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

Diagnosis: Missing tooth
Treatment: False Tooth-Shaped Cap for Tooth number 14 and Tooth Shaped Cap for Bridge for Teeth number 13 and number 15

The insurer denied: False Tooth-Shaped Cap for Tooth number 14 and Tooth Shaped Cap for Bridge for Teeth number 13 and number 15

The denial is overturned.

The patient is an adult male. The request is for a three-unit upper left bridge to replace missing tooth number14. The health plan denied coverage of the request as not medically necessary. The denial is being appealed.

The requested health service is medically necessary.

The patient is missing tooth number 14 (upper left first molar). There is no other edentulous space in the upper arch. This means there is no other area of his top teeth where he is missing a tooth. To have a partial denture, which is the only option allowed, when there is only one tooth on the denture, is not the correct choice. In order to hold up the one denture tooth, the partial denture needs to cross the palate and anchor on the right side for stability. This is a lot of material, plastic and metal, to place in the mouth for only one tooth. By crossing over the palate, it will definitely interfere with eating as the taste, texture and temperature of the food will be affected. A three-tooth fixed bridge going from tooth 13 to 15 is the correct conservative treatment in this case.  The health plan's denial is not appropriate, and the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Frontal sinus anterior table fracture
Treatment: Inpatient hospital services
The insurer denied coverage for inpatient hospital services.
The denial is overturned.

This is an adult with a history of left frontal sinus fracture as a result of an assault. Anesthesia pre procedural note indicated no relevant active problems for this patient. The American Society of Anesthesia (ASA) score was 2. Otolaryngology History and Physical indicated the patient had a history of trauma to face resulting in an open depressed left frontal sinus anterior table fracture. Laceration was repaired by outside emergency department (ED) at the time of injury. The patient was evaluated in Ear, Nose and Throat (ENT) clinic where there was pain and deformity with no facial numbness or weakness or rhinorrhea or malocclusion. The patient was seen again, and imaging revealed depressed comminuted fracture of left frontal sinus, anterior table with posterior table intact. The plan was for surgery at the hospital. Patient underwent surgery under general anesthesia. Operative note indicated the patient underwent open reduction internal fixation (ORIF) left frontal sinus fracture, direct approach. Surgery was uneventful. Post op (operative) anesthesia note indicated the patient was doing well. The patient was extubated with respiratory function appropriate with stable vital signs. The patient was discharged after observation.

The hospital is appealing and noted in a letter that the standard of care in this community and its resources as recognized by Centers for Medicare & Medicaid Services (CMS), they have determined that based on the presenting symptoms the inpatient admission should be approved at an inpatient level of care. Per CMS approval criteria, when a patient does not meet level of care, the medical records should be sent for secondary review. Secondary review determines the appropriateness of the current proposed level of care when it is not supported by criteria on primary review. Secondary reviewers may refer to the CMS approved criteria but is not required as part of the review process. The hospital noted that the surgery is at a higher risk of complications for significant bleeding that would require immediate intervention that outpatient surgery centers are not equipped to manage. The fracture is also comminuted reflecting the magnitude off injury and reconstruction to be done.

The patient did meet criteria based on national guidelines for admission. As per Milliman Care Guidelines (MCG) Health General recovery care 26th Edition: Head and Neck Disease GRG GRG:MG-HND (ISC GRG). This patient met clinical indications for the surgery to be done at the hospital potentially as an inpatient admission as he did have a comminuted fracture which could require inpatient status. He could not have been treated in a surgery center for this surgery.

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 inpatient hospital services is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visits
The insurer denied coverage for D8080 braces and D8670 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, 
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, ectopic eruption, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index attaining 31 total points to support orthodontic care. 

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 HLD. 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 31 points to justify orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 19 total points (7 overjet, 5 overbite, 5 anterior crowding and 2 labiolingual spread).

Regarding the validity of the HLD 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. 

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

The insurer's denial of coverage for the D8080 braces and D8670 monthly visits is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, hypertension, and osteoarthritis. 
Treatment: Home care/personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift). 

The insurer denied coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift). 

The denial is overturned. 

This is a male with chronic medical problems including congestive heart failure, hypertension, and osteoarthritis. The insurer approved home care/personal care HHC - level 2 personal care services, per 15 minutes; 24 hours/day (live in) and the request is for 24 hours/day (split shift). 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "minimally impaired." However, he is only "alert and oriented x 1 (to person), disoriented to place and time, not self-directed, unable to recall recent events." He is totally dependent for bathing, personal hygiene, dressing, eating and toilet transfer/use. He is frequently incontinent of bowel and bladder. He is independent for bed mobility, but otherwise totally dependent for mobility and locomotion. 

