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

Diagnosis:  Substance abuse.
Treatment:  Inpatient rehabilitation.

The insurer denied coverage for inpatient rehabilitation.  The denial is overturned.

This adult male was admitted to this inpatient substance rehabilitation treatment, as he reportedly was using opiates, Methadone maintenance, and was using cocaine daily. He reportedly had a positive toxicology for opiates, cocaine, and Methadone. He also reportedly had withdrawal symptoms and lethargy. He reportedly had 5 past treatment episodes and could not maintain abstinence and his last treatment. He reportedly had past legal issues for burglary and was unemployed. He reportedly had comorbid psychiatric diagnoses including depression and post traumatic stress disorder (PTSD) and was noncompliant with medications. His mother reportedly committed suicide and was an alcohol abuser, and he reported a history of physical and emotional abuse victimization. He also reportedly had a past overdose. 

The medical records provided enough specific evidence to support that he required this level of care. The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. In this case this patient was considered in need of 24-hour substance rehabilitation treatment, as he was using large amounts of multiple serious substances and methadone maintenance treatment. 

He reportedly had a long history of opiate and  cocaine use and had a past overdose, so he was considered at risk of harm to self. He reportedly was at risk of severe withdrawal and other medical issues due to his opiate and cocaine use. According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of serious substances of use and was unable to stop use without a 24-hour substance free therapeutic treatment setting, despite multiple past treatment episodes. He reportedly lacked coping skills for abstinence, the ability to identify triggers to use, insight into use, and needed to learn better coping skills, improve insight into use, and better identify relapse triggers. He was at risk for medical complications from his serious substances of use and also overdose, as well as severe withdrawal symptoms. He was unable to stop substance use without being in a sober and supervised therapeutic inpatient substance rehabilitation setting. 

He had past legal issues and was in withdrawal initially, which put him at risk for severe withdrawal and medical risks. 

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 rehabilitation admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

The patient is an adult female with a history of asthma, diabetes, hyperlipidemia, transient ischemic attack (TIA), and schizoaffective disorder, who presented to the hospital with shortness of breath not relieved by inhalers.

Vital signs at presentation were: Temperature 97.6 degrees F, Blood Pressure 117/72, Heart Rate 83 and Respiratory Rate 18. Oxygen saturation was 95% (percent) on 3 liters (L) Oxygen via nasal cannula. The patient was in mild respiratory distress. The lung exam revealed wheezing.

White Blood Cell (WBC) count was 13.3, Lactate was 2.5. There was no acute infiltrate on chest X-ray. Blood sugar levels remained high.

The patient was treated with intravenous (IV) steroids, fluids and Magnesium. The patient was noted to have paranoid ideation, and she was also noted to be aggressive to nurses and other staff. She was at a risk for decompensation, so it was appropriate to admit her to the hospital for treatment and stabilization. She could not have been managed safely in a lesser setting than inpatient due to her multiple comorbidities.

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 hospital admission from 12/17/22 to 12/20/22 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion.
Treatment:  D8080 braces and D8670 monthly visit x 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 maxillary canines among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the 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 HLD index by internal reviewers attaining a score of 21 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, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labia-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 HLD index, choosing the impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance as documented (maxillary canines) 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. This is confirmed by several referenced studies. 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 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Psoriasis
Treatment: Pharmacy/Prescription Drugs/Taltz
The health plan denied the requested medication, Taltz, as not medically necessary. The health plan's determination is upheld.

The patient is a female with moderate to severe plaque psoriasis affecting 15% body surface area including involvement of the ears, hands, legs, and scalp who has failed previous therapy with topical corticosteroids and topical vitamin D analogs. The prescriber notes that the patient has elevated liver enzymes reported on labs drawn (aspartate aminotransferase (AST) of 148, alanine aminotransferase (ALT) of 90).
At issue is the medical necessity for the requested health service/treatment of Taltz.

