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

Immunologic Disorder
Nursing Services (including Private Duty Nursing)

Diagnosis: rheumatoid arthritis
Treatment: Personal Care Worker (PCW) Service Hours 
The insurer denied the Increase in Personal Care Worker (PCW) Service Hours to 7 Days per Week/11 Hours a Day. The health plan's determination is upheld. 

The patient is a female with a past medical history significant for rheumatoid arthritis, osteoarthritis, dyslipidemia, hypertension, osteoporosis, coronary artery disease, obesity, breast cancer and is status post bilateral knee replacement.
The request is for an increase in personal care service hours to 7 days per week 11 hours per day for total of 77 hours a week. The patient is currently receiving 6 hours a day 7 days a week for a total of 42 hours a week.

The Increase in Personal Care Worker (PCW) Service Hours to 7 Days per Week/11 Hours a Day is not medically necessary for this patient. According to the UAS there has not been a significant change in the patient's condition or cognitive status since the last evaluation. The hours which are approved (42 hours a week) are sufficient to meet the medically necessary services for the patient. Additional services/patient care service hours for monitoring without a specific noted task would not be medically necessary. In order for services to be considered medically necessary there must be demonstrated medical need such as support for an ADL or IADL. Additional needs were not noted in the information provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders
Treatment: Inpatient Hospital
The insurer denied: Inpatient stay
The denial is: Upheld in whole

The patient is a female with past medical history of hypertension, hyperlipidemia, obesity, and prior vein stripping of her right leg with subsequent development of a keloid, who presented to the emergency department with right leg pain with yellow drainage. She denied fevers, chills, nausea vomiting, or other symptoms aside from mild cough for the past 2-3 weeks.

On presentation, she was afebrile with blood pressure 165/91, heart rate 92, respiratory rate 18, and with oxygen saturation of 96% on room air. Exam otherwise noted right lower extremity that was erythematous, warm to touch with a large open ulcerated lesion on the posterior leg that weeping with serosanguinous drainage. Labs resulted with white blood cell (WBC) count of 15.22, hemoglobin (HGB) 10.8, platelets 458, sodium 140, potassium 3.5, blood urea nitrogen (BUN) 36, creatinine 1.54, and liver function tests within normal limits. X-ray of the right lower extremity showed no evidence of tissue gas or underlying osteomyelitis. In the emergency department, she was given intravenous (IV) antibiotics, an IV fluid bolus, Benadryl, oxycodone and aspirin. She was subsequently admitted to the hospital with concerns for lower extremity cellulitis and acute kidney injury and plans for IV antibiotics, duplex of the lower extremity to rule out deep vein thrombosis, IV fluids, renal ultrasound, wound care consult, and possible infectious disease consultation.
Venous duplex subsequently revealed no evidence of deep vein thrombosis and renal ultrasound showed no evidence of hydronephrosis.

The health plan's determination is upheld.

the requested health service/treatment of inpatient stay medically necessary for this patient. 
This is a patient with a chronic history of keloid who presented with lower extremity cellulitis and ulceration. She had leukocytosis and mild tachycardia on presentation in addition to mild acute kidney injury. She otherwise had no fever or hypotension, had not failed outpatient treatment with oral antibiotics or local wound care, and did not have a high risk comorbidity such as uncontrolled diabetes or other immunocompromise placing her at high risk of failing outpatient therapy. She additionally improved quickly with IV antibiotics, IV fluids, and local wound care, and was subsequently able to be discharged within a reasonable period of time.
In the absence of a high risk comorbidity placing her at risk of outpatient treatment failure (significantly uncontrolled diabetes, other immunocompromise, severe peripheral artery disease, etc.), fevers, chills, hypotension, or failure of outpatient therapy, this patient presenting with leg ulceration and cellulitis accompanied by leukocytosis and mild acute kidney injury both of which improved rapidly within a reasonable period of time could have been treated at a lower level of care status. Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cardiac/Circulatory Problems / Other 
Treatment:  Radiology Services 

The patient has a history of essential hypertension, hyperlipidemia, asthma, obstructive sleep apnea (OSA) treated with continuous positive airway pressure (CPAP) and abnormal computed tomography (CT) calcium score consistent with coronary artery disease.  A follow up exercise stress test was normal.  The patient has been treated with aspirin and high intensity statin therapy.  The patient has complaints of dizziness and paresthesia of the lower extremities.  For further cardiovascular risk evaluation the patient's treating physician ordered bilateral lower extremity ankle brachial index (ABIs) and carotid arterial doppler.  Overturn in whole the health plan's determination of medical necessity.

