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

Diagnosis: Asthma Exacerbation

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

The patient has a history of asthma, diabetes mellitus (DM) and hypertension (HTN). The patient presented to the emergency department (ED) with complaints of shortness of breath (SOB) for 1 day. The patient also complained of cough of 2 days duration. The patient used his inhalers and nebulizers and as he did not get relief came to ED. The patient was ex-smoker and reported current Marijuana use.

The patient was treated with intravenous (IV) Steroids, Duo Nebs, and Magnesium.  In the ED, Temperature 98.4, Heart Rate 100, Blood Pressure (BP) 146/84, and Respiratory Rate 26. The patient was placed on bilevel positive airway pressure (BIPAP) and appeared comfortable. There was no respiratory distress. There were some rales and wheezing described. The patient was admitted to the hospital for treatment of asthma exacerbation.

As per the history & physical (H&P), the patient was in no acute distress (NAD). On noninvasive positive-pressure ventilation (NIPPV), oxygen (O2) saturations 100% (percent), respiratory rate (RR) 23. The lungs showed mild rhonchi. White blood cell count (WBC) 13.9, hemoglobin (Hb) 13.4, and electrolytes were within normal limits (WNL). Chest x-rays revealed (CXR) no acute infiltrate.

The patient was treated with IV Steroids, bronchodilators and maintenance BP medications and Diabetes meds.

By the next day, the patient remained afebrile, had some elevation in BP which he reported that usually happens in the morning. The patient was saturating 97% on room air.

The patient was feeling better, was in no acute distress, and the patient was switched to oral (PO) Prednisone. He was medically cleared for discharge (DC) with outpatient follow up.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated.
Observation period can be for up to 48 hours. The patient was afebrile and hemodynamically (HD) stable and was maintaining good oxygen saturations. No Pneumonia, Pleural Effusion or pneumothorax (PTX) on CXR. The patient had improved after treatment in ED and was discharged home the next day in less than 48 hours. He was tolerating oral (PO). The patient was switched to PO steroids by the next day, and was discharged home with follow up in the outpatient setting. The patient could have been treated in the observation setting.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip Pain/Total Hip Arthroplasty
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient underwent a right total hip arthroplasty with computer assisted navigation. The operative report indicates that the procedure went well and the patient was transferred to the recovery room in stable condition. The discharge summary states that the comorbidities include spinal stenosis, spondylolisthesis, gallstones, fracture, cancer, thyroid nodule, gastrointestinal (GI) bleeding, obesity, constipation, depression, and acute blood loss anemia. The hospital course involved 24 hours of prophylactic antibiotics postoperatively as well as Eliquis for deep vein thrombosis (DVT) prophylaxis. Postoperatively, the patient did have mild acute blood loss anemia which was monitored clinically. The pain was managed with Dilaudid and Oxycodone. Postoperative hypotension was treated with intravenous (IV) hydration. The patient tolerated physical therapy and achieved all necessary goals for discharge. There is an appeal letter stating that the patient was initially admitted as an outpatient; however, due to episodes of hypotension, severe pain, and inability to progress during physical therapy, the admission was promoted to the inpatient level in anticipation that the patient would require a higher level of care. At issue is the medical necessity of the inpatient stay.

The inpatient level of care was appropriate and medically necessary in this case. The Official Disability Guidelines (ODG) were referenced as specific recommendations are made for inpatient length of stay following a total hip arthroplasty. The ODG supports a 3-day inpatient stay as the best practice target when there are no complications following a total hip arthroplasty. The article cited below from the archives of orthopedic and trauma surgery states that outpatient joint arthroplasty pathways are as safe and effective as inpatient pathways in selected populations. The article also notes that considerable risk of bias in the majority of studies emphasizes the need for further research. In this case, the patient underwent a right total hip arthroplasty with computer assisted navigation. The documentation does not suggest that there was an outpatient joint arthroplasty pathway in place at the surgical facility. Additionally, the patient had postoperative acute blood loss anemia and episodes of hypotension. The postoperative hypotension was treated with intravenous (IV) hydration.  An inpatient admission for a total hip arthroplasty is the current standard of care. In consideration of the available information, the inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System-Asthma/Breathing Problem.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

At the time of his admission, the patient was brought by Emergency Medical Services (EMS) to the emergency department (ED) with difficulty breathing and a croupy cough. By EMS arrival, the patient's breathing appeared ok, and he was transported to the ED on oxygen. Exam showed a nontoxic child, speaking in full sentences. Vitals signs were normal, including normal respiratory rate (RR) and 100% oxygen saturation on room air. There were no signs of respiratory distress, but some wheezing on lung exam. Respiratory virus panel was positive for rhinovirus. The patient was placed in the ED observation unit, given Decadron and albuterol twice. His vital signs and oxygenation continued to be normal, but he also continued to have some wheezing, so was admitted to the pediatric ward. On arrival, he looked well, without tachypnea or retractions. There were bilateral wheezes and rhonchi, so he was continued on albuterol. The next day, he was essentially the same, still without respiratory distress, tachypnea, or hypoxemia, but still some bilateral wheezes. He was discharged home. 

