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

Diagnosis: Status asthmaticus.
Treatment: Inpatient admission.
The insurer denied coverage for Inpatient admission.
The denial is: Overturned.

This is an adolescent patient with a history of asthma with two previous admissions to the hospital for asthma. The patient had been sick with cold symptoms for 2 weeks and during this illness, the patient was seen by his pediatrician who treated the patient with Albuterol and Prednisone. The medical record indicates that the patient had been prescribed Montelukast in the past. When the patient was complaining of shortness of breath (SOB) during the night, the child's mother treated the patient with 2 Albuterol treatments at 2 AM and 5 AM. In addition, she administered another Albuterol at 8 AM before sending the child to school. When the child continued to have shortness of breath and was complaining of chest tightness at school the adolescent was sent by ambulance to the emergency room (ER) and the Emergency Medical Services (EMS) team administered 2 Combivent treatments during the ambulance ride to the ER.

In the ER, the patient was noted to be in respiratory distress with wheezing and tachypnea. The pulse oximeter reading was 92%. The child was treated with oxygen, 3 doses of Duoneb, Dexamethasone, and Magnesium Sulfate. There was a continued increase in work of breathing and wheezing following treatment in the ER. A chest radiographic image (x-ray) did not demonstrate pneumonia and a respiratory viral panel showed rhinovirus. Following treatment in the ER, the pulse oximeter remained in the 91- 94% range and the child continued to have wheezing. The decision was made to be admitted to the hospital with a diagnosis of status asthmaticus for continued treatment with oxygen, Albuterol every 3 hours and Atrovent every 6 hours.

The patient was treated appropriately in the ER for an acute episode of wheezing, and difficulty breathing. When the child failed to improve with treatment in home and the patient continued to have persistent hypoxemia and wheezing in the ER following appropriate therapy for asthma it was appropriate and consistent with the standard of care to admit the patient to the hospital with a diagnosis of status asthmaticus for ongoing treatment with oxygen and Albuterol every three hours.  The patient was not stable enough to be safely discharged.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient hospital stay is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: developmental delay
Treatment: genetic testing
The insurer denied genetic testing
The health plan's determination is overturned.

The patient is a boy who has been diagnosed with hypotonia, proximal muscle weakness, mild scoliosis, developmental delay and intellectual disability. A neuromuscular gene panel indicated that he has a PMP22 (peripheral myelin protein 22) deletion, which results in a Hereditary Neuropathy with Predisposition to Pressure Palsies. He also had a variant of unknown significance in the RYR1 (Ryanodine Receptor 1) gene. The deletion in the PMP22 does not explain his proximal muscle weakness nor his intellectual disability/developmental delay. His parents do not have a PMP22 mutation.

Genetic Testing: GeneDx XomeDxPlus - Trio is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
In a recent systematic review by the American College of Medical Genetics and Genomics (ACMG), authored by Manickam et al, the authors stated: "The literature supports the clinical utility and desirable effects of exome and genome sequencing (ES/GS) on active and long-term clinical management of patients with congenital anomalies (CA) with onset prior to age 1 year or developmental delay (DD) or intellectual disability (ID), and on family-focused and reproductive outcomes with relatively few harms. Compared with standard genetic testing, ES/GS has a higher diagnostic yield and may be more cost-effective when ordered early in the diagnostic evaluation." The authors concluded: "We strongly recommend that ES/GS be considered as a first- or second-tier test for patients with CA/DD/ID."
In a meta-analysis of whole genome sequencing versus whole exome sequencing versus usual care with regard to the diagnostic yield for children with suspected genetic disorders, Nurchis et al found that whole genome sequencing (WGS) had a diagnostic yield of 38.6%, in respect to whole exome sequencing (WES), 37.8%, and usual care, 7.8%.
Riley et al investigated the utility of genome sequencing (GS) in the diagnosis of suspected pediatric mitochondrial disease (MD). They reviewed 40 pediatric patients with clinical features suggestive of mitochondrial diseases. The authors found that "GS efficiently identifies variants in MD genes of both nuclear and mitochondrial origin. A likely molecular diagnosis was identified in 67% of cases and a definitive molecular diagnosis achieved in 55% of cases."
In summary, the GeneDx XomeDxPlus - Trio is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: developmental delay
Treatment: genetic testing
The insurer denied genetic testing
The health plan's determination is overturned.

