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

Diagnosis: Anemia of Malignancy, Acute kidney injury (AKI)

Treatment hospital admission

The insurer denied coverage for hospital admission

The denial is upheld

This is a male with known metastatic prostate cancer, to multiple sites, atrial fibrillation, chronic kidney disease (CKD), who fell at the infusion center. The patient was sent to the emergency room (ER). In the ER his vital signs were stable. His creatinine was 2.67 (up from baseline), and electrolytes were otherwise normal.  A head computed tomography (CT) was negative. The patient was admitted to the hospital. Orthopedics was consulted the next day, and a magnetic resonance imaging (MRI) of the hip was obtained. He was given a transfusion and discharged home the following day.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The hospital admission was not medically necessary for this patient. This patient could have been managed in a lower level of care, such as observational status, on the date of service (DOS) in question. 

He would have been able to receive Amicar, transfusions, and monitoring of bleeding, in observational status. As this patient was hemodynamically stable and could have been managed in a lower level of care, acute hospitalization was not medically necessary for the date of service.

As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

"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).

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anterior crossbite.
Treatment: D8080 Braces and D8670 Monthly Visit.
The insurer denied the D8080 Braces and D8670 Monthly Visit.
The denial is overturned.

The patient is a female. The request is for orthodontic treatment (braces) and monthly visits.  Per the dental clinical summary: the patient presents with a class I skeletal relationship, moderate maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss (mandibular canine).

The health plan denied the claim because the patient did not score a 26, the score on the Handicapping Labio-Lingual Deviation (HLD) Index Report necessary for approval of the orthodontic treatment.  The attending physician (AP) appealed the case based on the seriousness of the diagnoses.

Yes, the proposed orthodontic treatment and monthly visits are medical necessary.
The severity of the crossbite and the rotation of the premolars are very evident and supported in the photos submitted.  The inflammation of the soft tissue (gums) around those teeth are very pronounced. This is based on the degree of malalignment of these teeth.  These conditions will impact the health of the gums, and ability to have normal chewing and speech function.

No, the health plan did not act reasonably with sound medical judgement and in the best interest of the patient.
The long term negative effects of non treatment will have far reaching negative consequences for this patient's dentition.

Deterioration of the gums, impaired speech and chewing function and possible eventual tooth loss is a high probability in a case of this severity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.

Treatment D8080 braces and D8670 visits x (times) 12.

The insurer denied coverage for D8080 braces and D8670 visits 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, 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 (mandibular left canine) in addition to 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 when clinical attachment loss and recession of the gingival margin are present. 

Upon review of the submitted documentation, 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, an HLD 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 met and does support comprehensive orthodontic care. In this case, 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. This is confirmed by several studies referenced below.

Each of the peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.

The healthcare plan did not act reasonably and with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for D8080 braces and D8670 visits x 12 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Maxillary and moderate mandibular crowding.
Treatment: Braces and Visits.
The insurer denied the Braces and Visits.
The denial is overturned.

The patient is a male. The patient has Class I skeletal occlusion. He has severe maxillary and moderate mandibular crowding. The health plan's reason for denial of coverage of braces was that the patient's HLD (Handicapping Labio-Lingual Deviation) score was 6.

Yes, the braces and visits are medically necessary.
The patient's tooth #7 (upper right lateral incisor) is in crossbite (reverse bite). When there is an anterior tooth in crossbite with gingival attachment loss, this is an automatic qualifier for orthodontic benefits. Treatment to correct this is medically necessary through orthodontic treatment.

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: Overturned

Diagnosis: Crowding; protrusion; open bite; overjet.
Treatment: Braces and Monthly Visits.
The insurer denied the Braces and Monthly Visits.
The denial is overturned.

The patient is a male. The request is for orthodontic treatment (braces) and monthly visits.

Per the dental clinical summary, the patient presents with a class I skeletal relationship, class II canines, mild maxillary and mandibular crowding, moderate maxillary and mandibular protrusion, open bite, moderately excessive overjet, impacted 3rd molars, and blocked out mandibular second molars.

The health plan denied the coverage for the requested braces. The denial is being appealed.

Yes, the requested orthodontic treatment and monthly visits are medically necessary.
The patient presented with a severe 4mm (millimeter) anterior open bite, as supported by the photos and x-rays submitted. An open bite is when the upper and lower teeth do not contact when the mouth is closed.

The seal that is created when the anterior teeth comes together is critical for swallowing, proper speech, proper chewing function, and maintaining proper alignment of the teeth in the arch.

Therefore, given the above, the braces and monthly visits are medically necessary.