The patient's cognitive deficits and total dependence for activities of daily living support the medical necessity of the requested level 2 personal care services (PCS) increase to 24 hours/day (split shift). His condition and functional needs, which continue to decline, are at a level and unpredictable as to require the requested PCS; 24 hours, 7 days/week (split shift). 

Based on the enclosed documents reviewed, this physician would also agree that the patient's health and safety is more appropriately provided and maintained by the requested PCS increase to 24 hours per day (split shift). 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based. 

The insurer's denial of coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure, hypertension, and osteoarthritis

Treatment: home care/personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift)

The insurer denied coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift)

The denial is overturned

This is a male with chronic medical problems including congestive heart failure, hypertension, and osteoarthritis. The insurer approved home care/personal care HHC - level 2 personal care services, per 15 minutes; 24 hours/day (live in) and the request is for 24 hours/day (split shift).

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "minimally impaired." However, he is only "alert and oriented x 1 (to person), disoriented to place and time, not self-directed, unable to recall recent events." He is totally dependent for bathing, personal hygiene, dressing, eating and toilet transfer/use. He is frequently incontinent of bowel and bladder. He is independent for bed mobility, but otherwise totally dependent for mobility and locomotion. 

The patient's cognitive deficits and total dependence for activities of daily living support the medical necessity of the requested level 2 personal care services (PCS) increase to 24 hours/day (split shift). His condition and functional needs, which continue to decline, are at a level and unpredictable as to require the requested PCS; 24 hours, 7 days/week (split shift).  

Based on the enclosed documents reviewed, this physician would also male's health and safety is more appropriately provided and maintained by the requested PCS increase to 24 hours per day (split shift).

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

The insurer's denial of coverage for home care/personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day (split shift) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism.
Treatment: Applied Behavioral Analysis (ABA) Therapy: 2 Hours per Month of Supervision, 8 Hours per Month of Treatment Planning, and 3 Hours of Reassessment. The insurer denied Applied Behavioral Analysis (ABA) Therapy: 2 Hours per Month of Supervision, 8 Hours per Month of Treatment Planning, and 3 Hours of Reassessment. The health plan's determination is upheld. 

The requested Applied Behavioral Analysis (ABA) Therapy: 2 Hours per Month of Supervision, 8 Hours per Month of Treatment Planning, and 3 Hours of Reassessment is not medically necessary for this patient.
The patient has been approved for 15 hours per week of direct ABA therapy, ie ~60 hours per month. He has been approved for 10 hours per month of supervision, 4 hours per month of parent training, 1 hour per week of treatment planning, and 3 hours of reassessment. These hours are appropriate for the amount of authorized direct ABA therapy approved. He is documented as reaching many goals in multiple subdomains. He is making progress towards mastery of additional goals. The additional requested hours are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, atrial fibrillation, and breast cancer
Treatment: Personal care aide 7 days x 24 hours live-in
The insurer denied coverage for personal care aide 7 days x 24 hours live-in
The denial is upheld 

This is a geriatric patient with medical problems that include hypertension, atrial fibrillation, and breast cancer. The patient lives alone in a 2-bedroom private residence with around the clock private duty aides. The insurer approved Personal Care Aide (PCA) 8 hours per day, 5 days per week and 7 hours per day, 2 days per week (total 54 hours per week). The request is for PCA 7 days x 24 hours live-in.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Independent- Decisions consistent, reasonable and safe."  According to the office visit note from the nurse practitioner (NP), the patient's judgment, insight, memory, mood, and affect are "within normal limits." The patient requires extensive assistance for bathing and ambulation (primarily wheelchair dependent). Only limited assistance is needed for personal hygiene, dressing, bed mobility, locomotion, and toilet use. The patient is independent with eating and toilet transfer. The patient is infrequently incontinent of bladder and continent of bowel. The patient's functional ability has significantly improved when compared to the previous UAS report. The patient's medical condition and functional ability are not at the level as to require the requested PCA services 24 hours per day (live-in). This physician would agree the patient may require additional monitoring. However, safety monitoring under Personal Care Services (PCS) does not include monitoring an individual when no other Level I or Level II personal care service tasks are being provided. Based on the records reviewed, attention to the patient's functional needs are appropriately provided and maintained by the currently approved PCA 8 hours/day, 5 days/week and 7 hours/day, 2 days/week (total 54 hours/week).