According to the submitted medical records, the patient has a listed diagnosis of Charcot-Marie-Tooth Disease. He is reported to have developmental delay, low muscle tone. Genetic testing is being requested, as prior testing identified a PMP22 (peripheral myelin protein 22) deletion which does not explain all findings.

Genetic Testing: GeneDx XomeDxPlus is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Genetic testing in this case may enable a precise diagnosis be made, which would then direct more appropriate treatment, if available. The requested genetic testing is substantially more likely to establish a definitive diagnosis and is the only way to establish a definitive diagnosis in suspected Charcot-Marie-Tooth and related diseases.
Appeal type: Experimental/Investigational
Decision: Overturned



Diagnosis: developmental delay
Treatment: genetic testing
The insurer denied genetic testing
The health plan's determination is upheld. 

The patient is a young male with a history of global developmental delay and low muscle tone of unknown etiology. Magnetic resonance imaging (MRI) scan of the brain revealed encephalomalacia and evidence of possible remote strokes involving the parietal region. For evaluation of the cause of the neurodevelopmental problems, he has been tested with an In Vitae Comprehensive Neuropathies Panel and a Comprehensive Neuromuscular Disorders Panel. These panels revealed a PMP22 (peripheral myelin protein 22) deletion, consistent with Hereditary Neuropathy with Liability to Pressure Palsies. However, his physician feels that his symptoms are not consistent with that diagnosis. The provider suspects that the patient has a different genetic condition underlying his developmental delay and hypotonia. 

The genetic testing with GeneDx XomeDxPlus - Trio is not likely to be more beneficial that standard treatment. Whole exome sequencing is a genomic technique for sequencing all of the exomes (protein-encoding) regions of a patient's genome. While the technique can reveal genetic variants that might underlie a patient's condition, it virtually never reveals information that alters the clinical management of the patient. Therefore, the information revealed is almost never of actual clinical benefit to the patient. In this patient's case, this is especially true. He has developmental delay and hypotonia. He is not receiving any medications or special treatments for these conditions, and it is difficult to envision a scenario in which information regarding his gene sequence could be used to alter his management. It is further difficult to justify genetic testing in this case, based on the results of tests that have already been conducted. In particular, the magnetic resonance imaging (MRI) scan of the brain has revealed encephalomalacia and possible previous strokes. This result alone can account for the developmental delay and hypotonia. Therefore, based on the results of previous testing, the genetic testing is not indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right frontal intraparenchymal hemorrhage
Treatment: Occupational therapy (8 visits) 
The insurer denied occupational therapy (8 visits). 
The determination is upheld.


This is a patient with a history of a right frontal intraparenchymal hemorrhage, left hemiparesis, dysarthria, and hypertension. There is a history of the patient being struck on the right side of his head several times by an angry restaurant patron, 1 week prior to his initial hospitalization. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain showed an interval decrease in size of the right frontal hematoma. An electroencephalogram (EEG) showed seizure activity and he was prescribed Keppra. The patient was previously treated with subacute rehabilitation. His treatment has also included occupational therapy. At issue is the medical necessity of the requested health service/treatment of occupational therapy (8 visits).

