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

Diagnosis: Malocclusion

Treatment: Orthodontics

The insurer has denied coverage for braces. The denial was reversed.

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.  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 on the HLD index. 

The patient exhibits a malocclusion.  The Handicapping Labio-Lingual Deviation Index Report 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 clinical circumstance as presented does substantiate medical/dental necessity of orthodontic care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skeletal class I, vertical growth pattern, permanent dentition, moderate maxillary and mandibular crowding, deep bite and slightly excessive overjet and anterior crossbite with gingival attachment loss (mandibular canines).

Treatment: Orthodontics

The insurer denied braces.  That denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, peer reviewed literature, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to Class I malocclusion, deep bite, anterior crossbite with gingival attachment loss, and vertical growth pattern.  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.  

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, a Handicapping Labiolingual Deviation Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other, secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care.  This reviewer concurs with attaining a score of 14 points on the HLD index (4 overjet, 3 overbite, 5 anterior crowding, 2 labiolingual spread) which is below the threshold of 26 points to justify orthodontic care.
Appeal type: Medical necessity
Decision: Overturned

The patient with past medical history significant for gastroesophageal reflux disease (GERD), bipolar disorder, and social anxiety, presented to the emergency department with chief complaint of fall backwards when getting up in the middle of the night to urinate. The patient denied chest pain, lightheadedness, recurrent episodes, or other recent illness. The patient did report sharp pain on the left side worse with breathing following the event. Otherwise, review of systems was negative.

On presentation to the emergency department, vital signs were within normal limits. Exam otherwise was notable for left chest wall tenderness and bibasilar crackles. Labs showed complete blood count (CBC) grossly within normal limits aside from mild anemia, basic metabolic panel (BMP) within normal limits, and troponin within normal limits. Computed tomography (CT) of the head revealed no evidence of intracranial hemorrhage. CT of the chest showed 7th and 8th rib fractures with lateral displacement. Electrocardiogram (EKG) did not reveal evidence of acute ischemia or arrhythmia. Given concerns for syncope and chest wall pain from rib fractures, the patient was subsequently admitted to the hospital. The patient underwent transthoracic echocardiogram (TTE) which showed no obvious valvular or other abnormalities. The patient was discontinued off telemetry and tamsulosin was stopped.The patient had an electroencephalogram (EEG) performed which was within normal limits. The patient remained in the hospital for pain control until ultimately was deemed stable for discharge.
The health plans determination is overturned.
Inpatient stay was medically necessary. The patient did not require inpatient services for syncope but did require them for pain management. As noted above, this patient had rib fractures that contributed to splinting which could result in complications such as pneumonia. Discharging this patient was not appropriate until the pain could be managed in the outpatient setting and avoid complications such as pneumonia. Acute inpatient hospitalization was necessary for this patient with severe pain requiring constant adjustment of pain medications and repeated doses of IV pain medications.
Appeal type: Medical necessity
Decision: Overturned

The patient and her spouse are carriers of Tay-Sachs disease. They are requesting in-vitro fertilization with preimplanatation genetic testing to prevent having a child born with the disease. The health plan has denied the IVF medications - Gonal F 225-300IU Daily 900Iu and Menopur 75-150 IU Daily as not medically necessary. The health plan's determination is overturned. The IVF medications are medically necessary for this patient. If services are not provided, the couple have a 25% chance of having a child with a fatal childhood disease. With the testing the chances of having a child with Tay-Sachs are less than 1%. IVF with PGT-M is in accordance with accepted standards of medical practice for this patient's circumstances.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicide Attempt, Substance abuse
 
Treatment: Inpatient admission

The insurer denied the continued inpatient. The denial was reversed

This patient was admitted to inpatient mental health treatment due to a suicide attempt by an intentional overdose of heroin and cocaine.  She reported depressive symptoms including depressed mood and feelings of hopelessness and worthlessness. She felt ashamed, had poor sleep and appetite, poor activities of daily living (ADLs), and had difficulty managing her substance cravings. This was evidenced by using cannabis, cocaine, and alcohol daily. She had also used heroin.  She had a positive toxicology screen for opiates, cocaine, cannabis, and methadone.  She was homeless, had no family support and had lost custody of her child.  She also had developmental delays and had intellectual Disability, in addition to depression and substance use.  She had past inpatient substance treatment, hospitalizations, and outpatient treatment including a Methadone Clinic.  It was reported that when she could not make it to her Methadone Clinic, she would use heroin instead.  In this hospital, she took Methadone, Venlafaxine, Zyprexa, and Gabapentin.  

