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

Diagnosis: Circadian Rhythm Sleep Disorder. 
Treatment: Hetlioz. 

The insurer denied coverage for Hetlioz. 

The denial is overturned. 

This case involves a teenage male who has been previously diagnosed with circadian rhythm sleep disorder. The documentation indicated he also suffers from attention deficit disorder (ADD), autism spectrum disorder (ASD), anxiety, fatigue, restless leg syndrome, and obstructive sleep apnea (OSA). The documentation indicated he has had a trial of prior medication such as Ambien as well as melatonin and light therapy with little to no relief. The documentation indicated the requested medication does allow him to fall asleep and get restful sleep. Without medication he is up all night and sleeps all day. The documentation indicated the patient has been recommended to continue the use of the requested medication. 

As discussed in Up to Date, "Tasimelteon (Hetlioz) is an oral melatonin agonist that was developed for treatment of circadian sleep-wake rhythm disorders. It is our preferred agent in patients who do not respond to over-the-counter melatonin and is an alternative first-line agent in patients who are not comfortable taking an over-the-counter supplement." 

The patient has been diagnosed with circadian rhythm sleep disorder. Hetlioz is the only Food and Drug Administration (FDA)-approved treatment for Non-24-Hour Sleep-Wake Disorder, which is a circadian rhythm sleep disorder. The patient has also benefitted from this medication. Based on the above, Hetlioz was considered medically necessary treatment for the patient's condition. 

The health care plan did not act reasonably, with sound clinical judgment or in the best interest of the patient. 

The insurer's denial of coverage for Hetlioz is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, dysphagia, bed confinement, functional quadriplegia. 

Treatment: CDPAS (consumer directed personal assistant services) of 7 days per week, 2-12 hour shifts per day (split shift). 

The insurer denied coverage for CDPAS of 7 days per week, 2-12 hour shifts per day (split shift). 

The denial is overturned. 

The patient is female who is homebound. The patient has dementia, dysphagia, bed confinement, functional quadriplegia, incontinence of bowel and bladder, primary osteoarthritis of multiple joints of upper and lower extremity contractures, gastroesophageal reflux disease (GERD), and peeling skin. 

The Uniform Assessment System-New York (UAS) completed notes the patient and her daughter were present for the phone call. The patient's daughter requested consumer directed personal assistant services (CDPAS). The patient lives with her daughter on the ground floor of a condominium. The records show that the patient's cognition is severely impaired. She cannot make herself understood. The patient has severe difficulty with vision and at the time of the UAS, appeared to follow objects but saw only light. She requires a caregiver for meal preparation, housework, managing finances, managing medications, phone use, managing stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing her upper and lower body, locomotion, bed mobility, eating, toilet transfer and toilet use, and she is frequently bowel and bladder incontinent. The patient uses a wheelchair for locomotion, and she has a hospital bed. 

The provider's letter noted the patient would benefit from split shifts as she has episodes of intermittent diarrhea and urinary incontinence that requires frequent cleansing to help skin breakdown. The patient has a history of stage II buttocks decubiti that requires frequent repositioning. She needs monitoring when eating, due to dysphagia. The patient is unable to make her needs known, is bedbound, and cannot be left alone. The daughter is unable to provide nighttime care because she needs to work during the day. The request was received for personal assistant services 7 days/week 2-12-hour shifts per day (split shift). 

The requested CDPAS of 7 days per week, 2-12 hour shifts per day (split shift) is considered medically necessary for this patient. 

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This is a medically complex patient who is fully dependent on others for assistance. 

The carrier's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 7 days per week, 2-12 hour shifts per day (split shift) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain. 
Treatment: Synvisc-One Injections, Bilateral Knee (code J7325RT and J7325LT). 

The insurer denied the Synvisc-One Injections, Bilateral Knee (code J7325RT and J7325LT). 
The denial is upheld. 

This is a female. She presented with knee pain. There was an episode of trauma noted. 

No, the Synvisc-One Injections, Bilateral Knee (code J7325RT and J7325LT) are not medically necessary. 

There has been discussion in the literature with regard to the use of viscosupplementation. The initial recommendations were made for people with osteoarthritis who had not improved with conservative management. The facts are the patient reported a two-week history of knee pain. There was an episode of trauma. She does not have osteoarthritis. She has not received a course of conservative treatment. There would be no indication for the use of viscosupplementation regardless. 

