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

Diagnosis: Malocclusion

Treatment: Adjustment of braces (periodic orthodontic treatment visit); and Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition)

The insurer denied coverage for adjustment of braces (periodic orthodontic treatment visit); and Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition)

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, and montage of extraoral and intraoral clinical images, as well as insurer correspondence, this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet and overbite and has recommended orthodontics. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required medical necessity requirements attaining only 9 points on the required Handicapping Labio-Lingual Deviation (HLD) index by internal reviewers. Remanisa A. Cartagene is appealing the decision on behalf of the patient.

Upon review of the submitted documentation (study models were not provided for review, nor were an HLD Index or panoramic radiograph) there is minimal evidence that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used in which a point system is utilized 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 provide the required documentation. The documentation provided is insufficient and inadequate to approve 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 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 adjustment of braces (periodic orthodontic treatment visit); and Insertion of braces (comprehensive orthodontic treatment of the adolescent dentition) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal Creatinine
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
The patient was admitted for joint pain and was found to have abnormal creatinine. He was evaluated by nephrology service and was started on intravenous (IV) fluid. His creatinine improved and pain was managed with systemic steroids and pain meds. He required adjustment of anti-hypertensive regimen and was discharged in stable condition.

The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease: Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN (acute tubular necrosis). This member's kidney function improved back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy.

In addition, he was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function.

He did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration.

There was no documentation of refractory pain, and he was able to tolerate oral diet and did not require total parenteral nutrition.

His condition could have been treated safely under 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 hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease with acute chest syndrome
Treatment: Inpatient Hospital Admission:
The insurer denied: Inpatient Hospital Admission:
The denial is upheld

The patient is an adolescent female child with sickle cell anemia and acute chest syndrome. She was admitted to the hospital. Upon admission, the patient had a hemoglobin level of 7.8. Chest x-ray demonstrated no evidence of consolidation, and the lung exam was unremarkable. The patient complained of severe chest pain and had scleral icterus. The review is for inpatient hospital stay.

The proposed inpatient hospital admission was not medically necessary.

The health plan's denial was appropriate in that the patient did not have symptoms or evidence of a medical condition that required acute inpatient level of care. Clinical indications for acute inpatient level care for a vaso-occlusive pain crisis or other sickle cell complication include patients with signs and symptoms concerning for stroke, patients with acute chest syndrome with demonstrated chest x-ray changes such as alveolar infiltrate associated with pulmonary symptoms that include chest pain, hypoxia, tachypnea, wheezing, cough, patients with significant hypoxia or acidosis, patients with aplastic crisis or splenic sequestration, and patients with priapism or traumatic hyphema. In addition, patients with severely high fevers and toxic appearance can be admitted to the hospital and managed in the inpatient level of care. In this case this patient was managed within an observation period of time and did not demonstrate the severity of symptoms upon presentation or the intensity of care that is consistent with inpatient level of care. As such, the inpatient level of care would not be considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism

Treatment: Applied Behavioral Analysis

The insurer denied Applied Behavioral Analysis (ABA): Additional 15 Hours a Week of Direct ABA Therapy and 3 Hours a Week of Supervision. 

The health plan's determination is upheld. 

The patient is a boy who was diagnosed with autism spectrum disorder. He has not received applied behavioral analysis (ABA) therapy, speech therapy, occupational therapy or physical therapy in the past. He attends a local charter school for 27.5 hours per week.
An ABA assessment performed describes that the patient lives with his parents and sister in an apartment.   He is described as having significant deficits pertaining to communication and socialization. Concerning behaviors include elopement, hitting and throwing items, and spitting at adults. These behaviors are often preceded by transition from a preferred reinforcer to a new activity. 