Yes, the treating physician's request for resting ABI and carotid duplex studies are medically necessary to evaluate for vascular disease in this patient, who is at elevated risk.  With the results of these vascular studies the treating physician would have the necessary clinical information to appropriately treat to reduce risk of future cardiovascular events.  Additional clinical information was provided and reviewed for this case that highlights the patient's elevated coronary calcium score and hyperlipidemia.  This information does not change the medical necessity determination for this patient.  The treating physician's evaluation and management plan of obtaining lower extremity ABI and carotid doppler tests for further cardiovascular risk evaluation was medically necessary.  Given the patient's abnormal CT calcium score and cardiovascular risk factors of hypertension and hyperlipidemia, he is at risk of having vascular disease of the lower extremities and extracranial carotid disease.  According to the 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease published in the Journal of the American College of Cardiology, it is reasonable to evaluate for lower extremity peripheral artery disease (PAD) by resting ABI doppler given the increased prevalence of disease in asymptomatic patients (1).
Based on the pertinent clinical information of this case and the referenced guidelines on the management of patients with lower extremity peripheral artery disease and extracranial carotid and vertebral artery disease, the ABI and carotid duplex scan are medically necessary to optimally care for this patient (1,3).
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with multiple uterine fibroids, the largest is 8.1 centimeters (cm) with an enlarged uterus. She has menorrhagia and pelvic pain. She had a uterine artery embolization in 2009, however, her symptoms did not resolve. No anemia was documented for her menorrhagia. She has opted for a laparoscopic radiofrequency ablation, however, this has been denied by the health plan. no anemia was documented for her menorrhagia.
The health plan's determination is upheld.
The proposed health service or treatment ablation with imaging guidance surgery is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. This is a patient with multiple uterine fibroids. She has menorrhagia and pelvic pain.
In 2012, the Acessa System approved by the Food and Drug Administration (FDA) for percutaneous laparoscopic coagulation and ablation of soft tissue and treatment of symptomatic uterine fibroids under laparoscopic ultrasound guidance. Berman in 2014 found that radiofrequency volumetric thermal ablation of uterine fibroids resulted in sustained relief from fibroid symptoms and continued improvement in health-related quality of life through 36 months postablation. The cumulative re-intervention rate is 10.4 % at 36 months. The investigators concluded that the low re-intervention data through 36 months is a positive outcome for patient well-being. Brucker (2014) reported that radiofrequency volumetric thermal ablation resulted in the treatment of more fibroids, a significantly shorter hospital stay, and less intraoperative blood loss than laparoscopic myomectomy. However, neither study compared this technique to a traditional hysterectomy and no long term studies have been completed to show long-term effects. In addition, the studies were completed by the parent company.
Therefore, there is no proven benefit over traditional therapy such as hysterectomy.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a patient with multiple uterine myomas and menorrhagia who has been recommended treatment with imaging guided ablation of her myomas. At issue is whether the ablation with imaging guidance surgery is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
The health plan's determination is upheld.
The proposed treatment of the ablation with imaging guidance surgery is not likely to be more beneficial than any standard treatment or treatments for the insured's condition. 
This is a patient with multiple uterine myomas and menorrhagia. There is no data to show that use of this treatment is superior or safer to other treatment options including use of the Mirena intrauterine device (IUD), or progestin or hormonal therapy or other surgical procedures. There is no data to show that this treatment is safer than the other options listed above. It is not standard of care, it is not supported by professional organizations, and lacks data from well conducted studies to show that it is safer or superior in efficacy to other treatment options.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class II canines, maxillary and mandibular crowding and anterior crossbite

Treatment: Orthodontic treatment (braces) and periodic treatment visits

The insurer denied coverage for orthodontic treatment (braces) and periodic treatment visits.

The denial is upheld. 

The patient is a female. Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to Class II canines, maxillary and mandibular crowding, and anterior crossbite. 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 to support orthodontic necessity.

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 as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion.

In this case, the clinical circumstance does not meet criteria to justify for orthodontic care. This reviewer concurs with the HLD index of the insurer attaining 19 points (3 points overjet, 1 point overbite, 6 points ectopic eruption, 5 points anterior crowding and 4 points labiolingual spread). 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. Thus, the orthodontic treatment (braces) and periodic treatment visits are not considered medically necessary for this patient.

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

The carrier's denial of coverage for the orthodontic treatment (braces) and periodic treatment visits should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Incontinence
Treatment:  Non-sterile gloves
The insurer's denied the Non-sterile gloves.
The determination is upheld.

