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

Diagnosis: Class I Malocclusion, Deep Impinging Overbite and Maxillary and Mandibular Crowding 
 
Treatment: D8080 Braces 

The insurer denied the D8080 Braces. The denial was upheld. 

This is a patient who consulted an orthodontist for orthodontic treatment. The patient underwent lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical imaging. A comprehensive orthodontic examination was performed including Handicapping Labio-Lingual Deviation (HLD) index. 

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 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 and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. This reviewer concurs with the insurer attaining a score of 19 points on the HLD index (4 overjet, 6 overbite, 5 anterior crowding, 4 labiolingual spread) which is below the threshold of 26 points 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. 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 healthcare plan acted reasonably and with sound medical judgment in the best interest of the patient. The carrier's denial of coverage for D8080 braces is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Foot Infection
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was upheld.   

This is a male patient with a medical history of substance abuse, herniated disc; status post L5-S1 discectomy. He presented to the emergency department (ED) with complaints right foot pain following intravenous drug injection. His presenting vital signs were stable, temperature 98.7 F, blood pressure 137/80, pulse 93, respiratory rate 18, and oxygen saturation 99% on room air. Laboratory results included the following; WBC-10, Hgb-13.8, Hct-40.5, glucose-143, creatinine-0.9, ESR-11. A chest x-ray was performed with negative results for infection. He was started on intravenous (IV) antibiotics empirically for a right foot infection. A right foot x-ray was done with negative results for an osteomyelitis. The patient was able to ambulate; he was requesting Morphine for pain management.  He remained afebrile and hemodynamically stable. He was discharged on oral antibiotics with outpatient follow up instructions.   

According to documentation, patient was admitted for a possible right foot infection. He was otherwise, afebrile and hemodynamically stable. Laboratory results were only notable for a mildly elevated WBC. The patient had a localized infection with no evidence of systemic toxicity, no failure of outpatient intervention, and no surgical intervention was required. Based on above findings, the patient was clinically stable for outpatient management. The patient did not meet criteria for acute inpatient admission.  

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

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

Diagnosis: Alzheimer's disease
Treatment: Nursing Services (including Private Duty Nursing)

The patient is a female with past medical history of Alzheimer's disease, osteoarthritis, coronary artery disease and skin cancer of the scalp who has 45.5 hours per week of personal care aide hours based on prior assessment. The provider requested an increase in hours of personal care services to 56 hours per week. The patient had a face to face assessment showing most of her assessments were similar to her previous assessment. The plan requested notes from PCP (primary care provider) outlining medical necessity for increased services but this was not received. The plan approved 45.5 hours per week. 

The health plan's determination is upheld. The increase in personal care aide service hours from 45.5 to 56 hours per week is not medically necessary. Per the assessment compared to repeat face to face assessment, the patient did not require an increase in personal care services. The patient actually required less assistance on two tasks and the same assistance with all other 13 tasks compared to the previous assessment. The patient's assessment of her needs for personal care aide service did not change. The patient's PCP requested and increase in personal care aide services but documentation of medical necessity was not provided. In summary, 56 hours a week of personal care services is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite 
Issue under review: Braces 

Determination: The braces are medically necessary.

The patient is an adolescent female. The patient has a deep, impinging overbite, with soft tissue damage to her palate. This is an automatic qualifying condition according to the handicapping index scale. Orthodontic treatment is needed to correct this.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary/Kidney Disorder 
Ambulance 

The patient is a male with a history of end stage renal disease (ESRD) on hemodialysis since beginning of 2016 due to type I diabetes mellitus (DM), hypertension (HTN), neurogenic bladder, peripheral neuropathy, diabetic retinopathy, hypothyroidism, and atrial fibrillation status post (s/p) ablation procedure. The patient was placed on the kidney and pancreas transplant wait list in another state. The patient received an organ offer for a combined kidney/pancreas transplant. He was transported to the other state via air ambulance. The subject under review is the medical necessity of the air ambulance transportation. Uphold in full the health care plan's determination of medical necessity. This case involves a patient with ESRD due to type I DM who is requesting coverage for air ambulance transportation from his home to another state to receive a simultaneous kidney-pancreas transplant. The patient's air ambulance transportation does not meet the criteria for non-emergency transport. There is no documentation as to why the patient had to be listed in another state. There are many other transplant centers much closer to where the patient resides which would not have required such a long transport time. The decision to list in another state is the right of the patient but the limits of the distance to the transplant hospital should have been disclosed to the patient. In addition, it is not the standard of practice for potential solid organ transplant recipient to travel from home to a transplant hospital by ambulance, either ground or air, when coming in for an organ offer. There is no reason that they cannot take private or public transport. Transplant centers often know about an organ offer many hours prior to organ procurement to allow time for transportation, dialysis or other procedures that might need to be done prior to surgery. There is no documentation regarding when the organ offers first became known or when the patient was notified as commercial air transportation might have been a viable option. In summary, the air ambulance is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Inpatient hospital

