, and has recommended orthodontics. The orthodontist has completed the Handicapping Labiolingual Index (HLD) index attaining 29 total points to support orthodontic care. 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 15 points by internal reviewers.

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, as of September 1, 2012, 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 does not claim an automatic qualifying condition and completes the second portion of the index arriving at 29 points to justify orthodontic care. This reviewer concurs with the index completed by the insurer attaining a total of 15 points on the Handicapping Labiolingual Index (HLD) index (5 overjet, 3 overbites, 5 anterior crowdings, 2 labiolingual spread) which is below 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 needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic needs.

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 D8080 braces/comprehensive orthodontic treatment of the adolescent dentition is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sore throat
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

According to the medical records, the patient is an adult male. He presented with a sore throat. There is a prior history of peritonsillar abscess in college. The pain was rated 8/10 and was noted to be progressively worsening. Oral intake was not possible due to the pain, and foods were becoming stuck in his throat. The patient was admitted for IV (intravenous) fluids and antibiotics. His pain improved over time, and his white count decreased. Imaging was performed and showed tonsil enlargement and pharyngeal edema. An ENT (otolaryngology) consultation was performed. He was diagnosed with sepsis and acute pharyngitis. It was recommended that he have outpatient follow-up for possible tonsillectomy.

The inpatient admission was medically necessary.

The patient was diagnosed with pharyngitis and sepsis. These findings were corroborated using lab work, vitals, and CT (computed tomography) scans. He also had the inability to tolerate oral intake. Admission allows for hydration, imaging, monitoring of symptoms, and assurance of improvement after consultation acutely with consultants.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pharyngeal bleeding
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

Per clinical documentation, this adult patient was transferred from an outside hospital due to bleeding from a pharyngeal mass. He underwent groin access for embolization of the facial artery. There were no reported complications. Admission is indicated for inpatient monitoring that requires vital signs, neurologic signs, or vascular checks more frequently than every four hours. Hemostasis was achieved and there was no further bleeding. There is no indication of frequent monitoring of vital signs or bleeding status. 

Secondary epistaxis generally involves neoplastic sites within the nasopharynx. Bleeding may arise from the tumor due to erosion of vascular structures which are invaded, or due to tumor necrosis in those who have responded to treatment. The bleeding may occur in those with complete remission as a result of irradiation-induced damage that may be promoted by osteoradionecrosis or the tracheostomy cannula. Endovascular treatment is an option for treatment. There is a risk of rebleeding particularly in patients with hemorrhagic telangiectasias.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for inpatient hospital services is not substantiated.