I recommend up to uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of Taltz is not considered medically necessary for this patient.
The prescriber is requesting coverage of Taltz for the treatment of this patient's plaque psoriasis affecting the ears, hands, legs, and scalp. The prescriber notes that the patient has a history of elevated liver enzymes, and therefore systemic immunosuppressant therapies such as Methotrexate, Acitretin, and Cyclosporine are contraindicated. However, elevated liver enzymes are not a contraindication for the use of ultraviolet (UV) phototherapy, which is a form of treatment recommended by consensus psoriasis treatment guidelines and listed as a formulary alternative treatment per the patient's health plan.
Review of the consensus treatment guidelines published by the American Academy of Dermatology shows support for the use of UV phototherapy for plaque psoriasis affecting all areas of the body, including the scalp, ears, hands, and extremities; UV phototherapy in the form of excimer laser has shown to provide a psoriasis area and severity index (PASI-75) rate of 70% in the treatment of localized plaque psoriasis including scalp and palmoplantar psoriasis. Therefore, UV phototherapy remains a viable alternative treatment option for this patient; due to the availability of alternative treatment options, the use of Taltz for this patient's plaque psoriasis is not considered medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Inpatient hospital

Diagnosis: fibrous dysplasia right femur
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a girl with extensive fibrous dysplasia of bone involving the right femur. Previous treatment included both biopsy of the abnormal bone and corrective osteotomy of the right proximal femur. The patient had developed pain, recurrence of some deformity at the distal portion of the fixation, and possible impending fracture at this site as well. She underwent removal of the original implant and replacement with a longer fixed implant, as well as a supplemental plate.

The inpatient hospital admission was medically necessary. This procedure is essentially an extensive open reduction and internal fixation of the femur, with the additional work of dissecting through previously-operated tissue (which often has greater bleeding) and removing the previous implants. There is an extensive incision and extensive stripping of muscle from bone, which can cause pain and bleeding. The procedure lasted nearly 3.5 hours in this child. Careful monitoring afterward for possible complications of the surgery and anesthesia would be required. Pain could be considerable and would need to be managed. There would be the potential for blood loss and possible transfusion. All of these matters indicate that inpatient hospital admission would be medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Cancer
Home health care

diagnosis: bladder cancer
Treatment: home health care
The insurer denied Personal Care Aide Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week. The health plan's determination is overturned. 

The patient is a male with past medical history of bladder cancer, congestive heart failure (CHF), hypertension, paroxysmal A-fib (atrial fibrillation), coronary artery disease, malnutrition, chronic obstructive pulmonary disease (COPD), pulmonary hypertension, diabetes mellitus type 2, benign prostatic hyperplasia (BPH), and urinary incontinence who had been assigned PCA (personal care aide) services.

Personal Care Aide Services: 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week medically are necessary for this patient.
There is documentation by the patient's PCP (primary care provider) of medical necessity of increased PCA services. There is documentation from the patient's family that they are unable to provide informal support outside of currently assigned PCA services. The plans own assessment documents an increase in assistance needs with multiple tasks when comparing the previous assessments. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

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

This adult patient presented to the hospital with complaints of chest pain for three days. Past medical history was significant for coronary artery disease and percutaneous coronary intervention four months prior to presentation. On arrival to the hospital vital signs were stable (blood pressure 127/85, Pulse 85). Physical examination revealed no significant abnormality. 12 lead electrocardiogram (ECG) demonstrated sinus rhythm without ischemic ST or T wave abnormalities. Serum blood testing demonstrated no elevation in troponin. The patient was admitted to the hospital for monitoring and treatment. Exercise stress echocardiography was performed and demonstrated no ischemic changes on ECG nor on echocardiographic imaging.  Left ventricular ejection fraction was normal (72%). The patient was discharged one day after presentation on medical therapy.
 