The inpatient stay was not medically necessary for this patient.
The patient did not require acute hospitalization. The parent called EMS for transport to the ED, because they thought the child was in respiratory distress from croup. In the ED, the patient was not diagnosed with croup, but rather with wheezing associated with rhinovirus, one of the common cold viruses. At no time, from arrival in the ED to discharge, did the patient have tachypnea, respiratory distress, or hypoxemia. Exam abnormality was limited to wheezing, and this wheezing did not respond to the albuterol nebulizer treatments administered in the ED, which is often the case with wheezing-associated respiratory illnesses where the wheezing is caused by mucus and not bronchospasm. Further administration of albuterol as an inpatient was not medically necessary, and the patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 Braces and D8670 Monthly Visit (x12), Pre-service.
The insurer denied the D8080 Braces and D8670 Monthly Visit (x12), Pre-service.
The denial is overturned.

The patient is a male. He has Class I skeletal and Class II canine malocclusion. The health plan denied coverage for braces due to his scoring 23 on the handicapping scale.

Yes, the braces and monthly visits are medically necessary.
The patient has a deep, impinging overbite with soft tissue damage on the palate. This is an automatic qualifier according to the Salzmann handicapping index scale. The patient also does not have room for his permanent upper left and right canines to be in their proper positions. Without the upper canines in proper position, there can be no "canine guidance," which is when the upper canines help guide the lower jaw during the chewing cycle so the teeth do not grind together and traumatize each other. The way the patient is now, without the canines in their proper places, there will be trauma over time to multiple teeth, with resulting fractures and loosening of teeth. Orthodontic treatment is needed to correct these problems, and therefore the case has medical necessity.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ectopic eruption, mandibular protrusion, open bite, maxillary and mandibular anterior crowding, skeletal Class I, and impacted permanent anteriors.

Treatment: D8080 - braces and D8670 - 12 monthly visits.

The insurer denied coverage for D8080 -braces and D8670 - 12 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, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to ectopic eruption, mandibular protrusion, open bite, maxillary and mandibular anterior crowding, skeletal Class I, and impacted permanent anteriors. The orthodontist has completed the Handicapping Labiolingual Deviation Index (HLD) index: as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated

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, a Handicapping Labiolingual Deviation Index is utilized. 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 claims an automatic qualifying condition of
impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontics. This reviewer concurs with the findings of the insurer of attaining 4 points on the HLD index (2 points overjet, 1 point overbite, 1-point labiolingual spread).

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. 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.

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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

The insurer's denial of coverage for D8080 - braces and D8670 - 12 monthly visits is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Flank pain
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male with a past medical history remarkable for depression bipolar disorder, chronic knee pain, and nephrolithiasis, who was admitted for reports of right flank pain. Review of system was positive for foul smelling urine, nausea, vomiting, back pain, runny nose and sore throat.
The patient was afebrile (Temperature of 37.2) and described as comfortable. His blood pressure was 120/82, pulse rate of 97, respiratory rate of 19, and oxygen saturation of 95% (percent) on room air. Physical examination was remarkable for right costovertebral angle (CVA) tenderness.
Laboratory evaluation demonstrated a sodium of 146, potassium 4.4, chloride of 109, carbon dioxide (CO2) of 24, blood urea nitrogen (BUN) of 19, creatinine of 1.19, glucose of 77, white blood cell count (WBC) of 10.3, Hb (hemoglobin) of 10.3, Hematocrit (HCT) of 32.8, and platelet of 323. Renal ultrasound revealed right ureteral stent in place without hydronephrosis, nonobstructive stone in the lower pole of the right kidney, and findings suggestive of bilateral upper urinary tract infections. The patient was admitted for right flank pain consistent with non-obstructing kidney stone and pyelonephritis. 