The patient has multiple medical problems. He states that he has problems with intermittent incontinence and the aide uses gloves to help him with his care. The patient has a past medical history significant for urinary incontinence, weakness, status post pacemaker, cardiac arrhythmia, insomnia, osteoarthritis, lower extremity edema, recurrent falls, blurry vision, Alzheimer's disease, hypertension, dysphagia, hearing loss, hypothyroidism, osteoarthritis of the spine, coronary artery disease, benign prostatic hypertrophy, dysuria, type 2 diabetes and gastroesophageal reflux disease. This review is for the medical necessity of nonsterile gloves size medium, 1 box per month. These were denied based upon medical necessity. At issue is the medical necessity of nonsterile gloves.
The requested health service is not medically necessary for this patient.
The Uniform Assessment System (UAS) State of New York was reviewed. Per the UAS, there were noted no pressure ulcers or other skin lesions. The patient does not use any type of catheter or other urinary collection device. The patient does not use any type of ostomy device for bowel incontinence and his skin is reported as intact.
Therefore, the patient has no medical needs that would require him to use nonsterile gloves.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Gait ataxia, Meniere's disease, CHF.
Treatment:  Increase in Personal Care Assistance service hours to five hours/day, seven days/week, for a total of 35 hours/week.
The insurer denied the increase in Personal Care Assistance service hours to five hours/day, seven days/week, for a total of 35 hours/week.  The denial is overturned. 

The patient is a female with a history of morbid obesity, gait ataxia, Meniere's disease with associated dizziness and congestive heart failure (CHF).  Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs).  Appeal review requested for potential approval of an increase in Personal Care Assistance service hours to five hours/day, seven days/week, for a total of 35 hours/week to offer increased assistance with completion of the patient's ADLs.

Yes, the proposed treatment of an increase in Personal Care Assistance service hours to five hours/day, seven days/week, for a total of 35 hours/week is deemed medically necessary. 

This is a female with a history of morbid obesity, gait ataxia, Meniere's disease with associated dizziness and CHF.  Due to impairments related to these conditions, she requires assistance for completion of many of her activities of daily living (ADLs).  Recent correspondence from the patient's provider indicates that the patient has demonstrated progressively worsening functional decline due to recent hospitalizations for treatment of CH exacerbation, worsening gait ataxia, venous sufficiency and lower extremity cellulitis.  Due to her worsening functional status, she now requires more assistance with ambulation, food preparation, cleaning, laundry and dressing.  For these reasons, the currently approved plan of 15 hours/week Personal Care Assistance service is insufficient to meet the patient's current needs.  Hence, the proposed treatment of an increase in Personal Care Assistance service hours to five hours/day, seven days/week, for a total of 35 hours/week is deemed medically necessary to offer increased assistance with completion of the patient's ADLs.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Central nervous system/ Migraine 
Treatment: Pharmacy Prescription drugs 

The insurer denied Treximet. The denial is upheld. 

Treximet is a fixed-dose combination tablet that contains 119 milligrams (mg) of sumatriptan succinate, which is equivalent to 85 mg of sumatriptan and 500 mg of naproxen sodium. Sumatriptan and Naproxen are available separately as generic products. There have been no clinical studies to demonstrate that Treximet is superior to the combination of both generic agents. The patient failed Almotriptan, Rizatriptan, and Zolmitriptan. There is no documentation of a trial of generic Sumatriptan used concurrently with Naproxen which would be equivalent to Treximet. 

There is insufficient evidence to conclude that Treximet is safer or more effective than the formulary drugs (Eletriptan, Naratriptan, Rizatriptan, Sumatriptan nasal spray, Sumatriptan tablet, Zolmitriptan, Zembrace Symtouch, and Zomig nasal spray).
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer 
Treatment: Diagnostic laparoscopy and cytoreductive (the use of extreme cold to destroy abnormal tissue) surgery with HIPEC (hyperthermic chemotherapy)
The insurer denied the Diagnostic laparoscopy and cytoreductive (the use of extreme cold to destroy abnormal tissue) surgery with HIPEC (hyperthermic chemotherapy).
The denial is overturned.

The health plan should cover the proposed treatment.

The patient is a female with metastatic adenocarcinoma of unknown primary to the peritoneum felt to be possibly pancreatic cancer.  She was initially treated with Folfox.  The attending physician (AP) has now proposed cytoreductive surgery with Hyperthermic Intraperitoneal Chemotherapy (HIPEC).  

The proposed HIPEC cytoreductive therapy proposed would be more beneficial than standard therapy (observation) for this individual. 