No, the health plan did not act reasonably, with sound medical judgement and in the best interest of the patient.
The long term consequences of an anterior open bite typically will worsen over time and will manifest itself by decreased function and increased severity, along with additional shifting of the teeth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Kidney Injury. 
Treatment: Full hospital admission. 

The insurer denied coverage for full hospital admission. 
The denial is upheld. 

This is a female with past medical history of diabetes and pancreatitis. She presented to the emergency department with complaint of abdominal pain and tachycardia with heart rate to 107. Creatinine level was 2.4, with baseline of 1.0. Urinalysis positive for leukocyte esterase (LE). Chest x-ray was negative. The patient was admitted with diagnosis of acute kidney injury in the setting of a complicated urinary tract infection (UTI). The patient was given sliding scale insulin treatment, intravenous (IV) fluids, IV Rocephin and Maalox. The patient improved with treatment, and she was discharged home on oral cefpodoxime twice per day for 5 days. 

Per MCG (Milliman Care Guidelines) Health (25th) UTI (Urinary Tract Infection), patient fails to meet clinical indications for admission to inpatient care. These include hemodynamic instability, altered mental status that is severe or persistent, pregnancy greater than 24 weeks gestation, immunocompromised state, urinary system finding that requires invasive procedure or places patient at increased risk for systemic illness (Ureteral obstruction, stone, pyonephrosis, emphysematous pyelonephritis, etc). The patient had normal renal ultrasound and was hemodynamically stable through her hospital stay. 

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

The inpatient admission is not considered medically necessary for this patient. 

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

Diagnosis: asthma
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld.

The patient is a female with a history of asthma who presented with dyspnea, wheezing, and a productive cough.
In the emergency department (ED), the patient's temperature was 98.5, blood pressure (BP) 133/86, heart rate (HR) 115, respiratory rate (RR) 24, and pulse oximetry 96% (percent) on room air (RA). She was not in distress, breathing comfortably, diffuse wheeze, alert and oriented. White blood cell count (WBC) was 11.3, Na (sodium) 141, bicarbonate 22, blood urea nitrogen (BUN) /Creatinine 15/0.93, and venous blood gas (VBG) 7.33/43. A chest x-ray (CXR) was clear. She was diagnosed with an acute asthma exacerbation.

The inpatient hospital admission was not medically necessary.
She presented with shortness of breath (SOB) and was found to have an asthma exacerbation with no additional diagnoses. She did not present with severe disease, with no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, or acute kidney injury or electrolyte abnormality. She did not have any high-risk features. She did worsen early in the course but improved after an extra dose of intravenous (IV) steroids. Within an observation care time frame, she had improved and was ready for discharge. With a low severity of illness, low risk of bad outcome, and no additional diagnoses, she did not need inpatient only testing, monitoring, or treatment. She improved within an observation care time frame. As such, an inpatient hospital admission was not medically necessary. A lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Surgical Wound. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

This case involves a female with a history of right Achilles tendon surgery and repair who presents to the hospital with three days of drainage from the surgical site. The patient was receiving oral cefdinir, starting the night before the presentation, and expected the wound to get better within a few hours, but it continued to drain. She was referred to the emergency department for intravenous (IV) antibiotics. The patient denied fevers or chills, nausea, vomiting, diarrhea, or headache. 
Vital signs in the emergency department included a temperature of 36.9 C, blood pressure 129/80 and pulse rate of 83. The patient had generalized edema and tenderness to the right ankle on the exam. 

The patient was placed in the observation unit. 

The Inpatient hospital admission is not medically necessary for this patient. Observation is appropriate. At the time that the decision was made to admit the patient, she was responding to antibiotic therapy felt improved; there was no additional purulent drainage. The progress notes state that the patient should remain in the hospital to observe the wound. The patient remains afebrile, hemodynamically stable, and the white blood cell count is also improving. Therefore, all clinical parameters showed improvement at the time of the decision to admit to an inpatient level of care.
Based on the Milliman criteria for wound and skin management, inpatient criteria are not met. 
The patient underwent wound irrigation in the observation unit and surface debridement of hyperkeratotic skin. Beyond this, there were no necessary interventions. The patient is not septic; there is no evidence of necrotizing fasciitis or gas-producing infection on the imaging studies. Based on the images of the patient's wound supplied in the documentation, this is a very superficial-looking wound that does not track and is healing appropriately after the irrigation. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient stay. 
The denial is overturned. 