The requested inpatient hospital admission was medically necessary for this patient.
The patient was admitted for acute pyelonephritis with non-obstructing renal stone in the setting of intractable pain resistant to pain medications. Additionally, the patient had a urinary tract infection with E. coli that was resistant to many oral medications. As such, intravenous broad-spectrum antibiotics were required. The patient also required IV (intravenous)  pain medications for persistent pain due to renal colic.
Urinary Tract Infections (UTIs) can be divided into lower and upper tract infections. Lower tract infections involve the bladder (cystitis) and urethra (urethritis). UTIs can be further categorized as simple or complicated. Simple UTIs, also referred to as uncomplicated UTIs, occur in young, healthy, nonpregnant women with normal anatomy. Complicated UTIs are associated with involvement of the upper urinary tract; and can be caused by drug-resistant organisms and are more likely to require long antibiotic courses or parenteral antibiotics. Patients with features consistent with systemic inflammatory response syndrome such as fever, elevated white blood cell count and positive blood cultures can be associated with multi-organ dysfunction, hypo-perfusion or hypotension. The Infectious Diseases Society of America (IDSA) recommends that urine cultures with susceptibility testing be obtained for all patients with acute pyelonephritis. Additionally, the antimicrobial choice should be reassessed once culture results become available, usually within 48 to 72 hours to assess for improvement in clinical status. Elderly patients with UTIs are also at increased risk for serious complications and mortality.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteomyelitis of Tooth #17. 
Treatment: D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone, lower left quadrant. 

The insurer denied coverage for D7550 partial ostectomy/sequestrectomy for removal of non-vital bone, lower left quadrant. 

The denial is upheld. 

The radiographs show that tooth #17 is still present. There are other images which are non-diagnostic. There is no documentation of a sequestrum, sclerotic bone or retained root. Osteomyelitis is an inflammatory infectious disease affecting the bone and bone marrow. Histology remains the gold standard in the diagnosis. Diagnosis of osteomyelitis is primarily performed through panoramic radiography, oral cavity photography, and clinical diagnostic examination. Typical clinical symptoms of patients with osteomyelitis are edema and/or pain and formation of fistula. Radiologically, the condition demonstrates a radiopaque image with an unclear boundary. Early administration of antibiotics with an accurate diagnosis is the best approach to treatment of osteomyelitis, and intravenous injection rather than oral medication sometimes shows better prognosis. If osteomyelitis is confirmed by tissue biopsy, a surgical approach of removing the infection source and pus and concurrent administration of antibiotics is recommended for improved prognosis. However, if early diagnosis is not achieved or suitable antibiotics are not used, the prognosis may prove to be unfavorable due to the increase of focus or spread of infection to other bone sites. Based on the available clinical documentation the indicated procedure is an exploration of the area, removal of the root and treatment of the condition that is found. If there is a question, this can be documented, and the tissue submitted for biopsy. 

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

The insurer's denial of coverage for D7550 partial ostectomy/sequestrectomy for removal of non-vital bone, lower left quadrant is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anterior crossbite with gingival attachment loss.

Treatment comprehensive orthodontic treatment.

The insurer denied coverage for comprehensive orthodontic treatment.

The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the handicapping labio-lingual deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth (mandibular right canine) when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

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, a Handicapping Labiolingual Deviation Index is utilized. 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 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 criteria to justify orthodontic care. This reviewer score on the HLD index attains 15 points (4 overjet, 2 overbite, 5 anterior crowding, 4 labiolingual spread) which is below the required 26 points.

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 cited below.

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.

Comprehensive orthodontic treatment is not considered medically necessary for this patient

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

The insurer's denial of coverage for comprehensive orthodontic treatment is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee replacement
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a female with a complaint of long standing left knee pain and known left knee osteoarthritis. She underwent left primary total knee replacement. The surgery was successful with no documented complications. She remained in the hospital and was discharged home with home care. 

The inpatient hospital admission was medically necessary for this patient based upon the provided medical records and the recommendations of the current, peer-reviewed literature. The medical records document that the patient's blood sugars were elevated during her hospital stay. This required the use of insulin and close blood glucose monitoring after surgery. In addition, the patient had a drop in her oxygen level on post-operative day two. A chest x-ray was obtained which showed some evidence of fluid overload. This necessitated intravenous (IV) Lasix and the use of oxygen via nasal cannula.
Based upon the peer-reviewed article published by Edwards and colleagues in the Journal of Knee Surgery, inpatient care was necessary for this medically complex patient. The care rendered for this patient justifies the medical necessity of the inpatient hospital admission because oxygen monitoring and diuresis with Lasix cannot be accomplished in an outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I skeletal bite with Class II canines.
Treatment: Braces (D8080) and Monthly Visits x (times) 12 (D8670).

The insurer denied the Braces (D8080) and Monthly Visits x12 (D8670).  The denial is upheld.

This patient is a male with a Class I skeletal bite with Class II canines. There is moderate upper crowding and severe lower crowding. The health plan denial was due to an insufficient score on the Handicapping Index Scale and no auto-qualifiers.

No, the proposed braces and monthly visits are not medically necessary.

This patient has a Class I skeletal bite with Class II canines. There is also crowding. However, the requested braces and monthly visits are not medically necessary based upon the lack of occlusal problems (it is not over the threshold amount on the Handicapping Index Scale). In addition, there are no auto-qualifiers.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.