Applied Behavioral Analysis (ABA): Additional 15 Hours a Week of Direct ABA Therapy and 3 Hours a Week of Supervision are not medically necessary for this patient. The patient is attending school for 27.5 hours per week. If 40 hours per week of direct 1:1 ABA therapy were to be approved, this would involve 67.5 hours per week of supervised activity for this child, which appears excessive, and would prevent the provision of additional therapies that may be necessary, such as speech therapy. The 25 hours per week of direct ABA therapy approved by the health plan appear appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This is a young adult female with history of renal calculi who presented to the emergency department for evaluation of abdominal pain for 5 days with nausea. Patient was febrile and tachycardic in emergency room, computed tomography (CT) revealed right upper pole anterior poorly defined hypodense renal abscess (new), felt to be possible complicated cyst or early abscess. Patient admitted for intravenous antibiotic treatment, consults with Urology, Infectious Disease, Gynecology, diagnosis of complicated pyelonephritis. Patient improved on intravenous (IV) Levaquin, then on day 2 she was transitioned to oral Levaquin. She was stable for discharge with outpatient follow up. 

Per Milliman Care Guidelines (MCG) Health (26th) Urinary Tract Infection, the patient fails to meet clinical indications for admission to inpatient care. There was no evidence of hemodynamic instability, altered mental status that is severe or persistent, pregnancy, persistence or worsening of clinical findings despite observation care, ureteral obstruction, renal or perinephric abscess. 

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: Pregnancy, Hypertension. 
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 an elevated blood pressure. The patient was admitted for blood pressure control. She was noted to have chronic hypertension. She was noted to have a blood pressure in her provider's office of 177/114. She denied vaginal bleeding or abdominal cramping. She denied any past medical history. She was seen for pregnancy and hypertension. At presentation, her blood pressure was 154/104. She was noted to have nausea and vomiting of pregnancy. The patient had an intravenous (IV) placed. Labs were sent. A repeat blood pressure was 146/92. The patient had one prior uncomplicated vaginal delivery. She had no allergies and was on no medications. The labs returned normal. The exam was also normal. At the time of the obstetrics/gynecology (OB/GYN) exam, the blood pressure was 149/96. The patient was ordered for a 24-hour urine and blood pressure control was planned. 

At issue is the medical necessity of an inpatient stay. 

An acute inpatient level of care was not medically necessary. The patient was noted to have chronic hypertension in pregnancy. The patient had an elevated blood pressure and was treated in the hospital with oral Procardia for control of blood pressure. This regimen and plan of care can be provided at a lower level of care. The patient had no acute signs of hypertensive emergency. There was no acute range blood pressure. The patient was noted to have mild range blood pressures without any hypertensive emergency. There was no evidence of end organ damage in this case. There was no evidence of cerebral infarction or intracerebral hemorrhage. There was no evidence of vision loss or unstable angina. The patient had no history or symptoms suggesting myocardial infarction, pulmonary edema, aortic dissection, seizures, or acute renal failure. The patient was noted to have normal renal function as measured by her creatinine and had a normal physical exam with normal neurologic exam. There is no evidence of intracranial abnormality or indication for imaging. 
At 15 weeks gestation, fetal status would not be considered as a part of the evaluation. Thus, the main goal of management would be for control of hypertension. This was achieved with oral Procardia XL. There was no need for hospitalization at the acute inpatient level of care for this or for the performance of labs and a 24 hour urine. These studies can be completed at a lower level of care. There were no indicators for admission to acute inpatient level of care in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Metastatic Papillary Thyroid Cancer
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient is a female with a history of metastatic papillary thyroid cancer of the neck. Because of lymph node involvement, the patient required additional surgical treatment.
The patient was admitted for a neck dissection of the right neck for levels 2 and 3. She was discharged the following day.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient.

The inpatient stay is not medically necessary for this patient. During the hospitalization, the patient received intravenous (IV) antibiotics and drain monitoring. According to Milliman Care Guidelines (MCG) Guidelines which outline the medical necessity for hospital admission, the patient did not meet criteria. There were no high-risk perioperative factors, extensive tumor removal, post operative events or other complications.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient Hospital Admission 
The insurer denied Inpatient Hospital Admission.
The denial is Overturned.