Additionally, Orthopedic Guidelines of Practice do not recommend its use. A review of the Clinical Practice Guideline by AAOS (American Academy of Orthopaedic Surgeons) cites the following: 

The OA (osteoarthritis) knee treatment CPG (clinical practice guidelines) contains one significant recommendation change from the CPG (clinical practice guidelines), and this is with regard to the issue of viscosupplementation. The OA (osteoarthritis) knee CPG (clinical practice guidelines) included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG (clinical practice guidelines). 

The second edition CPG (clinical practice guidelines) recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA [osteoarthritis] of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria. 

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the CPG (clinical practice guidelines)'s best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight HA (hyaluronic acid) preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS [American Academy of Orthopaedic Surgeons] CPG [clinical practice guidelines]," AAOS [American Academy of Orthopaedic Surgeons] Now, May.) 

The Orthopedic group reports "strongly do not recommend use." There has been no change to this Guideline. Additional references and expert opinion do not support benefit. Additionally, a meta-analysis was completed of multiple references. This is a high-level evidence-based source that does not support its use. 

Therefore, given the above, the requested Synvisc-One Injections, Bilateral Knee (code J7325RT and J7325LT) are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Otitis Media and Externa

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned
	
The patient was admitted to the Emergency Department (ED) for intravenous (IV) antibiotics and Ear, Nose, and Throat (ENT) evaluation after ear culture from a previous ED visit grew pseudomonas aeruginosa. The claimant reported ear discharge, hearing loss, and ear pain and tenderness. She was admitted as an inpatient to Internal Medicine with Otitis Media and Externa (M/OE) with pseudomonas. The patient Infectious Disease (ID) recommended Cefepime. Otolaryngology recommended no acute intervention. Tobradex was initiated per ENT and an ear wick was placed. She was discharged with outpatient ENT follow-up.

"Otogenic brain abscesses are one of the most significant life-threatening complications of otologic infections." (Duarte, M. J., et al.). 

"Mastoiditis is a common complication of acute otitis media." (Sahi D, Nguyen H, Callender KD.).                                                         

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient had failed outpatient medical management with worsening otitis media ear pain (OM/OE) with a past medical history (PMH) of chronic ear infections and cultures still pending. The risks of the infection worsening include mastoiditis, brain abscess, and meningitis. This would not be in the best interest of the patient.  Inpatient admission was considered medically necessary. 


The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a history of asthma. He also has bilateral cochlear implants and obesity. He had been admitted to the Pediatric Intensive Care Unit (PICU) once as a child and required continuous positive airway pressure (CPAP). He had a recent admission for asthma. He had been prescribed inhaled steroids in the past, but he has not been compliant with this treatment. He began to experience shortness of breath and wheezing on the evening before his admission and his mother administered one dose of albuterol with improvement in his symptoms. When his symptoms recurred, his mother brought him to the emergency room (ER) for further treatment.

In the ER he was not noted to have subcostal retractions and biphasic wheezing. His pulse oximetry was 96% (percent). He received treatment with Decadron and two treatments with Combineb. His symptoms improved following treatment and an additional treatment with Combineb was administered. Respiratory viral testing for influenza, Respiratory syncytial virus (RSV) and COVID (coronavirus) virus were negative. Although he was clinically improved there was some wheezing noted on physical exam and the decision was made to admit him to the hospital for additional treatment with albuterol every 3 hours. The admitting note indicated that he was no longer wheezing and he was discharged home on the same day after he was observed and continued to improve following additional albuterol.

The patient was treated in the ER for mild wheezing. His subcostal retractions resolved with treatment; he improved clinically with mild wheezing. He was not in acute respiratory distress, and he did not require oxygen supplementation. He could have been safely discharged with oral prednisone and albuterol administration every 4 hours at home with a follow up appointment with his pediatrician in 24 to 48 hours. The decision to admit to the hospital was not consistent with the standard of care for mild asthma who improved with Decadron and 3 Combineb treatments over 3 hours in the ER. 

The standard of care for assessing the response to treatment for an acute asthma episode in the ER and determining if the patient is in status asthmaticus is administration of steroids and multiple "back-to-back" or continuous treatment with bronchodilators: Albuterol nebulization combined with ipratropium every 20 to 30 minutes for three doses or continuously. 