The patient is a girl who presented with a severe anaphylactic reaction.
She had a history of asthma and severe dairy allergy, with 2 prior episodes of anaphylaxis. It was unclear what she had ingested, however, she developed hives on her face and upper arms and her lips were pale and dusky. She also described having difficulty breathing. An ambulance was called and in transport she was given a dose of intramuscular epinephrine, Decadron, and Benadryl. In the emergency room, she was found to be tachycardic with a heart rate of 188 beats per minute (bpm). Her oxygen saturation was 89% on room air and she was irritable with a hoarse cry. Her physical examination was notable for perioral cyanosis and poor peripheral perfusion. She had a diffuse erythematous rash and peripheral cyanosis of her hands and feet. She was given an additional 2 doses of epinephrine within 30 minutes of arriving to the emergency department. She also received a bolus of normal saline, Pepcid, Benadryl, and 3 albuterol nebulized treatments for desaturations into the 80s. Following this treatment, her symptoms improved, and she was subsequently admitted to the pediatric intensive care unit for continued monitoring for anaphylactic shock, due to her very concerning presentation and the need to monitor for rebound symptoms.

The health plan's determination is overturned. The inpatient stay was medically necessary. This is a young girl who presented to the emergency department with a severe anaphylactic reaction. She initially had difficulty breathing, hypoxemia, and cyanosis. She required intensive treatment including epinephrine, corticosteroids, and diphenhydramine. She also required fluid resuscitation. She then required an additional 2 doses of epinephrine for persistent and severe symptoms.
All patients with severe anaphylaxis need to be admitted for further monitoring and prompt delivery of treatment as needed. This patient required admission to the intensive care unit, due to her severe episode of anaphylaxis, requiring multiple doses of epinephrine as well as additional supportive treatments, and the need for continued intense monitoring with prompt intervention as needed for potential rebound of symptoms that can be seen after epinephrine administration.
Appeal type: Medical necessity
Decision: Upheld

Gynecologic Issues
Inpatient Hospital

This is a patient who underwent a bilateral uterine artery embolization for uterine fibroids and vaginal bleeding and then was admitted as an inpatient for pain after the procedure. Vital signs were stable and there were no intraoperative nor postoperative complications with the procedure. She was given intravenous pain medication and then discharged home the following day with oral pain medication. At issue is the medical necessity of an inpatient hospital stay.
The health plan's determination is upheld.
The patient underwent the procedure, bilateral uterine artery embolization, without complications. She also had no comorbid conditions that would complicate her recovery. She had complaints of pain, however, there was no hemorrhage, infection, hemodynamic instability nor abnormal vital signs. Care could have been provided at a lower level without the need for full inpatient admission as pain control does not require an acute inpatient level of care. She was also discharged the following day with oral pain control. There are no laboratory tests, physical exams nor postoperative findings that would support the need for an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Displaced fracture to distal radius

Treatment: Inpatient level of care

The insurer denied coverage for inpatient level of care. The denial is upheld. 

This patient is a female with a history of hypertension and hypercholesterolemia. She sustained a fall and was evaluated in ED. She injured her right wrist and was diagnosed with a displaced fracture to distal radius. She underwent a closed reduction. She was provided with medications and admitted to hospital. She underwent open reduction internal fixation to her fracture. The post-surgical course was non-complicated. She was discharged.

The medical record was significant for admission to hospital. Surgery was performed. The woman did not require management of other underlying medical conditions. Her injuries were not complex, nor extensive. There was no evidence of high level service required, nor provided. Overnight stay at a lower level of care would thus be appropriate (Observation). The operation was performed through a limited incision, reduction completed and hardware placed. There were no complications, blood loss nor treatment for other injuries. 

There were no extenuating circumstances to require the inpatient admission and length of stay. The health plan acted reasonably with sound medical judgment 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Remitting multiple sclerosis (RRMS)
 
Treatment: Gammaplex Intravenous Immune Globulin (IVIG) 

The insurer denied coverage for Gammaplex Intravenous Immune Globulin (IVIG). The denial is upheld. 

This patient is a female who presented with relapsing-remitting multiple sclerosis (RRMS). The patient has tried multiple standard care treatments but could not tolerate due to adverse reactions. Considering this patient's clinical course of therapy, the patient's provider recommended IVIG treatment as the safest and the least immune suppressive option to treat this patient's RRMS, medical condition.