The patient is a male child who was admitted for breathing trouble and wheezing for the prior four days. He also had four days of fevers, URI (upper respiratory infection) symptoms and decreased oral intake. On the day of evaluation, his breathing worsened. The family tried albuterol at home with no improvement, so they went to the ED (emergency department) for evaluation.

In the ED (emergency department), the patient was ill-appearing and in respiratory distress with wheezing. The patient's vitals were T (temperature) 101.4, P (pulse) 148, R (respiration rate) 40 and pulse oximetry 97% on room air. The patient was given a normal saline bolus, 1 albuterol treatment, 3 Duonebs, ibuprofen, and ceftriaxone. A chest x-ray showed a right middle lobe infiltrate. Labs were sent.

Later that day, the patient had improvement in his work of breathing and vomiting. He remained on IV (intravenous) fluids with suctioning, albuterol every two to three hours, and ceftriaxone.

On day two, the patient's breathing improved, but his oral intake remained poor and cough continued. He also continued to have slight wheezing and retractions. He remained on IV (intravenous) antibiotics, and IV (intravenous) fluids were titrated.

On day three, the patient had improved breathing and oral intake. He was discharged home on every-four-hours albuterol and oral antibiotics.

The Inpatient Hospital Admission was medically necessary.

The health plan denied coverage of the inpatient admission based on MCG (Milliman Care Guidelines) criteria for bronchiolitis; however, the notes document that the child met multiple criteria, including "signs of difficulty getting air into the lungs" (retractions, increased work of breathing are documented on admission) and "difficulty feeding and unable to take in enough fluids." As the child had significant increased work of breathing, was unable to maintain oral hydration, and required frequent albuterol treatments, the care could have not been provided safely at an observation level of care. The requested acute inpatient hospital stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
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 by ambulance after she was found down at home, presumably after a seizure. When the ambulance arrived, the patient had a seizure that was witnessed by emergency medical workers. The patient was transported to the emergency room. She was confused. She was treated with midazolam and loaded with Keppra. The patient's vital signs were within normal limits. The patient underwent a computed tomography (CT) scan of the head that showed no acute findings. The patient was transferred to the general medical floor for further care. On arrival to the floor, the patient was fully alert and oriented. The patient had no complaints. She did not require an inpatient electroencephalogram (EEG). She was continued on her home seizure medications. She complained of a headache and was treated with Tylenol. She was discharged home. At issue is the medical necessity of an inpatient stay.

An acute inpatient admission was not medically necessary for treatment of this patient's condition.
The patient had a seizure at home. She was transported to the emergency department. The patient was stabilized with midazolam and loaded with Keppra. The patient had no further seizures in the emergency department after treatment with anticonvulsant medications. The patient did not have abnormal vital signs or abnormal imaging of the brain. The patient did not have any significant laboratory abnormalities. The patient was then transferred to a general medical floor where she was noted to be alert and oriented without any focal neurologic deficits or further seizure. The patient did not have any further seizure in the emergency department or on the medical floor. She was treated with her home seizure medication regimen. The patient complained of a headache that responded to Tylenol. None of the care meets the intensity required for an acute inpatient hospitalization. The patient did not have clusters of seizures or status epilepticus. The patient did not have changes to her anticonvulsant regimen. The patient did not require inpatient EEG. The patient was subsequently discharged home and did not have any persistent altered mental status or neurologic deficit.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
Treatment: Sacroiliac arthrodesis 
The health plan denied: Sacroiliac arthrodesis 
The determination is: Overturned