The requested health service/treatment of occupational therapy (8 visits) is not medically necessary.
The patient's gait was unassisted and symmetric. There was no foot drop and no clonus. Strength was 5/5 on the right and 3/5-4 plus (+)/5 on the left.  There was slight shoulder subluxation on the left with decreased range of motion both active and passive for abduction and internal rotation. The occupational therapy note stated that there was a decline in grip strength and dexterity on the Nine Hole Pet Test. The decline in strength and dexterity was in comparison to a previous occupational therapy note. Presently, the patient could participate in a home exercise program to include strengthening and range of motion exercises. Occupational therapy (8 visits) is not medically necessary as there was no documentation of significant improvement in strength, range of motion, pain levels, or function. The peer-reviewed medical literature in the United States at this time would not include occupational therapy (8 visits). Further, the medical standard of care does not support occupational therapy (8 visits).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion

Treatment: Braces (comprehensive orthodontic treatment)

The insurer denied coverage for Braces (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, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 11 points by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September l, 2012, 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 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. 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 Braces (comprehensive orthodontic treatment) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is the case of a patient who presented to the emergency department (ED) with abdominal pain. As per the ED provider note, the patient had pain for 2 days and was recently evaluated at a hospital for similar complaints and was discharged with biliary colic. The symptoms were relieved and not being able to follow-up with surgery as an outpatient and with continued pain, the patient presented to this ED. The pain was colicky and radiated to the left shoulder. The patient denied fevers or chills. Exam revealed the patient to be afebrile, nontoxic in appearance, obese in mild discomfort. Abdomen was tender in the right upper quadrant (RUQ) without rebound or guarding. The plan was general surgery consult, possible discharge versus admission. The patient's white blood cell (WBC) count was 4.1, and liver function tests (LFTs) were normal. Lipase was normal. The patient was treated with ceftriaxone and Flagyl intravenous (IV). Computed tomography (CT) of the abdomen showed cholelithiasis with trace pericholecystic fluid raising concern for acute cholecystitis. Ultrasound of the abdomen revealed cholelithiasis with to normal to minimal gallbladder wall thickening and negative sonographic Murphy sign with no evidence to suggest acute cholecystitis.

Milliman Care Guidelines (MCG) General recovery care 27th edition Ambulatory surgery exception criteria GRG:CG-AEC (ISC GRG) notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: inpatient care needed for clinically significant preoperative disease or condition, complex surgical approach or situation anticipated, procedure is not low risk and patient at high anesthetic risk, presence of drug-related risk, inadequate outpatient care situation, postoperative event, condition, or finding that warrants inpatient stay. Given the above, the patient did not warrant inpatient status as she should have been managed in an ambulatory setting/observation setting. 

Finally, the reviewer is knowledgeable in this condition and the recommended health care services provided through actual clinical experience for this condition and therefore feel that the admission was not justified at the inpatient admission level as the patient should have been managed in an ambulatory/observation setting until the surgery was performed. The reviewer believes that based upon these findings the health care plan did act reasonably and with sound medical judgment. The criteria the reviewer has utilized included their personal experience as to what constitutes good acceptable standard of care, as well as the MCG guidelines as noted. 

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

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bowel obstruction. 
Treatment: SNF (skilled nursing facility) Alternate Level of Care. 
The insurer denied SNF Alternate Level of Care. 
The health plan's determination is upheld. 

The patient is a male who initially presented to the emergency room secondary to abdominal pain. The patient had a bowel obstruction secondary to malignant neoplasm. He underwent initial surgery with colostomy along with multiple complications and subsequent interventional radiology procedures. He was admitted to skilled care for follow-up and recovery from recent hospitalization. 

Skilled Nursing Facility (SNF) Alternate Level of Care is not medically necessary for this patient. The patient does not meet medical necessity criteria for continued inpatient skilled services. 
Specifically, the patient is not receiving any services such as advanced nursing services, wound treatment services and/or physical therapy services that would preclude the patient from receiving services at an alternate level care. 
The patient has had recent multiple medical problems including colostomy and recent cancer diagnosis, however, at the time of the determination, the patient did not have any acute medical needs requiring skilled services. There were no physician notes provided that documented the ongoing need for skilled services, there were no physical or occupational therapy notes provided to document the need for ongoing inpatient skilled services. There were no wound care notes or other notes which delineated the need for ongoing inpatient skilled services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Knee Osteoarthritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

According to the discharge summary this patient had a past medical history of schizoaffective disorder, nephrolithiasis, hyperlipidemia, obesity, sleep apnea, herniated disc, heart failure with preserved ejection fraction (EF) 61%, psoriatic arthritis, right knee osteoarthritis and underwent a right total knee arthroplasty. 