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. From a physical medicine and rehabilitation perspective, a personal care aide 7 days x 24 hours live-in is 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 personal care aide 7 days x 24 hours live-in is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld
 
This case involves an adult who presented to the emergency room with reports of a fall with a loss of consciousness and incontinence. The patient was reportedly found on the floor by his wife. He had facial injuries and bleeding from the nose and mouth and did not remember any aspect of syncope. An electrocardiogram (ECG) 12-lead was ordered and interpreted as normal.  Vital signs noted his blood pressure was elevated at 161/92 with a pulse of 93. X-rays were obtained identifying a nasal bone fracture. The report stated the patient had a history of hypertension, hyperlipidemia, diabetes mellitus, and a possible heart problem that may have been related to syncope. He claims he had an episode a year ago and reported facial pain, dizziness, and lightheadedness. He was negative for tremors, speech difficulty, weakness, or numbness. His physical examination documented the patient as having "raccoon eyes", nasal deformity with signs of injury, and dried blood in the nares with nasal tenderness. The neurological examination was unremarkable. There were concerns for malignant arrhythmia versus seizure versus acute coronary syndrome (ACS) versus cerebrovascular accident (CVA).  The plan of care included obtaining labs, an ECG (electrocardiogram), COVID test, computed tomography (CT), and a chest x-ray with plans to admit the patient to telemetry. The patient remained on inpatient status for three days. He was treated with Keppra. A magnetic resonance imaging (MRI) of the brain revealed no abnormalities and an electroencephalogram revealed no seizure activity.  

According to the Milliman Care Guidelines, the patient did not meet criteria for admission to inpatient care for a syncopal episode. He was not found to be hemodynamically unstable, did not have an altered mental status that was severe or persistent, was not found to have any cardiac disease or findings that indicated a necessity of immediate intervention, nor did he have a pacemaker or an automatic implantable cardioverter-defibrillator (AICD) malfunction. The patient had no inheritable cardiovascular condition predisposing him to arrhythmias. They were never diagnosed or suspected. He did not have severe or persistent dehydration, and the nasal injury caused by the syncopal episode did not require hospitalization.  

It was determined that his care could have been rendered safely and efficiently on an outpatient basis or on an observational basis and he did not require an inpatient stay for any duration.  

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: Abdominal pain
Treatment: Inpatient level of care
The insurer denied coverage for inpatient level of care.
The denial is upheld.

The patient had a history of chronic abdominal pain. The patient presented with abdominal pain and vomiting. The patient had sinus tachycardia. There was no abdominal rebound or guarding. The white blood cell (WBC) count was 22. Intravenous (IV) hydration and pain medications were given. A recent Computed Tomography Angiography (CTA) of the chest, abdomen, and pelvis was negative for acute disease. The patient had opioid dependence and was on a chronic pain regimen. The patient was also on steroids for an undetermined rheumatological condition. The symptoms improved with treatment. 

Clinical indications for admission for Vomiting per Milliman Care Guidelines (MCG) M-370 include having a significant metabolic derangement such as ketoacidosis, hemodynamic instability, severe vomiting that does not respond to antiemetic therapy, severe electrolyte abnormalities, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

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

This patient had recurrent episodes of abdominal pain and vomiting. However, IV hydration, antiemetics, and pain control could have been given with observation status. The vomiting responded to the treatment that was given. The patient did not meet MCG criteria for admission for either Vomiting or Undiagnosed Abdominal Pain. The healthcare plan acted reasonably and with sound medical judgment. An inpatient admission was not medically necessary. The denial is upheld.

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 inpatient level of care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchitis.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld .



Patient is an adult with a history of Covid.  The patient reports that she has had some chronic shortness of breath (SOB) since that time. The patient now presents with complaints of a cough for the past three days, upper respiratory symptoms and wheezing. She uses an albuterol inhaler as needed (prn).

In the Emergency Department (ED) she was afebrile with normal vital signs and oxygen saturation 99% on room air. Peak expiratory flow (PEF) was 310.  There was no use of accessory muscles and she was in no acute distress.  Lung exam revealed bilateral wheezes. Heart sounds were normal. There was a non-focal neuro exam and she was alert and oriented x 3.

The patient was given 1 dose of steroids and bronchodilators in ED and improved following treatment. The patient was admitted to hospital inpatient care with a diagnosis of rule out pneumonia, upper respiratory infection and asthma exacerbation.  White blood cells (WBC) 11.2 and electrolytes within normal limits. Chest x-ray (CXR) had no acute infiltrates, effusion or pneumonia.  Respiratory virus panel was negative.

The patient was seen by the pulmonologist. The patient was afebrile and hemodynamically stable. There were some coarse breath sounds but no wheezing. Pulmonology recommended oral (PO) steroids and a short course of PO antibiotics. Patient was also placed on long-acting beta-2 agonist / inhaled corticosteroids (LABA/ICS) inhaler.  Patient remained stable after admission and was discharged home.

This patient did not need acute inpatient hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours. PEF after treatment was 350-400. This patient did not have pneumonia. Likely, she had bronchitis. This patient was stable to be discharged after a period under observation on PO medications with close follow-up in an outpatient setting.

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 emergency admission is not substantiated.