The patient is a male with chronic low back and bilateral hip pain requiring bilateral crutches for ambulation. He has been under the care of pain management for approximately 20 years as a result. The pain has worsened in the last several years. He is status/post multiple hip surgeries with a history of 2 prior motor vehicle collisions. The patient is a non-smoker. The physical exam was notable for positive (+) compression, distraction, and flexion, abduction, and external rotation (FABER), with Gaenslen's bilaterally. Lumbar magnetic resonance imaging (MRI) demonstrated mild degenerative changes without significant findings. Prior treatments include nerve blocks, cortisone injections, oral steroids, narcotics, heat, ice, physical therapy (PT), home exercise program (HEP), manipulation, and transcutaneous electrical nerve stimulation (TENS) unit. An initial bilateral sacroiliac joint (SIJ) injection was without relief, but sedation may have prevented him from noticing the benefit. He had a repeat bilateral SIJ injection with greater than 80 percent (%) pain relief for 2 weeks.
The patient was admitted and underwent bilateral sacroiliac arthrodesis. No intraoperative or postoperative complications occurred. He received perioperative antibiotics, sequential compression devices (SCD), home medications, pain control via oral medications, and PT. He was safely discharged home on postoperative day 1.
At issue is the medical necessity of the sacroiliac arthrodesis.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of sacroiliac arthrodesis is medically necessary for this patient. The patient has chronic low back and hip pain which has been localized to his bilateral SIJ. The physical exam is provocative for SIJ pain. Imaging does not identify another source of pain. He has tried and failed all conservative management treatments. He was recommended bilateral SIJ fusion, which would be medically necessary to provide him with long term relief.
According to Schmidt[1], "After failure of conservative treatment, percutaneous sacroiliac (SI) arthrodesis can be considered."
According to Polly[3], "This Level 1 study showed that minimally invasive SIJ fusion using triangular titanium implants was more effective than nonsurgical management at 1 year in relieving pain, improving function, and improving quality of life in patients with SIJ dysfunction caused by degenerative sacroiliitis or SIJ disruptions. Pain, disability, and quality of life also improved after crossover from nonsurgical to surgical treatment."
These and many other studies continue to support the treatment of SI joint pain in the properly selected patient with SI fusion.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Fibroids. 
Treatment: Sonata system - radiofrequency ablation (to remove growths) - outpatient procedure (0404T x 1). 

The insurer denied: Sonata system - radiofrequency ablation (to remove growths) - outpatient procedure (0404T x 1). 

The denial is Overturned. 

The patient is an adult female with multiple leiomyomas and was referred for the Sonata procedure, which is transcervical radiofrequency ablation of the leiomyomas with ultrasound guidance. The patient had heavy menstrual bleeding over one- year, bulk related pain/pressure, pressure on bladder/rectum, and dyspareunia (pain with intercourse). The patient's ultrasound 
demonstrated multiple myomas, the majority of which were under five centimeters size, two endometrial polyps, and a thin endometrial stripe. Of note, the patient had a history of a myomectomy previously performed. The patient wished to retain her uterus, i.e., declined the option for hysterectomy. 

The health plan contends that the procedure is not medically necessary because it is uncertain that it improves outcomes compared to standard care and cites Milliman Care Guidelines (MCG). The vendor authorization support contends that the procedure is not "experimental/investigational" based on establishment of a procedure code, support from the American College of Obstetricians and Gynecologists and support from the American Association of Gynecologic Laparoscopists. 

The health plan should cover the proposed treatment. 

Based on the published literature, the evidence supporting its advantages over standard treatments is clear, and therefore it is not experimental/investigational and therefore is medically appropriate. The requested health service or treatment is more beneficial than any standard treatment for the insured's condition or disease. The literature amply demonstrates that the Sonata transcervical radiofrequency ablation procedure is safe and effective. The patient declined hysterectomy and it is appropriate to respect this wish. In comparison with other organ-sparing procedures, the complication rate, blood loss, postoperative pain, adhesion rate, recovery time, re-intervention rate, and procedure time are superior with this approach. The American College of Obstetricians and Gynecologists endorses this approach with the only caveat being that it is not widely available. Although a randomized controlled trial comparing these techniques head-to-head has not been performed, it may be difficult to ethically perform such a trial given the strong weight of evidence in favor of this procedure. Therefore, its superiority to other treatment modalities has been adequately demonstrated and it is not experimental/investigational.