Full hospital admission was not necessary for this patient. The pretest probability of coronary artery disease is intermediate (1). Utilizing the 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. These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge. Numerous studies have demonstrated that workup can be performed in an observation unit without the need for hospital admission. Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care (4,5). They found no significant difference in outcome at 30 days between the two groups. Fernando Bellolio et al. noted that patients presenting with chest pain, which were managed in an observation unit, had similar 30-day myocardial infarction rates as those admitted to the hospital (5). Admission to the hospital to treat an acute cardiac event was not medically necessary for this patient. In conclusion, this 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine leiomyosarcoma
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

According to the medical records, the patient is an adult female with a previous diagnosis of uterine leiomyosarcoma. The patient presented to the emergency room (ER) with pain and was admitted. The patient's pain was controlled with Percocet, and she was discharged after two days.

This patient had her pain controlled with oral narcotics and had no acute abdominal process on imaging. The patient's pain improved within the first 12 hours, and she was not requiring continuous intravenous (IV) narcotics. Her status would be expected to improve within 24-48 hours under observation level of care, which would have been appropriate, as opposed to the acute level care, which was not medically necessary for this patient.

"Generally a person is considered to be in inpatient status if officially admitted as an inpatient with the expectation that he or she will remain at least overnight. The severity of the patient's illness and the intensity of services to be provided should justify the need for an acute level of care. An inpatient admission solely because the patient has been kept in observation status over 23 hours would not be considered medically necessary." (American Health Information Management Association, 2018).

"Observation was meant to be a short period of time for providers to assess whether patients required admission for inpatient care, or could be discharged. Typically, this was meant to last fewer than 24 hours and only rarely spanned more than 48 hours." (Society of Hospital Medicine, 2021).

"In summary, hospital case managers are a crucial resource for making admission decisions. Hospitalists should be familiar with Medicare criteria for inpatient versus observation status. Patients who are likely to require 24 hours or less for a disposition decision should be assigned observation status. When in doubt, admit to observation since conversion to inpatient status is a simple process." (Pinson, R., 2012).

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: Malocclusion
Treatment: Braces and monthly visits
The insurer denied coverage for braces and monthly visits
The denial is upheld 

Upon review of the submitted documentation, (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 Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used which utilize a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify 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. This is confirmed by several studies (1, 2, 3). These peer reviewed articles conclude that this index is a valid and reliable determinant of need for orthodontic care. This is an accepted methodology that has been determined to represent an appropriate approach for assessing orthodontic need.

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

The medical necessity for braces and monthly visits is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical stenosis

Treatment: Spinal surgery (codes 22853, 22551, 22554, 22846, 22552)

The insurer denied coverage for spinal surgery (codes 22853, 22551, 22554, 22846, 22552)

The denial is upheld

 
The indications for surgery include definition of the specific pain generator, failure to improve with conservative treatment and likelihood the operation will provide benefit. 

The facts are the patient has never improved despite lumbar procedures, hand operations, chronic opioid use and several pain management procedures to his neck. There is lack of consistency in the medical record for "stenosis or nerve compression in the cervical spine". His subjective complaints do not correlate. He has been reported to have ongoings symptoms of numbness to the median nerve distribution. His physical examination demonstrated loss on one occasion. The findings were global and nonspecific. He was reported to have positive (+) Tinel and Phalen tests. His electromyogram (EMG) cannot be discounted showing peripheral nerve compression. The reported cervical (C) 6-7 radiculopathy did not correlate with his "bilateral symptom" presentation. It is important to recognize the 90% reported relief after radiofrequency ablation (RFA). This signifies facet disease. The imaging study did not vary from a previous report. Simply stated there was multilevel degenerative disease but no evidence of specific nerve root compression. There was no evidence of cord compression. 

The proposed diagnosis of cervical stenosis and neurogenic claudication is not supported. The pain patterns were inconsistent with several other conditions which more than likely could be causative. (Diabetes, peripheral nerve compression, facet disease). It is extremity unlikely that the planned procedure will provide benefit. Also noted are documented post laminectomy syndrome and chronic narcotic use. There is no indication for the requested reconstructive cervical spine procedure. 

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 spinal surgery (codes 22853, 22551, 22554, 22846, 22552) is not substantiated.