This reviewer disagrees with the decision to deny coverage for continued inpatient mental health treatment in this hospital. This was a high risk patient who was using multiple substances and had made a suicide attempt by an intentional overdose of heroin and cocaine. On admission, she had worsened depression, she was homeless, she lacked family support, and had stressors including losing custody of her child. Additionally, she had developmental delays consistent with intellectual disability.  She needed to remain in this hospital setting until the next least available level of treatment was available. It was reported that the facility was working with OASAS (Office of Alcoholism and Substance Abuse Services) to attempt get her into a Methadone Maintenance Program upon discharge.  The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Suicidal Behaviors report that patients with suicide attempts are at high risk for suicide and also report that patients with major depressive episodes and co-morbid substance use are at increased risk of suicide.  Suicide attempts are the single most reliable indicator for suicide and this patient had a suicide attempt upon admission.  This patient made an intentional suicide attempt by an overdose of heroin and cocaine. She had worsened depressive symptoms, was using multiple substances of use, had developmental delays, stressors including loss of custody of her child, lacked family support and was homelessness. She was not considered to be safe for discharge from this hospital setting until her outpatient treatment was established.    The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

The patient with a past medical history significant for hypertension, hyperlipidemia, hypothyroidism, and depression  presented with complaints of subjective fever, chills, throat pain, malaise, and intermittent chills, muscle aches, and swollen glands for 4 days. Patient went to an urgent care center just one day before the day of admission wand was  prescribed Z-Pak. The  throat pain became worse and the  face started to swell up. The patient also complained of difficulty swallowing and voice changes.A computed tomography (CT) scan of the neck revealed findings reflecting bilateral parotitis and submandibular adenitis with associated subcutaneous facial edema. The patient was admitted to the hospital and placed in contact and droplet isolation. She was treated with intravenous antibiotics, and pain medications. The patient was started on a soft diet and warm compresses were applied. An IgM titer for mumps came back high confirming the diagnosis. County Department of Health was notified of findings. While in the hospital the patient remained afebrile with improvement in the facial swelling. The   health plan's determination of medical necessity was upheld in whole. According to the nationally recognized criteria, the patient did not meet medical necessity for an inpatient admission. Neither the severity of the patient's clinical condition nor the complexity of services provided justified admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation 

Treatment: Inpatient admission, diagnostic testing, medication management.

The insurer has denied inpatient admission. That denial was upheld.

This patient presented to the hospital with a complaint of palpitations and was found to be in new onset atrial fibrillation. 

Atrial fibrillation (AF) is the most common arrhythmia managed by emergency physicians. There is increasing evidence that most patients with recent-onset AF or atrial flutter (AFL) can be safely managed in the emergency department (ED) without the need for hospital admission. (1) 

