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

Diagnosis: Lymphedema, hepatitis and cancer
Treatment: in Personal Care Services, 24 hours a day, 7 days a week (split shift) (Mutual Case)
The insurer denied coverage for in Personal Care Services, 24 hours a day, 7 days a week (split shift) (Mutual Case).
The denial is overturned

This is an elderly patient with hepatitis, lymphedema and end stage metastatic cholangiocarcinoma. She is on hospice care. The patient lives with her spouse who has medical problems (including dementia, legally blind and poor balance) and is unable to assist with her care. The insurer approved personal care services (PCS) 12 hours/day, 7 days/week (mutual case) for a total of 84 hours/week. The request is for PCS 24 hours a day, 7 days a week (split shift); which is currently under review. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as modified independent. However, she requires maximal assistance to total dependence for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also totally dependent for lower body dressing, locomotion, and toilet use.  Maximal assistance is needed for bathing and toilet transfers. She requires extensive assistance for personal hygiene, upper body dressing, bed mobility and eating. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. She requires continuous nasal oxygen at night. Her functional ability has declined, and she has fallen several times over the prior 90 days. She is no longer ambulatory.

The patient's medical condition and functional ability are at a level and will continue to rapidly decline, rendering the requested PCS 24 hours a day, 7 days a week (split shift) as medically necessary. The option of live-in PCS is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain an uninterrupted 5 hours of sleep. Of particular concern are the patient's need for repositioning while in bed with a frequency of at least every 2-3 hours, her ongoing diuresis needed to improve oxygenation and decease ascites/lymphedema (with frequent bladder incontinence), aspiration risk due to frequent vomiting as well as her significant risk for pressure ulcers and contractures. Based on the enclosed documents reviewed, the patient's health and safety in the context of her terminal condition and functional needs are more appropriately provided and maintained at home with PCS 24 hours a day, 7 days a week (split shift) (Mutual Case), for a total of 168 hours.

Based on the above, the insurer's denial must be overturned. 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 increase in Personal Care Services, 24 hours a day, 7 days a week (split shift) (Mutual Case) for a total of 168 hours is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Attention Deficit Disorder. 
Treatment: Formulary exception for Vyvanse 70mg (milligrams) caps. 

The insurer denied: Formulary exception for Vyvanse 70mg (milligrams) caps. 
The denial is upheld. 

The patient is a teenaged female. She has been diagnosed with attention deficit hyperactivity disorder and co-morbid major depressive disorder. The patient is prescribed Vyvanse at a dose of 70 mg (milligrams) daily, with benefit from this medication noted by the patient's prescribing clinician. 

The health plan has denied coverage for Vyvanse based on the plan formulary. The patient has not failed to benefit from formulary alternatives for treatment of the ADHD (attention deficit hyperactivity disorder)/ADD (attention deficit disorder). The health plan requires that formulary alternatives be tried and fail before prior authorization for a non-formulary and non-preferred medication would be approved (step therapy). Formulary alternatives include generic formulations as follows: amphetamine-dextroamphetamine (Adderall XR [extended release]), methylphenidate (Ritalin LA [extended release] and Concerta and Metadate), atomoxetine (Straterra), dextroamphetamine (Dexedrine), and dexmethylphenidate (Focalin XR [extended release]). The patient's clinician is requesting coverage for continued treatment with the non-formulary drug, Vyvanse for treatment of the depressive disorder indicating that the patient has shown progress with use of Vyvanse at a 70 (milligrams) dose. 

The health plan should not cover the Formulary exception for Vyvanse in this case. 

The health plan formulary alternatives are reasonable and provide the same level of benefit for the treatment of the patient's attention deficit disorder or augmentation of major depressive disorder as indicated in the appeal. Thus, the health plan's rationale for a denial of coverage is provided with sound medical judgment in this case scenario. The formulary drugs have not been documented to have been ineffective for this patient and would be as likely to be as effective as the requested non-formulary drug, Vyvanse. Both the non-formulary drug, Vyvanse, and the formulary alternatives would pose risk for adverse effects for this patient, and the use of Vyvanse is reported to have "shown progress" in the care of the patient; however, the patient is not documented to have shown intolerance to the use of the formulary alternatives, and the risk of adverse effects can be managed with using the lowest effective dose.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces
The insurer denied Braces.
The determination is overturned.

This is a male patient with a Class II malocclusion with moderate crowding and protrusive maxillary incisors. He has a 7-millimeter (mm) overjet and 6 mm overbite. He is treatment planned for orthodontics to correct the crowding and protrusion. At issue is the medical necessity of braces.