This patient was not in status asthmaticus and was well enough to be discharged from the hospital the same day. He could have been discharged from the ER after an additional period of treatment and observation. The health plan acted reasonably with sound medical judgment

The insurer's denial of coverage for inpatient admission is upheld. Medical necessity not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, osteopenia, and arthritis
Treatment: Increase in Consumer Directed Personal Assistance Services (CDPAS) 32 Hours Per Week, Pre-service
The insurer denied the increase in consumer directed personal assistance services (CDPAS) to 32 hours per week, pre-service.
The denial is upheld. 

This female has medical conditions including hypertension, osteopenia, and arthritis.  She is appealing denial of increase in consumer directed personal assistance services (CDPAS) from 30 to 32 hours per week.  

The patient lives alone in an apartment.  Uniform Assessment System (UAS) performed showed the patient needed assistance with meal preparation, housework, shopping, dressing, personal hygiene, and bathing.  She has urinary incontinence.  She uses a cane for ambulation. 

An appeal statement recommended additional hours because the current hours provided are insufficient.  Appeal letter from the provider states the patient requires assistance due to unsteady gait and pain from arthritis; it is recommending two additional hours per week to the current 30 hours per week.

No, the proposed treatment is not medically necessary.

The proposed treatment is not medically necessary because it is not consistent with generally accepted national standard of medical practice.

Personal care services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs), health maintenance activities, and routine support services.  

This patient was approved for consumer directed personal care services (CDPCS) 30 hours per week.  She is appealing denial of 32 hours per week.  Uniform Assessment System (UAS) evaluation performed shows the patient needs assistance with meal preparation, housework, shopping, dressing, personal hygiene, and bathing.  She has urinary incontinence.  She uses a cane for ambulation.  Appeal letters recommend two additional hours for assistance with activities of daily living (ADLs) due to unsteady gait and arthritis.  The appeal letters do not indicate how the additional hours will be used.  Consumer directed personal assistance services (CDPAS) are not indicated when there are no tasks being performed.  The documentation provided is inadequate to support the medical necessity for additional consumer directed personal care service (CDPCS) hours.  Based on all available information, the approved consumer directed personal care services 30 hours per week is sufficient to provide assistance with activities of daily living (ADLs) and personal care as noted above.  The proposed increase in consumer directed personal care services (CDPCS) to a total 32 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enteritis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

This is the case of an adult female patient with colon cancer who received surgery and chemotherapy. She presented with epigastric discomfort, nausea, and vomiting. The patient developed diarrhea after receiving her first dose of chemotherapy. She was afebrile and the vital signs were stable. A computed axial tomography (CAT) scan revealed a short loop of mildly distended small bowel. The surgical consult advised that she was not clinically obstructed. The patient was treated with antibiotics for enteritis. Intravenous (IV) hydration and antiemetics were given. Her symptoms improved. 

Milliman Care Guidelines (MCG) clinical indications for admission for Gastroenteritis (M-170) include having a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, and an inability to maintain oral hydration after observation care. The patient did not have these conditions. 

This patient received chemotherapy and developed enteritis. She required IV hydration and antiemetics. The surgeon advised that clinically, she was not obstructed. The IV hydration and antibiotics could have been given with observation status. After receiving treatment, she was able to tolerate a diet. She did not meet MCG criteria for admission for gastroenteritis. 

The health care plan did act reasonably, with sound clinical judgment, and in the best interest of the patient. An inpatient admission was not medically necessary. 

The insurer's denial of coverage for the inpatient admission upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea (OSA)

Treatment: Office visit and procedure codes 98927 x (times) 6, 98928 x2, and 98929 x1 professional services (osteopathic cranial manipulations)

The insurer denied coverage for office visit and procedure codes 98927 x6, 98928 x2, and 98929 x1 professional services (osteopathic cranial manipulations).

The denial is overturned.