The patient's heart rate was slowed with diltiazem and he was anticoagulated with Lovenox. The following morning, the patient had a transesophageal echocardiogram and was successfully cardioverted back to normal sinus rhythm with one electrical shock. He was asymptomatic while in the hospital, his two troponins were normal, and his EKGs showed no sign of myocardial injury or ischemia. The literature cited clearly documents that hospital admission is not medically necessary for patients who are asymptomatic, have normal vital signs and examination, and are oxygenating well. The acute hospital inpatient admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to the emergency room (ER) with complaints of abdominal pain.  Vital signs were stable.  A right upper quadrant (RUQ) ultrasound revealed a gallstone and positive Murphy's sign consistent with acute cholecystitis.  The the health plan's determination of medical necessity is overturned.  This patient presented to the emergency room with findings of acute cholecystitis, and a decision to proceed with surgical treatment was made.  The patient was treated with antibiotics and bowel rest, and a decision was made to take the patient for laparoscopic cholecystectomy.  The patient required treatment with IV antibiotics and IV pain medication that warranted acute inpatient admission consistent with standard guidelines.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hyperlipidemia, migraine headaches, and celiac disease. She presented to the hospital with blurry vision and a right facial droop. She also reported a frontal headache. The patient was admitted for headache and transient ischemic attack (TIA). The health plan has denied the inpatient admission as not medically necessary. The health plan's determination is upheld. The patient was hemodynamically stable and had already received an initial diagnostic evaluation for acute stroke with negative head CT and negative initial toxic-metabolic lab studies in the ED. She did need further evaluation to diagnose symptoms concerning for TIA/CVA, including echocardiogram and carotid ultrasound, and to treat headache/migraine, but this could have been safely and effectively provided at a lower level of care because of her stability at the time of admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchopulmonary dysplasia and severe subglottic stenosis
Issue under review: Inpatient rehabilitation

Determination:
The inpatient rehabilitation was medically necessary.

The patient in this case was a medically fragile child with complex medical and nursing treatment needs who remained technology-dependent after his laryngotracheal reconstruction surgery.  He required close monitoring of his pulmonary function due to his medical history of past hypoxic episodes related to subglottic stenosis.  The clinical notes document that the patient required regular stoma care, nebulizer treatments, suctioning, monitoring of vital signs and oxygenation, and several changes of his trach.  He did require non-invasive respiratory support with the high flow oxygen machine that he was using.  During this time, the patient's mother was being trained in how to manage and change his trach and how to perform CPR.  During this time, the patient was at significant risk for deterioration of his health status due to bronchopulmonary dysplasia and subglottic stenosis with hypoxic episodes.  The patient could not have been safely or effectively discharged to a lower level of care during this time.
Appeal type: Medical necessity
Decision: Upheld

The patient has a skeletal class III malocclusion, unilateral posterior crossbite, anterior crossbite, mild anterior and posterior open bite, moderate crowding and blocked out tooth #11. The subject to be determined is the medical necessity for braces. The health plan's determination is upheld.

The malocclusion in question does not meet the standard criteria to be classified as handicapping, and therefore treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, which is a standard tool used to evaluate for handicapping and treatment, the malocclusion would score a 21 with no auto qualifier present. Using this evaluation method requires a score of 26 or more for treatment to be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of  coronary artery disease with previous coronary intervention ,hypertension, hyperlipidemia, and a low ejection fraction. The patient  was admitted for an elective coronary intervention of the right coronary artery.The health plans determination of medical necessity is upheld The procedure  can be performed at a lower level of care status. Therefore,an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System (COPD), Infectious Disease (Upper respiratory tract infection)
Treatment: Inpatient Hospital
  
Summary: This patient with a history of chronic obstructive pulmonary disease (COPD) presented to the Emergency Department (ED) with complaint of shortness of breath, productive cough and symptoms of an upper respiratory tract infection. The patient reported running out of his inhalers two weeks prior. He denied fever and chest pain. Vital signs at presentation at 19:24 hours showed the patient was afebrile with temperature of 98.1F, heart rate 106, respiratory rate 26 and blood pressure 161/123. Oxygen saturation was 94 % on room air. Repeat vital signs approximately 45 minutes later showed the patient to be afebrile, heart rate 92, respiratory rate 18 and blood pressure 139/90. Oxygen saturation was 99%. The patient was in moderate respiratory distress. Lung exam revealed diffuse wheezes. White blood count was 12.6K, hemoglobin 14.7, electrolytes were within normal limits. Troponin was 0.01, Brain Natriuretic Peptide (BNP) 24. Electrocardiogram (EKG) showed sinus tachycardia and chest x-ray showed hyper-inflated lungs with no infiltrates. The patient was placed on bilevel positive airway pressure (BiPAP), treated with steroids, bronchodilators and Azithromycin. Arterial blood gases were 7.42/43/7427. Oxygen saturation was 95%. Repeat Arterial blood gases were 7.41/39/79/25 with 96% oxygen saturation. The patient felt better after treatment in the ED. As per history and physical at 01:52 hrs, the patient was on BIPAP. He was alert and oriented x3. Lungs were clear. Cardiac exam was within normal limits. He had no edema and was moving all extremities.

