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

Diagnosis: Chronic traumatic encephalopathy (CTE)
Treatment: Code D6010 implant placement for teeth #'s 3, 4, 12, 13, 19 and 30
The insurer is denied coverage for code D6010 implant placement for teeth #'s 3, 4, 12, 13, 19 and 30
The denial is overturned.

This is a female patient who has a history of from prediabetes, chronic traumatic encephalopathy, attention deficit hyperactivity disorder (ADHD), depression and chronic vertigo. As a result of her poor health condition is was reported that the patient is unable to insert and remove her dentures. The patient consulted a dentist for an evaluation for dental implants. Permanent dental implants were recommended to assure adequate nutrition and promote good health.

Upon review of the submitted documentation which includes letter of support for multiple narrative letters from the patient, letter from her physician regarding underlying diagnosis of chronic traumatic encephalopathy (CTE), letter from her neuropsychologist MRI imaging report, extraoral and intraoral clinical photographs, undated panoramic and full mouth series radiographs, peer reviewed literature, NYS Dental Medicaid policy and procedure manual, Dentaquest/Fidelis Office Reference Manual, and insurer correspondence, it appears that this patient presented for dental evaluation and rehabilitation of multi-quadrant edentulous spaces in the maxilla and mandible. Dr. Mannini recommended the implants and related services due to the sequelae of the CTE including cognitive issues and motor skill impairment that would preclude the patient from successful use of removable oral appliances. The insurer has denied these services as not medically necessary stating that the patient does not have a medical condition that causes her to need an implant and is recommending as an alternative a denture. The patient is appealing the decision.

The comprehensive documentation provided for review amply documents the underlying CTE and the patient's psychomotor impairment due to this condition. The patient's clinicians uniformly note that the underlying CTE and correlated manifestations of this condition make it impossible for her to perform the necessary motor skills that would be necessary to wear a removable denture, skills that would be unnecessary with fixed implant retained prostheses. Further, these implants and related services are covered as per the Fidelis manual and NYS Medicaid policy and procedure manual after meeting certain criteria. As to that, the underlying medical conditions fulfill the medical necessity criteria of both the insurer and NYS Medicaid. As such the implants are deemed medically necessary.

The health care plan did not act reasonably and with sound medical judgement and in the best interest of the patient. Code D6010 implant placement for teeth #'s 3, 4, 12, 13, 19 and 30 is considered medically necessary.

 The carrier's denial of coverage for code D6010 implant placement for teeth #'s 3, 4, 12, 13, 19 and 30 is overturned. The medical necessity is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Myocardial Infarction.
Treatment: Wearable Cardiac Defibrillator (WCD).
The insurer is denied coverage for Wearable Cardiac Defibrillator (WCD).
The denial is upheld.

This is a male with no a history of hyperlipidemia, tonsillectomy and removal of a benign subcutaneous tumor. He presented to the Emergency Department (ED)  with complaints of chest pain. He was found to have an ST elevation anterior myocardial infarction (MI) and was taken emergently to the cardiac catheterization laboratory where he was found to have cardiomyopathy with a left ventricular ejection fraction of approximately 20%. Angioplasty and stenting to the left anterior descending (LAD) was done and an Impella device was inserted; he was admitted to the ICU.  His presenting vital signs were: blood pressure of 139/88, pulse of 72, respirations of 16 and an oxygen saturation of 100%. Laboratory work up was performed that included a white blood cell (WBC) count of 6.83, a hematocrit of 44.0, a sodium of 142, a potassium of 3.6, a blood urea nitrogen (BUN) of 20, a creatinine of 0.9, and a glucose of 116. His initial troponin was 64.3 and his troponin was 51.1. It was reported that the patient had an episode of non-sustained ventricular tachycardia that occurred a short time after his MI; a Life Vest was recommended prior to his discharge.  The patient was discharged was instructed to follow-up with his primary care physician. The patient was seen as an outpatient to check status of the LifeVest. 
Despite the high rate of sudden death after myocardial infarction among patients with a low ejection fraction, implantable cardioverter-defibrillators are contraindicated until 40 to 90 days after myocardial infarction. Whether a wearable cardioverter-defibrillator would reduce the incidence of sudden death during this high-risk period is unclear.
The literature cited indicates that the only randomized trial concerning the LifeVest was recently concluded and did not show any significant difference in the primary endpoints. The only justification for use of this device includes ICD ex-plantation for infection or lead displacement or contraindications to an ICD such as systemic infection that would temporarily delay an ICD implantation or being on the waiting list for heart transplantation. None of these conditions were present in this patient. The current medical literature does not support the use of the LifeVest that was requested. The patient had ischemic cardiomyopathy with his left ventricular ejection fraction of approximately 30%. The requested service is not likely to be more beneficial than any standard treatment/procedure in this patient's clinical scenario. 

