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

Diagnosis: Malocclusion, impacted permanent anteriors
 
Treatment: Orthodontic treatment

The insurer denied (D8080) braces and (D8670) monthly visit . The denial was reversed.

This patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to maxillary and mandibular crowding and impacted maxillary canines. The orthodontist completed the Handicapping Labio-Lingual Deviation (HLD) index as required. The insurer denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 20 points on review by internal reviewers. 

It is evident that the patient exhibits a significant malocclusion. To assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care the Handicapping Labio-Lingual Deviation Index Report ((HLD), New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index is required. 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.  

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 met and does support comprehensive orthodontic care. The clinical circumstance does 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.  

Based on the above, the medical necessity for (D8080) braces and (D8670) monthly visit is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

The patient is a female who presented to the hospital with a chief complaint of neck pain and concern for sickle cell pain crisis. She also complained of vaginal pain and reported a history of Bartholin's cyst. She denied tingling or weakness. She also denied abdominal pain. Review of systems was negative for fevers and chills. Past medical history included asthma and sickle cell anemia.

The patient was admitted for sickle cell pain crisis and labial cellulitis. The plan of care included analysis of urine, urine culture, monitor labs, intravenous (IV) fluids, IV opioids, acetaminophen, blood transfusion, and Keflex antibiotics for seven days. Gynecology also recommended warm compresses and found no evidence of fluctuance or active drainage. She received acetaminophen, morphine, Zofran, and tramadol. She was also seen by hematology. Symptoms improved and she was discharged home with a plan for outpatient follow-up.

The health plan's determination is overturned.

Inpatient medical care was medically necessary for treatment of the patient's condition. The reason is because the patient presented with sickle cell pain crisis and required IV opioids for at least 36 hours. Opioids are often used to treat vaso-occlusive crisis and patients managed with prolonged IV opioids, as this patient was, are typically treated at the inpatient level of care because of the increased risk of complications, such as respiratory depression, and the increased need for close monitoring and reassessment during treatment.
Patients with sickle cell pain crisis with ongoing IV opioid therapy are not typically treated at the observational level. They require close monitoring of vital signs to ensure that the patient does not become over-sedated or develop respiratory depression, and they require aggressive pain management. This patient's symptoms may also have been exacerbated by labial cellulitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Painful Scar Contracture of the Right Breast, Right Nipple Areola, Left Breast and Left Nipple Areola.

Treatment:  Revision of Reconstructed Breast

The insurer denied the Revision of Reconstructed Breast. The denial was reversed. 

This is a middle aged female who underwent an initial bilateral breast reduction secondary to bilateral Macromastia in early 2016.  Clinical notes from early 2018 indicated that the patient was experiencing pain and tenderness from the vertical scar secondary to irritation from the bra.  On examination of the right and left side vertical scars, there were signs of irritation, thickness and tenderness.  Scar revision of the vertical scars was discussed.  

The patient underwent excision and release of the scar contracture of the right breast, plastic surgical reconstruction of the right breast 6 cm x 4 cm total defect with local tissue rearrangement using advancement skin flaps, excision and release scar contracture the right nipple areola, complex repair right nipple areolar defect 10 cm x 1 cm, excision and release left nipple areola scar contracture, complex repair of the left nipple areola 13 cm x 1.5 cm defect, excision and release scar contracture left breast, plastic surgical reconstruction the left breast 6 cm x 3 cm total defect with local tissue rearrangement using advancement skin flaps.  The patient underwent removal of 78 g of tissue from the right side and 114 g from the left side.

The plastic surgery literature has several studies that show that outcome of breast reconstruction can change over time due to age and weight gain and loss.  Particularly with implant reconstructions, the quality of the reconstruction can change, and implants can rupture.  Breast reconstruction is not a one-time and done forever procedure.  Revisions are commonly required and can reasonably be considered a stage in breast reconstruction, which is now understood to be a multi-stage process, including revisions. Fat grafting and breast implant revision are stages of her reconstruction to restore her breasts to her pre-mastectomy appearance.  The documentation indicated that the patient was previously status post bilateral breast reduction.

Based on the above, the medical necessity for 19380-Revision of reconstructed breast is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Rectal swelling; pain
Treatment:  Inpatient admission

The inpatient admission was not medically necessary.

Perianal and perirectal abscesses are common anorectal problems.  The infection originates most often from an obstructed anal crypt gland, with the resultant pus collecting in the subcutaneous tissue, intersphincteric plane, or beyond (ischiorectal space or supralevator space) where various types of anorectal abscesses form.  