According to the medical records, the patient is a female with a history of obstructive sleep apnea (OSA), status post adenotonsillectomy. She has tried oral appliance therapy, myofunctional therapy, behavioral therapy and lingual tonsillectomy/turbinate reduction/epiglottis reduction. She is unable to tolerate continuous positive airway pressure (CPAP)/oral appliance therapy due to headaches from pressure on her head. There was significant upper airway crowding and craniofacial underdevelopment. The patient's mother stated that the patient had an Apnea Hypopnea Index (AHI) score of 1.7 after surgery and was unable to tolerate CPAP support. She had osteopathic cranial manipulations to treat her OSA.

According to Bell, R. B., et al (2001), "Skeletal advancement can be an effective treatment for medically refractory OSA in children. Success, however, is dependent not only on skeletal position but also on neuromuscular adaptation. Bronchoscopy is the most valuable diagnostic and predictive tool." 

Munawar, S., et al (2020) writes that, "the potential risks/benefits need to be weighed carefully before undertaking sleep surgery in syndromic children. They experience a longer length of stay, higher cost, and non-routine disposition when compared to non-syndromic children. This is especially true when considering the transition from tonsillectomy & adenoidectomy to tonsillectomy & adenoidectomy plus other site surgery, as syndromic children experience a longer length of stay and non-syndromic children do not."

And Noller, M. W., et al (2018) notes that, "this study's major finding is that obstructive sleep apnea has dramatically improved in pediatric patients with mandibular insufficiency when they have been treated with mandibular advancement or mandibular distraction osteogenesis."

As other options have been tried and failed, there was sufficient evidence to support that the office visit and procedure codes 98927 x6, 98928 x2, and 98929 x1, osteopathic cranial manipulations was considered medically necessary treatment for the patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for office visit and procedure codes 98927 x6, 98928 x2, and 98929 x1, osteopathic cranial manipulations is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left Hip Prior Prosthetic Joint Infection (PJI).
Treatment: full hospital admission.
The insurer denied coverage for full hospital admission.
The denial is overturned.

This is the case of an adult female patient with history of hypertension, hypothyroidism, and left total hip arthroplasty (THA). She presented to the hospital for a scheduled left THA articulating antibiotic cement spacer loosening. 1 unit (U) of packed red blood cells (RBC) was given. After the procedure the patient was weight bearing as tolerated. Hip precautions were maintained. The patient was given Aspirin, 1000 milligrams (mg) of intravenous (IV) Vancomycin twice a day (BID), and 3375 mg of Zosyn every 6 hours (Q6H). Pain medication was given as ordered. She was discharged after a period of medical stability.    

The records show the patient underwent complex and extensive revision hip surgery. The duration of the procedure by itself was over 4 hours. Her physicians performed several procedures which could not be considered similar to a primary total hip replacement. Her post-surgical management required IV antibiotics of three agents. Cultures were pending which would be important to determine definitive antibiotic management. She also required a transfusion. As her operation was associated with the blood loss, it would be important to monitor her hematocrit. The risk of bleeding would be higher than normal due to the complexity and extent of the procedure.

The patient required many subspecialists in her post-surgical management including Anesthesia, Infectious Disease, and Orthopedic Surgery. 

Based upon her entire clinical condition and course, the level of care and length of stay was appropriate. The services could not have been provided at a lower level.

The health care plan did not act reasonably and with sound medical judgment in the patient's best interest.

The insurer's denial of coverage for the full hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Over-bite.
Treatment: D8080 Braces, Pre-service.
The insurer denied the D8080 Braces, Pre-service.
The denial is overturned. 

The patient is a male requesting dental benefits for orthodontic treatment (Braces) preservice.
Orthodontic records were created --x-rays, photos, clinical consultation completed.

Health plan denied the claim because the patient did not score greater than a 26 on the HLD Index necessary for treatment.

The Provider appealed based on the Patient's diagnoses, particularly the deep impinging over-bite; an automatic qualifier for orthodontic treatment under the HLD index.

Yes, the proposed treatment of orthodontic therapy is medically necessary.
The patient presents with an overjet of 7mm and a deep impinging over-bite of approximately 100 percent. With an extensive overjet like this, the patient runs the risk of increased trauma to his front teeth because of the excessive protrusion. The deep impinging over-bite can cause damage to the gum and lead to gum recession; as well as increased speech and chewing difficulties.

If these two conditions, (excessive over-bite and over-jet) are left untreated, the patient is at risk for tooth loss, difficulty with proper speech and chewing. This sets the patient up for overall long term issues with his dentition.