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

This patient's COPD exacerbation may have been secondary to upper respiratory infection and running out of his meds. The patient was afebrile and hemodynamically stable and remained so throughout his stay. He was not hypoxic and arterial blood gases were acceptable and revealed normal pH and acceptable PCO2 and PaO2. The patient did not have pneumonia. He felt better after treatment in ED. His lungs were described as clear on history and physical. This patient did not need acute hospitalization. He could have been placed on observation status while diagnostic testing and treatment were initiated. He was stable for discharge after overnight observation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine headache
Treatment: Aimovig
The requested Aimovig is not medically necessary.
There is no reason the patient cannot be treated with standard of care, first line, oral migraine preventive agents. There are no high quality clinical trials or standard of care guidelines supporting that Aimovig should be used preferentially or is superior to the preferred, oral migraine preventive agents.  None of the medications the patient has been treated with are first line migraine preventive agents. She does have a contraindication to beta blockers, but there is no contraindication to amitriptyline, divalproex sodium, topiramate or venlafaxine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The proposed inpatient hospital admission was not medically necessary.
This is a female patient who was admitted through the emergency room (ER) for history of chronic low back pain and atypical chest pain that had become worse over the previous days to week.  She was admitted for pain control. X-rays were ordered; labs were ordered. There was no evidence of caudal equine or acute herniated nucleus pulposus (HNP), and there was no need for immediate surgical intervention. Pain management consult was ordered.  The patient sees pain management as outpatient for chronic pain issues.  Magnetic resonance image (MRI) was ordered.  The patient was diagnosed with costochondritis and treated with Ketorolac.  The patient did not have a surgical issue; there was no reason the patient could not have been treated at a lower level of acuity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: End-stage renal disease
Treatment: Inpatient admission
The inpatient admission was not medically necessary.
The patient was without complaints on presentation and did not have hyperkalemia, uremia, acidosis, or volume overload.  Vital signs were within normal limits.  Hemodialysis was performed without complication.  There were no decompensated medical comorbidities.  In summary, inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Issue under review: inpatient admission

Determination:
Inpatient admission was not medically necessary

The patient was admitted with a one-day history of abdominal pain (left lower quadrant, and upper abdominal pain), nausea and vomiting, and was diagnosed with small bowel obstruction due to flare-up of Crohn's disease. She was treated with IV fluids, NG tube placement (which she pulled out) IV Dilaudid, Solu-Medrol and Cipro and Flagyl. She was started on clear liquid diet, which she tolerated well. The next day, her bowel obstruction resolved and she was able to tolerate PO diet well. She was discharged home on PO Cipro and Flagyl. Given this clinical scenario, acute level care for the management of her condition was not medically necessary. She could have been safely and appropriately managed under lower level of care.

She had no evidence of hemodynamic instability, bowel perforation, peritonitis, sepsis etc to support the acute level of care. Her bowel obstruction was transitory and resolved within 24 hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal pain
Treatment: Inpatient admission
The inpatient admission was medically necessary.
This little girl presented to the ED with prolonged gastrointestinal illness and resultant significant dehydration, raising concern for possible acute appendicitis. Comprehensive testing and surgical consultation in the ED did not reveal appendicitis. However, she continued to demonstrate multi-system involvement, with abnormal gait, initial refusal to walk, significantly distended urinary bladder with distended urinary collecting system, and elevated lipase. She had already been observed during her comprehensive evaluation in the ED and was not stable at that point for discharge home. While her symptoms and findings either improved (vomiting, fever, diarrhea, gait, ambulation, urination) or were not immediately retested (lipase) during her admission, the level of care needed to fully evaluate her and manage her symptoms was most consistent with acute inpatient.