The primary treatment of anorectal abscess is surgical drainage.  Once diagnosed, all perianal and perirectal abscesses should be drained promptly; lack of fluctuance should not be a reason to delay treatment.  Any undrained anorectal abscess can continue to expand into adjacent spaces as well as progress to generalized systemic infection.

All incision and drainage procedures for anorectal abscesses follow the same general principles but may vary by surgical approaches (through a skin incision or into the rectum) depending on anatomical considerations.

The patient presented with classic signs and symptoms of a perirectal abscess with a localized infection only.  There were no evidence for a systemic spread due to the patient's vitals and laboratory studies.  Prompt surgical intervention was performed, and the patient was continued on antibiotics.  This patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is patient who was diagnosed with obstructive sleep apnea.  The polysomnogram revealed an apnea hypopnea index of 33.7.  The past related surgical history includes uvulopalatopharyngoplasty with partial inferior turbinectomy that afforded the patient no relief.  The patient  complains of daytime sleepiness and mild nasal congestion, and reports that he cannot tolerate positive airway pressure (CPAP).
The health plan's determination is upheld in whole.  Clinically, this is a patient with severe obstructive sleep apnea.  Currently there is a lack of efficacy and long-term outcomes in the peer reviewed medical literature in the treatment of obstructive sleep apnea.  Hypoglossal nerve stimulation in the treatment of obstructive sleep apnea remains in clinical trials and unproven in the treatment of obstructive sleep apnea.  This is a device that helps but does not cure obstructive sleep apnea.  Consequently, a patient such as this with severe obstructive sleep apnea has a lifelong problem.  There is barely five-year data in a device that is intended for lifelong use.  The implantation of a hypoglossal nerve stimulator system is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is the case of a previously healthy and developmentally typical male, who presented to the emergency department (ED) with a 5 day history of stuttering and expressive speech regression.  There was no fever or other symptoms of illness and no recent travel.  The patient, who had previously been verbal, was only able to communicate through gestures and one word answers.

In the ED vital signs were stable, and physical exam was unremarkable, except for lesions (probable molluscum) on the face and clear rhinorrhea.  Blood testing included complete blood count (CBC), which was normal; C-reactive protein (CRP) (4.374), erythrocyte sedimentation rate (ESR) (23), and Alk phos (1460) were all elevated.  Head computed tomography (CT) was normal for age.  Lumbar puncture was performed (normal cell counts), and patient was consulted by neurology.  Per neurology recommendation, the patient was admitted to the floor for video electroencephalogram (EEG) monitoring and head magnetic resonance imaging (MRI).  Head MRI revealed remote, nonspecific micro hemorrhages of the right cerebellum and was otherwise normal.  Differential diagnosis included encephalitis, tuberous sclerosis, epilepsy syndrome.

While inpatient, video EEG for 24 hours was normal, ruling out epilepsy as a cause.  In order to investigate possible causes for both the MRI findings and the patient's aphasia, blood work for vasculitis and hematologic conditions was drawn prior to the patient's discharge to home.

The health plan's determination is overturned.

This is a previously healthy child who was typically developing.  He experienced an acute regression of verbal skills, which has a broad differential diagnosis and complex work-up including blood work, lumbar puncture, and head imaging modalities.  This was best accomplished in an acute hospital setting given the patient's age, history of onset, and differential diagnosis.  In addition, given the diagnostic complexity and rapid onset, this patient had the potential for continued regression or deterioration, which required close monitoring.
Appeal type: Medical necessity
Decision: Overturned

Breathing Problem
Inpatient Hospital

This is the case of a previously healthy male who presented to the emergency department (ED) with a 1 day history of fever, cough, and rhinorrhea. Temperature maximum at home was 105, per mother. There was no vomiting, diarrhea, ear pulling, or rash. Urine output was decreased. The child attends daycare and immunizations are current. There is a history of prior hospitalization for bronchiolitis. Home medications include twice daily nebulized budesonide and albuterol as needed.

Complete blood count (CBC) results were white blood cell (WBC) count 24.5 with 68% segs, 21% lymphs, and 10% monos; hematocrit (Hct) 38, platelets (Plt) 308. Electrolytes were normal except for carbon dioxide (CO2) 18. Respiratory swab was positive for adenovirus; flu and respiratory syncytial virus (RSV) were negative. Chest x-ray showed no infiltrate. He was given 3 intravenous fluids (IVF) boluses and 2 ipratropium/albuterol nebs. He was admitted to the hospital for further care; he quickly spaced to every (Q) 4 hr. albuterol nebs and was able to be discharged home the following day.