The patient is a male who presented with abdominal pain, nausea, and vomiting of 1-week duration. He had been seen 4-days earlier with the same symptoms but left the emergency department (ED) against medical advice. Past medical history included substance abuse. At the time of presentation, the patient was without fever, heart rate was 99 and blood pressure was 143/99 millimeters of mercury (mmHg). He was tender in the right upper abdomen and epigastrium. The white blood cell (WBC) count was elevated at 26.5 thousand (K). The complete metabolic panel identified elevated blood urea nitrogen (BUN) and creatinine (39/4.24) and elevated bilirubin (2.4). Abdominal ultrasound showed gallstones and findings of acute cholecystitis. He was admitted to the hospital with the diagnoses of acute cholecystitis, acute kidney injury and sepsis. 

The patient underwent laparoscopic cholecystectomy. The operative dictation describes findings of acute cholecystitis. The BUN and creatinine had normalized to 20 and 1.29. The WBC count was still elevated at 20.8 K. He was clinically stable following surgery and was treated with post-surgical monitoring, intravenous (IV) fluid, IV analgesia, antibiotics, and antiemetics. Post-operative day #2 following surgery, the patient had stable vital signs. BUN and creatinine were 13 and 1.05. The WBC count was still elevated at 12.5 K. The patient was having diarrhea and stool studies identified positivity for clostridium difficile. The diet was advanced. The patient was discharged from the inpatient setting with continued oral antibiotics for Clostridium (C.) Difficile colitis. 
The subject under review is the medical necessity for the inpatient stay. 

An inpatient level of care was medically necessary in this case. This patient presented to the hospital with acute cholelithiasis/cholecystitis, dehydration and acute kidney injury, a markedly elevated WBC count, and developed the post-surgical complication of Clostridium difficile colitis. These clinical conditions support the need for an inpatient level of care. The care provided in this case was expeditious and appropriate. The severity of his presenting condition supported the need for an inpatient level of care to provide IV antibiotics, acute surgical intervention, follow up lab data, IV fluid and detection of the post-surgical complication of Clostridium Difficile colitis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, left total knee replacement.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient had end stage left knee osteoarthritis. She failed conservative treatment and opted to undergo elective left total knee replacement surgery. The surgery was successful with no documented complications. She recovered well and was deemed stable for discharge home. At issue is the medical necessity of an inpatient stay.

The requested health service/treatment of an inpatient hospital stay was not medically necessary for this patient.

The provided medical records document that this patient underwent elective left total knee replacement surgery. The surgery was successful with no documented complications. The post-operative progress notes detail that the patient recovered well and progressed well with supervised physical therapy after the knee replacement surgery. There was no documentation of any bleeding complications or infection that would necessitate a two night inpatient hospital admission. The patient had a hypertensive episode and was administered anti-hypertensive medication and her blood pressure was normalized on post-operative day one.  The administration of these medications immediately after surgery did not necessitate inpatient admission. Therefore, the inpatient hospital stay for this patient was not medically necessary. The current, peer-reviewed orthopedic literature, including articles published by Leroux and colleagues and by Lovald and associates have documented the advantages and efficacy of both short stay and outpatient total joint replacement surgery. In their article in the Journal of Bone and Joint Surgery in 2020, Leroux and colleagues concluded that "When comparing matched cohorts of patients who underwent short-stay and longer-stay total hip arthroplasty (THA) or total knee arthroplasty (TKA), we observed no difference in outcomes, suggesting that a short stay with a discharge home in the appropriately selected patient is safe following THA or TKA." Thus, the care rendered for this patient did not require a two night inpatient hospital admission.

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

Diagnosis: Missing teeth.
Treatment: Implants (replacing teeth #4 and #13).

The insurer denied the Implants (replacing teeth #4 and #13).  The denial is upheld. 

The case is an request to review the medical necessity regarding proposed dental implant surgery to be performed on an adult male dental patient, who is missing two teeth. The request was previously denied on the basis that alternative, more conservative, treatments are available.

No, the proposed treatment is not medically necessary.

The case is a New York State Appeal request to review the medical necessity regarding proposed dental implant surgery to be performed on an adult male dental patient who is missing two teeth. The patient is missing these two teeth, and while implants are one treatment option available, they are not medically necessary. Alternative treatment options of fixed or removable dentally supported prostheses are also acceptable, serviceable alternatives.

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

The case is a New York State Appeal request to review the medical necessity regarding proposed dental implant surgery to be performed on an adult male dental patient, who is missing two teeth. The services were denied by a previous review. The requested services are reasonable when needed to replace missing teeth; or when needed to replace teeth that are lost.  However when alternate services are available that could be performed to treat a dental condition, it is reasonable and customary for health plans to cover benefits based upon the most conservative modality if such service would produce a professionally acceptable result under generally accepted dental standards. In this case request, more conservative alternative treatment options of fixed or removable dentally supported prostheses are also acceptable, serviceable alternatives.

Therefore the Plan has acted with sound medical judgment and in the best interest of the patient.  The denial is therefore upheld.