However, the literature support for IVIG treatment for RRMS is lacking. According to UpToDate, "Although data are equivocal, there is no compelling evidence that intravenous immune globulin (IVIG) is effective for patients with RRMS.  Some [177-180], but not all [181] early clinical trials reported beneficial effects for IVIG in RRMS.  However, these trials generally involved small numbers of patients, lacked complete data on clinical and MRI outcomes, or used questionable methodology [182].  A later multicenter placebo-controlled trial of 127 patients with RRMS found that IVIG treatment conferred no benefit for reducing relapses or new lesions on MRI [183]." A recent neurology systematic review stated that "There is insufficient evidence to determine the efficacy of the following [disease modifying therapies] compared with placebo in reducing the risk of disability progression in people with RRMS (very low confidence): azathioprine, immunoglobulins, IFN-[beta]-1b subcutaneous alternate day and methotrexate." As to date, literature review does not support the efficacy of IVIG treatment for RRMS. Thus, IVIG is not considered medically necessary to treat this patient's RRMS, medical condition.

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

The carrier's denial of coverage for Gammaplex Intravenous Immune Globulin (IVIG) is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I, Class II canines, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss
 
Treatment: Braces

The insurer denied coverage for braces. The denial is reversed. 

This patient is a male who presented for evaluation for orthodontic care.  The Orthodontist recommended comprehensive orthodontics due to skeletal Class I, Class II canines, maxillary and mandibular crowding, and anterior crossbite with gingival attachment loss.  The Orthodontist has completed the 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.  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 attaining a score of 12 points on the HLD index where 26 points is required.

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.  

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the use of 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 met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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

Based on the above, the medical necessity for braces is substantiated. The insurer's denial is reversed.
Appeal type: Formulary Exception
Decision: Upheld

This is a patient with a history of insomnia, headaches, hypothyroidism. She is requesting coverage for brand-name Ambien. She is on a large number of medications including multiple supplements, Belviq, eletriptan, and Xanax. In a progress note, her attending physician documents the patient's history of developing a side effect of insomnia from generic zolpidem. There is no further information regarding trials of other benzodiazepine receptor agonists. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.
The health plan's determination is upheld. It has not been established that all formulary preferred drugs have been ineffective, or would not be as effective, or would have adverse effects.
It has been clearly established that modern generic medications are bioequivalent to the brand name original agent and it is extremely rare for them to be less effective or more toxic than the brand name product. A search of the literature did not find any credible report compilations suggesting a significant issue with generic zolpidem versus brand name Ambien. Occasionally a patient will have an intolerance to one of the inactive components of a particular product. This is usually, and easily, rectified by switching to another generic version from a different manufacturer. In addition, there are other benzodiazepine receptor agonists available, such as eszopiclone and zaleplon, that are in the same class as zolpidem. There is no evidence that one of these products is superior to the other. There is no evidence that the patient tried and failed one of these other products. Finally, the drug-drug interactions and side effects in this patient on a large number of prescription medications and supplements cannot be predicted and may be contributing to her insomnia.
Appeal type: Medical necessity
Decision: Upheld

Hypertension/High Blood Pressure
Nursing Services (including Private Duty Nursing)

The patient is a male with a past medical history significant for hypertension, atrial fibrillation, coronary vascular disease and right above knee amputation (AKA) secondary to vascular disease. The patient also has issues with depression. The patient requests increase in personal care service hours to 7 days a week 24 hours live in services.

The health plan's determination is upheld. The increase in personal care services, 24-hours (Live-In) a day, 7 days a week is not medically necessary for this patient. The care plan noted that the patient required help preparing meals, housekeeping, laundry, shopping, managing medicines, dressing, bathing, personal hygiene and toileting. He was noted in his place of residence he has a shower chair and grab bars. He has a walker and also a wheelchair. There is noted to be intermittent incontinence of bladder and bowels. The plan provides pull ups to help with toileting needs. Overall, the services being provided are adequate to meet the patient's medical needs in the time noted. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not covered under the terms of the plan. In order for services to be considered medically necessary, the aid must be performing a service such as medically necessary ADL or IADL.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gait/mobility issues
Treatment:  Stair Lift

The proposed treatment of installation of a mechanical stair lift is deemed medically necessary. 

Patient is a female with a history of gait/mobility issues resulting in inability to climb stairs.  For this reason, installation of a mechanical stair lift is requested to assist the patient with going up/down the stairs in her home safely.

This is a female with a history of gait/mobility issues resulting in inability to climb stairs. The denial letter states that the patient has a lower level family room, which could be converted into a bedroom.  However, given no separating wall with attached bathroom, this would offer the patient zero privacy and lend to difficulty ambulating to and from the bathroom.  For these reasons, installation of a mechanical stair lift is deemed medically necessary to assist the patient with going up/down the stairs in her home to enter/exit her bedroom safely.  Hence, the proposed treatment of installation of a mechanical stair lift is deemed medically necessary.