As per the discharge summary, the patient was initially to be done as an ambulatory case; however, because of uncontrolled pain and inability to be cleared by physical therapy he was kept overnight. Patient reported poor pain control with oxycodone, switched to oral Dilaudid with improvement in pain. The patient ambulated a total of 300 feet with physical therapy. Patient was hemodynamically stable for discharge. 

Based upon the information provided, the hospital inpatient admission is not justified at the acute inpatient level as the patient should have been treated on observation level of care.  The patient did not need acute inpatient admission.  According to MCG Health Guidelines Inpatient and surgical care 27th Edition: Knee arthroplasty, total ORG: S-700 (ISC) the operative status criteria is ambulatory for the majority of patients, specifically those undergoing a primary unilateral elective procedure who are without active or unstable comorbidities that significantly increase risk or require prolonged postoperative monitoring. It is inpatient for patients undergoing nonelective bilateral or revision procedures, patients with comorbidities which require more prolonged postoperative treatment or monitoring. Thus, this patient did not need an inpatient admission but rather 23-hour observation.

The reviewer, therefore, agrees with the insurer as the inpatient admission was not medically necessary at the acute inpatient level as the patient should have had the surgery done under a 23-hour observation/ambulatory status. The patient was admitted and had surgery on the same day and was discharged the following day. Thus, observation care was all that was needed.  Thus, the denial is upheld.  The reviewer does believe that based upon these findings the health care plan did act reasonably and with sound medical judgment.   

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbosacral disc herniation
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

This is a patient who presented to the emergency room (ER) with complaints of right lower extremity pain. The imaging revealed lumbosacral disc herniation with lumbar (L) 5-sacral (S) 1 lumbosacral radiculopathy. The patient underwent a right L5-S1 laminotomy, microdiscectomy for neural element decompression. Intraoperative findings noted right side L5-S1 lumbosacral radiculopathy. The patient was monitored after surgery and was discharged.

Based on the records reviewed, the admission was not medically necessary. The patient was stable after surgery. The patient had complaints of pain, however, there was no other indication for inpatient admission.

"Microdiscectomy is a safe and effective treatment modality for disc herniations. The landmark study of the Spine Patient Outcomes Research Trial used a large, multicenter, prospective, randomized controlled trial to compare open discectomy with nonoperative management. It has demonstrated that while both treatment groups did achieve good clinical outcomes, patients who underwent discectomy had greater improvement than those who had nonoperative management. A recent Cochrane database systematic review focused on open versus minimally invasive discectomy techniques. It presented low-quality data suggestive of lower infection rates, and shorter hospital stays, but possibly inferior improvements in back and leg pain with the minimally invasive techniques." (Dowling, T. J., et al, 2023)

"Discectomy is a classic surgical technique for the treatment of lumbar disc herniation (LDH). Traditional open discectomy causes disruption of the paraspinal muscles. Moreover, some complications are associated with discectomy, including durotomy, nerve root injury, surgical site infection and epidural hematoma. With the development of minimally invasive spine surgery techniques, the operating microscope and tubular or expanding retractor systems have been applied to discectomy surgery, thus introducing the concept of microdiscectomy (MD). Compared with open discectomy, MD has a more minimally invasive operation and can avoid the detachment of the lumbar paraspinous muscles. MD has become a standardized surgery and has been widely used for the treatment of LDH." (Lu, Y., et al, 2023)

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

The medical necessity for the inpatient hospital admission is not substantiated.