HIPEC therapy remains controversial for multiple malignances with the exception of appendiceal mucinous carcinoma and primary peritoneal mesothelioma.  The approach has been used in multiple malignances such as colon cancer, gastric cancer ovarian cancer with various degrees of success.  Studies of this method are highly flawed by patient selection bias.  The theory of this approach is that the peritoneal surface dose not generally experience therapeutic levels of systemic cancer chemotherapy and that by performing surgery with debulking, followed by heated chemotherapy that these areas can be exposed to tumoricidal concentrations of chemotherapy.  This in turn leads to improved tumor control and prolonged survival.  

This patient has disease limited to the peritoneum with no evidence of disease outside the abdomen with good control to initial systemic therapy for her cancer of unknown primary. Patients such as this are typically included in HIPEC studies and appear derive benefit.  Therefore it is concluded that the proposed HIPEC cytoreductive therapy proposed would be more beneficial than standard therapy (observation) for this individual.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer 
Treatment: Diagnostic laparoscopy and cytoreductive (the use of extreme cold to destroy abnormal tissue) surgery with HIPEC (hyperthermic chemotherapy)
The insurer denied the Diagnostic laparoscopy and cytoreductive (the use of extreme cold to destroy abnormal tissue) surgery with HIPEC (hyperthermic chemotherapy).
The denial is overturned.

The health plan should cover the proposed treatment -- diagnostic laparoscopy and CRS/HIPEC. 

The patient is a female. She was diagnosed with peritoneal carcinomatosis of adenocarcinoma of unknown primary site. She requested approval to undergo diagnostic laparoscopy, cytoreductive surgery [CRS], and hyperthermic intraperitoneal chemotherapy [HIPEC] with an out-of-network surgeon, one who "has extensive experience treating all forms of gastrointestinal and gynecological tumors with perfusion to the peritoneal cavity". 

Diagnostic laparoscopy entails determining feasibility of proceeding with CRS/HIPEC; CRS entails resection of all macroscopic disease; and HIPEC entails infusion of heated chemotherapeutic agents into the abdominal cavity. 

The requested health service or procedure is likely to be more beneficial than any standard treatment or treatments for the insured's condition or disease. 

For patients with peritoneal carcinomatosis, compared to systemic chemotherapy, CRS/HIPEC offers improved overall survival -- "a randomized trial compared systemic 5- FU/oxaliplatin to cytoreductive surgery and intraperitoneal 5-FU without heat. Although terminated prematurely because of poor accrual, analysis suggested that the cytoreductive surgery plus IPEC approach may have been superior to the systemic therapy approach (two-year OS, 54% vs. 38%; P = .04)" [NCCN]. 

Moreover, since the patient already underwent chemotherapy, CRS/HIPEC constitutes the next steps in treatment -- to eliminate or reduce residual disease.

Guidelines from the National Comprehensive Cancer Network (NCCN) state: "complete cytoreductive surgery and/or intraperitoneal chemotherapy can be considered in experienced centers for selected patients with limited peritoneal metastases for whom R0 resection can be achieved.". In summary, the patient should be treated in an "experienced center".
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Alcohol/Substance Abuse
Treatment Inpatient Substance Abuse Services
The insurer denied Inpatient Substance Abuse Services
The determination is upheld.

The patient was admitted to inpatient detoxification for alcohol and benzodiazepine use disorders. His toxicology on admission showed positive for benzodiazepines and cannabis. His blood alcohol (BAL) was zero. His last drink was 1 day prior to admission. He was homeless and lacked social support. It was noted that he needed to develop more skills. His Clinical Institute Withdrawal Assessment (CIWA) was low. He had no active mental health conditions or symptoms. It was noted that his symptoms warranted medical supervision. A 4-day Librium protocol was started. However, the patient refused the treatment. He then was discharged AMA (Against Medical Advice). At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient substance abuse services was not medically necessary for this patient. He did not have any BAL on admission. He did not have any major withdrawal symptoms from alcohol or other drugs. He had no active psychiatric condition which required him to be treated at the inpatient level. His CIWA score was low. Data suggests that his condition could be treated at a lower level care The LOCADTR criteria was reviewed. It was noted that the patient's substance with the most potential to cause harm was alcohol. However, his BAL level on admission was zero. It was also noted that he was experiencing cravings. He had no unstable medical or physical disorder as major risk factors. He did not have any major withdrawal symptoms from alcohol or other drugs. He reportedly had interpersonal or personal skill deficits which could be managed at a lower level of care. 
Therefore, the requested health service/treatment of inpatient substance abuse services was not medically necessary for this patient.