There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjets, which this patient has. (2) For these reasons, the requested orthodontic treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Choking
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld

The patient is a toddler-aged female. She presented with a history of choking after eating chicken soup. The patient presented to the ED (emergency department), and on exam, she was noted to have a noodle in the vallecula. The patient underwent a laryngoscopy and was admitted as an inpatient.

Coverage of the inpatient admission was denied by the health plan. The denial is being appealed.

The Inpatient Admission was not medically necessary.

The patient present to the ED (emergency department) after choking on chicken soup. A noodle was noted in the vallecula on exam. The patient's vital signs were stable. The patient was taken to the OR (operating room), where she underwent an endoscopy and esophagoscopy, where no foreign body was found, and no esophageal perforations were reported. There were no complications documented. Therefore, based on the information provided, the medical necessity of the inpatient stay cannot be confirmed, as the patient's care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Consumer directed personal assistance, a total of 84 hours per week.
The insurer denied consumer directed personal assistance, a total of 84 hours per week.
The determination is overturned.

This is a female patient with a medical history notable for a prior ischemic stroke. The patient is currently approved for 35 hours per week of consumer directed personal assistance. The patient and her care team requested an increase to 84 hours per week, and this request was denied by the health plan.

In the request for additional personal assistance, the physician states that the patient needs help with "light housekeeping and preparing appropriate meals" as well as helping with appointments, ambulation, and medication reminders.

A letter of support for this appeal was provided by the patient's neurologist. The letter states that the patient has expressive aphasia and right hemiplegia since her stroke. The letter state that "she would benefit from additional home health care hours" and that currently these needs are being provided by her daughter.

A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted via teleconference with the patient's daughter present. The patient lives with her two children. The patient is unable to answer questions due to aphasia but uses hand gestures to demonstrate understanding. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, finances, medications, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires total dependence for dressing. She requires maximal assistance for bathing, hygiene, toilet transfer, and toilet use. She requires extensive assistance for walking, locomotion, bed mobility, and eating. The patient is wheelchair-bound at this time. She relies on others for all activities and transfers. She is continent of stool and urine. A task tool associated with the assessment recommended 27 hours per week to address her personal care needs. At issue is the medical necessity of consumer directed personal assistance, a total of 84 hours per week.

The requested health service of consumer directed personal assistance, a total of 84 hours per week is medically necessary for this patient.

The patient is wheelchair bound. She is not able to toilet or perform ADLs//IADLs independently. She will have personal care needs that can be expected to be continuous and unscheduled in nature. She has young children at home who cannot be expected to fulfill her personal care needs. She is working to gain more strength but at this time is still maximal assistance for transfers and toileting. Therefore, the requested services are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain	
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This adult patient presented to the hospital complaining of chest pain after smoking marijuana. Chest pain was noted over a 2-3 day period and increased with deep inspiration, coughing and movement of his body. Accompanying symptoms included diaphoresis, nausea and vomiting. Past medical history was significant for hypertension. On arrival to the hospital vital signs were stable (BP 134/96, Pulse 96). Physical examination revealed no abnormal findings. 12 lead electrocardiogram (EKG) demonstrated normal sinus rhythm without ischemic abnormalities. Serum blood testing revealed an elevated high sensitivity troponin of 97. Computed tomography (CT) angiogram was ordered and plans were made to admit the patient to the hospital for serial troponin testing. The patient signed out against medical advice. 

This patient presented to the hospital with atypical chest pain and a past medical history of hypertension. His pretest probability of coronary artery disease was low. (Reference 1) Utilizing the History, Age, Risk Factors, and Troponin (HEART) score he was considered low risk. (Reference 2) Utilizing the thrombolysis in myocardial infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST (interval on EKG) changes on EKG was reviewed by Hedayati et al. (Reference 3). Using the History, Electrocardiogram (EKG), HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary.
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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ingestion of a Foreign Body.
Treatment: Inpatient Stay.
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male with an esophageal foreign body. The patient had swallowed multiple coins. An x-ray revealed a coin in the cricopharyngeal region. There were no breathing concerns. The patient's vital signs were stable. A laryngoscopy and esophagoscopy were done and no complications were noted.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. There was no medical indication documented for an inpatient stay.

The requested health service/treatment of an inpatient stay was not medically necessary. There was no documentation of any aero-digestive complication secondary to the ingested coin. There was no documentation of any esophageal injury or the inability to swallow after the procedure.

It is not considered standard of care to admit a patient under an inpatient status after an uncomplicated removal of a coin from the esophagus. The patient had a coin stuck in the cricopharyngeal region. Most times these children are discharged home directly after the procedure. The patient could have been managed at an alternate level of care or discharged after the procedure.

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

Diagnosis: Cavity
Treatment: White glass with Metal Crown for Tooth Number (#) 12
The insurer denied the request for a White glass with metal crown for tooth #12.
The health plan's determination is overturned.