The health plan's determination is overturned, in whole. 

This is a child with history of prior admission for bronchiolitis who is taking daily asthma medication. He presented with fever, cough and wheeze, and was found to have adenovirus. He was treated in the ED with multiple IVF boluses and nebulizer treatments and was noted to have continued vital sign (fever, tachycardia) and physical exam abnormalities. Therefore, given the time course of multiple hours in the ED and continued symptoms, this child required inpatient hospitalization for further management.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Edentulous
Issue under review: CT scan and dental procedures

Determination:
The CT scan and dental procedures are medically necessary.

The patient is edentulous (has no teeth). His upper and lower jawbones are flattened, especially the lower. This condition will severely compromise the retention of conventional dentures. There will be little to no suction. The patient also has a severe gag reflex, which means he cannot get a denture that fully covers his palate, like a conventional denture does. He will need the palatal part of the denture removed, which will totally destroy any retention the denture has. These conditions, little to no bone and the need for the palate to be removed means that the only way this patient can wear dentures is if they have implants to attach to. The patient also needs proper and adequate nutrition, which is why having stable dentures are needed to make sure his diet will help his medical conditions. Both his dentist and his physician have attested to the necessity of the implant denture procedures. This case has a medical necessity for the implants and the associated dentures for this person to properly chew and eat. This case follows all the needed benefit guidelines also.

In addition, CT scans are considered necessary to help determine just where the optimal place is for implant placement. Its use helps to avoid placing the implant in problem areas such as touch nerves or in sinuses.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mild Dementia with Behavioral Disturbances; Persistent Depressive Disorder
 
Treatment: Adult Medical Day Care Services

The insurer denied the Adult Medical Day Care Services. The denial was reversed.   

This is an elderly female who has attended an Adult Day Health Care program for a significant number of years. She has a history of hypertension, hyperlipidemia, pre-diabetes, depression, obesity, osteoarthritis, sleep apnea, asthma, irritable bowel syndrome, gastroesophageal reflux disease (GERD), transient ischemic attack (TIA), gait abnormality, and breast cancer. She required help with taking medications, handling finances, grooming, dressing, washing and bathing. Per the Core Service Review from early 2019, the patient relied on the program support where her breakfast and lunch were provided. The patient was taking Remeron and seeing a psychiatrist and required assistance with her psychiatric care compliance. Per the Uniform Assessment System (UAS) dated early 2019, the patient has reported depression and lacks family support. She spent 8 hours or more alone daily. She required assistive device for walking due to her unsteady gait.  With the support from the program, she is able to maintain medication compliance and ongoing support with activities of daily living (ADLs); provide assistance at the program (no specific ADLs noted). 

The psychiatrist noted that the patient has a diagnosis of mild dementia and she has poor short term memory.  Due to memory impairment, the patient faces challenges to properly manage her medications.  Day care records indicate that nursing staff assisted/supervised the patient's medication administration (most recently 6 drugs) in the morning and at lunch.  Nursing assistance with medication was first noted in the plan of care in 2017 and most recently noted in mid - 2019. This qualifies as a skilled need that was provided every day that she attended the program. The patient has memory impairment due to dementia.  It is unlikely that this is going to improve to any significant degree.  For a person with memory impairment who has no support system at home, there is a high risk for medication errors.  The more frequently assistance/supervision can be provided, the less opportunity for mistakes.  It is reasonable to consider that the frequency of medical day care 4 days per week improves the patient's overall compliance with medications. In addition, the patient has a diagnosis of depression.  The patients UAS indicated that she had feelings of anxiety and sadness, but mood was better when she attended the day care program 4 days per week.

The carrier's denial of coverage for Adult Medical Day Care services, 4 days per week is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior Crossbite
Treatment: Comprehensive Orthodontic Treatment
The comprehensive orthodontic treatment is medically necessary.

The patient has an anterior crossbite between teeth 7 and 26. This is causing an attachment loss around the lower lateral incisor. This "anterior crossbite with attachment loss" is an "automatic qualifying" condition according to the handicapping scale. Orthodontic treatment is needed to correct this condition. Therefore, the case has established medical necessity.
Appeal type: Medical necessity
Decision: Overturned

The patient has an anterior crossbite on teeth 11 and 22. She presents with a skeletal Class I malocclusion and significant crowding. Additionally, tooth #4 is partially impacted and is being prevented from fully erupting by the position of teeth 3 and 5. She is treatment planned for 24-30 months of orthodontics with extraction of teeth 5, 12, 21 and 21 to address the crowding and crossbite. This is the subject under review.

The health plan's determination is overturned. The Comprehensive Orthodontic Treatment: Braces medically are necessary for this patient.
Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. If left untreated the damage that will likely occur due to the impaction of #4 and/or the crossbite on #22 will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For these reasons, the treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The acute level care for the management of this patient was not appropriate or medically necessary. 

The patient was admitted with two-day h/o of abdominal pain, nausea, vomiting, and subjective fever. In the ED, she was hemodynamically stable and afebrile. Her abdominal examination was remarkable for right upper quadrant tenderness but no definite Murphy's sign. Her CBC did not reveal any leukocytosis and hemoglobin (Hb) / hematocrit (HCT) were normal. The CMP did not reveal any electrolyte imbalance or renal insufficiency. The liver function tests were moderately elevated. The ultrasound and CT scan of the abdomen revealed gall bladder thickness but no gall stones or biliary dilatation. The HIDA scan ruled out acute cholecystitis, and MRCP revealed gall bladder wall edema and no cholelithiasis, or choledocholithiasis. The patient was seen by GI and hepatitis work-up was done which was negative. The autoimmune markers were negative and EBV/CMV serologies were sent and the results were pending at the time of discharge. During her hospitalization, the patient was managed with supportive care with IV antiemetics, and IV pain medication. She was able to tolerate liquids after two days and her diet was advanced to full liquid as tolerated and then to regular diet. She was discharged in a fair stable condition. As this patient, did not demonstrate any evidence of hemodynamic instability, gastrointestinal bleed, Infection, or surgical abdomen, she could have been safely managed under a lower level of care, and acute inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: PANDAS
 
Treatment: Medication- IVIG Therapy

The insurer denied the IVIG Therapy. The denial was reversed.

This case involves a child who had a history of repeated strep infections.  The patient had a tonsillectomy previous, and has been treated numerous times with antibiotics.  He began licking everything around him and developed irritability with anger and extremely oppositional behavior.  He became aggressive, began bedwetting, and had regression of speech back to baby talk.  The patient has only had limited improvement in behavior with prior treatment.  He has been treated with psychotherapy, multiple psychiatric medications which caused many side effects but no benefit.  The patient had an anti-DNA SeB titer result of 594.  The physician indicated the patient met full diagnostic criteria for PANDAS, and recommended treatment with IVIG.  

This patient has had a trial and failure of multiple treatment options related to the diagnosis of pandas.  The patient has been treated with multiple antibiotics as well as undergone psychotherapy, been treated with antipsychotics and antidepressants, and has undergone a tonsillectomy, without benefit. Treatment with IVIG is appropriate for a severely affected child, and the patient has exhausted other treatment options.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heavy vaginal bleed; Anemia 

Treatment: Inpatient admission

The insurer has denied coverage for inpatient admission. The denial was upheld.

This patient is a female child who presented with a chief complaint of heavy vaginal bleeding, dizziness and weakness. The patient's hemoglobin level was 5.8 and hematocrit was 18%. She was admitted, hydrated and received one unit of packed red blood cells. Transvaginal ultrasound was unremarkable. Bleeding was most likely related to anovulatory uterine bleeding. She was started on oral contraceptives. The patient was discharged after symptoms had improved.  

This patient was actively bleeding. She was symptomatic for anemia. This patient fulfills the transfusion guidelines for use of blood components: her hemoglobin was less than 8g/dl and she was symptomatic (weak and dizzy), so transfusion was necessary. It is obvious that transfusions are done routinely in outpatient settings (oncology clinics, infusion centers, even at home), so the need for transfusion is not a reason for admission.The patient had a pelvic ultrasound and was started on oral contraceptives. Neither pelvic ultrasounds nor taking a pill requires hospital admission.

In summary, this patient could have been transfused in the ED, and given oral contraceptives without the need for inpatient admission. She could have been monitored for a few hours in the ED, her complete blood count repeated and then been discharged home with a follow up within 24 hours with her primary physician or gynecologist.

Nothing was done in the hospital that could not be done as an outpatient.

MCG lists the clinical indications for inpatient care for patients with anemia. These include active massive hemorrhage, active hemolysis, cognitive impairment, tachycardia, orthostatic changes, heart failure, chest pain, syncope. 

Following the transfusion, the patient was stable and did not have any of the above indications for admission.

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

Based on the above, the medical necessity for the inpatient level of care is not substantiated.  The insurer's denial is upheld.