The patient is a female who presented for evaluation and treatment of tooth number (#)12. Provided for review are previous letters of appeal and denial, a narrative from the provider explaining the need for restoration for tooth #12, multiple radiographic images, and one page of American Dental Association (ADA) claim forms. Previous denials have been made on the basis that the decay has reached below the bone level of the distal of the tooth arguing that the tooth will not last long.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment nor in the best interest of the patient.

The requested health service/treatment of a white glass with metal crown for tooth #12 medically necessary for this patient. The current decay does not reach below the bone at any level. Further, even if the decay did reach to below the bone, crown lengthening is a predictable and common procedure performed in order to retain the tooth and place a crown for the patient. The root itself is long and is restorable with a good prognosis. This is a common everyday situation and the crown that is necessary to replace the missing tooth structure is also indicated and has a good prognosis. 

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

Diagnosis: Deep Vein Thrombosis.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient in this case is a teenage female. She presented to the emergency department with right calf pain and swelling for two days. The pain made it difficult for her to ambulate. On initial evaluation, the patient's vital signs were noted to be unremarkable except for heart rate of 126. Imaging revealed a deep venous thrombosis of the right calf. She was also found to have bilateral pulmonary embolism. CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate) were elevated.
The patient was admitted for anticoagulation and was started on enoxaparin. While in the hospital she was continued on this medication, and rheumatology labs were obtained. Thrombophilia labs were also obtained. Due to concern for potential right heart strain on her initial CT (computed tomography), cardiology was consulted. Echocardiogram was done and revealed no significant cardiac abnormality. She did well during her hospitalization and noted improvement in right calf pain without any chest pain or shortness of breath.

The Inpatient Hospital Admission was not medically necessary.

This patient was diagnosed with right calf DVT (deep venous thrombosis) and bilateral pulmonary embolism. While there was initial concern for right heart strain, that was ruled out on echocardiogram. Records indicate no symptoms due to pulmonary emboli and no significant abnormality in respiratory function. The patient did have tachycardia but did not have hypotension. Tachycardia alone is not sufficient justification for acute care inpatient admission. She did not have any other significant or concerning symptom or medical manifestation supporting the need for acute care inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a child with a history of asthma who had been sick for a few days with a cough, congestion, and a fever of 102 degrees F (Fahrenheit). There was a sister who had also been sick. His grandmother decided to bring him to the emergency room (ER) when she noted that he had "a racing heartbeat."

In the ER he was noted to have respiratory distress with intercostals retractions, nasal flaring, and increased work of breathing. On physical exam he had tachypnea, decreased breath sounds at the lung bases and bilateral expiratory wheezing. His pulse oximeter was 92-94% (percent). He was treated with an intravenous (IV) fluid bolus of normal saline, prednisone and 3 doses of albuterol and Atrovent. A chest x-ray did not show evidence of pneumonia. A respiratory viral panel was positive for the rhinovirus. When his symptoms did not improve, he was treated with IV magnesium sulfate. When he did not improve with treatment in the ER, the decision was made to admit to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours. 

The patient was treated appropriately in the ER for a cough, wheezing, and respiratory distress. He has a history of previous asthma episodes. Despite appropriate treatment in the ER and IV magnesium sulfate administration, there was persistent wheezing and increased work of breathing. It was appropriate and consistent with the standard of care to admit him to the hospital for ongoing treatment with albuterol every 2 hours. He was not stable enough to be discharged to home. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Facial Laceration.
Treatment: Emergency Department Visit.
The insurer denied: Emergency Department Visit.
The denial is overturned.

The patient is an adult male who was seen in the emergency department. The patient was assaulted, sustaining a three-centimeter (cm) laceration to his left cheek. There was no evidence of fracture. A plastic surgeon was consulted to repair the wound. The wound was closed by the plastic surgeon while the patient was in the emergency department (ED). Following the patient's emergency department evaluation, he was discharged home. The patient's health plan has denied coverage for this emergency department evaluation on the grounds that the plan criteria for medical necessity have not been demonstrated. Specifically, it is written that insufficient records were received to establish medical necessity. The patient has appealed this denial.

The proposed treatment (emergency department visit) was medically necessary.

The patient presented to the emergency department with a complex facial laceration. A plastic surgeon was consulted. The plastic surgeon repaired the patient's facial laceration in multiple layers. Debridement of devitalized tissue was required. There is no lower level of care that could have accomplished this complex surgical procedure. This health plan states that for a service to be medically necessary it must be clinically appropriate in terms of site and considered effective for the patient's Illness, injury or disease. A hospital emergency department evaluation was clinically appropriate for this patient. He had a complex facial laceration that required repair by a plastic surgeon. There was no other site of care that could have provided the medical treatment that this patient required.