The carrier's denial of coverage for the Wearable Cardiac Defibrillator (WCD) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Myocardial Infarction (MI).
Treatment: Wearable Cardiac Defibrillator (WCD).
The insurer is denied coverage for Wearable Cardiac Defibrillator (WCD).
The denial is overturned.

This is a male patient with a history of hyperlipidemia. He was otherwise healthy when he developed substernal chest pain, diaphoresis, palpitations and brief syncope due to an acute anterior wall myocardial infarction (MI). Coronary arteriography revealed a total left anterior descending coronary artery occlusion and he was treated with a drug eluting stent and insertion of an Impella device. Peak troponin was 64.3 and an EKG revealed a new left bundle branch block. Non-sustained ventricular tachycardia was noted after 24 hours post myocardial infarction (MI) and both echocardiography and ventriculography revealed extensive anteroapical wall motion abnormalities and severe left ventricular dysfunction with a left ventricular ejection fraction (LVEF ) of 25%. A LifeVest wearable cardiac defibrillator was fitted and he was discharged home. He was seen as an outpatient by his Cardiologist. An echocardiography revealed a left ventricular systolic function of 45% with distal septal and apical hypokinesis to akinesis. His wearable cardioverter defibrillator was discontinued.
LifeVest Wearable Cardioverter Defibrillator has received final approval from the appropriate regulatory bodies for use in this diagnosis and was the best available treatment for this patient at that time. This service was likely to be more beneficial than any of the standard treatments for this patient during the period of use, based on a IIb level of recommendation in major societal guidelines for use of this device in motivated patients following MI with LVEF<35%.  Scientific evidence in peer-reviewed literature supports improvement in health outcomes with this device in motivated patients following myocardial infarction with left ventricular systolic function <35% until it is determined whether left ventricular systolic function has improved with optimal medical treatment. 

The carrier's denial of coverage for the Wearable Cardiac Defibrillator (WCD) should be reversed.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Myocardial Infarction.
Treatment: Wearable Cardiac Defibrillator (WCD).
The insurer is denied coverage for Wearable Cardiac Defibrillator (WCD).
The denial is upheld. 

This is a male patient with a medical history of hyperlipidemia. He presented to the hospital with complaints of syncope, diaphoresis and chest pain. The patient was found to have an acute anterior wall ST elevation myocardial infarction (MI) and cardiomyopathy. The patient underwent an angioplasty with stenting to his left anterior descending (LAD) artery. The patient's ejection fraction was 25%. He was admitted to the Intensive Care Unit (ICU) to treat cardiogenic shock. It was reported that the patient had non-sustained ventricular tachycardia after 24 hours post-MI. The Zoll LifeVest was ordered for an estimated 3 months for myocardial infarction with ejection fraction (EF) of less than/equal to 35%. The patient was discharged after being fitted for the LifeVest. Outpatient medication adjustments were made and he completed cardiac rehabilitation. An office visit note reported that the patient's echocardiogram showed an improved ejection fraction of 45% and his LifeVest was discontinued.
The LifeVest is Food and Drug Administration (FDA) approved for prevention of sudden cardiac death; however, the use of LifeVest for the dates under review is not considered to be the standard of care in this clinical scenario. The patient was diagnosed with ischemic cardiomyopathy with an ejection fraction of 25% following an acute ST elevation myocardial infarction (STEMI). This technology has not been shown to be clinically beneficial when compared with standard-of-care medical therapy for prevention of sudden cardiac death in patients with newly diagnosed ischemic cardiomyopathy immediately following STEMI. There is no clinical research evidence documenting incremental benefit of this technology over conventional medical therapy in prevention of sudden cardiac death. Therefore, this technology does not represent the standard of care for such patients in this clinical setting. This patient is not a good candidate for the LifeVest and it is not likely to be more beneficial than any standard treatment.
The carrier's denial of coverage for the Wearable Cardiac Defibrillator (WCD) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal Stenosis at L2 -L3, L4-L5
Treatment: Back surgery (percutaneous or endoscopic spinal decompression and fusion)
The insurer is denied coverage for back surgery (percutaneous or endoscopic spinal decompression and fusion).
The denial is upheld.

This is a male patient who underwent surgical intervention. The physician detailed that the patient had classical symptoms of spinal claudication. The physician detailed that the patient's symptoms would be alleviated with rest; however, once he resumed walking, the symptoms would recur. The physician also referenced an MRI and indicated that the patient demonstrated claudicatory symptoms with the patient able to cycle without pain, but ambulation would cause pain extending into the thigh and calves. It was recommended that the patient undergo surgical intervention. The physician detailed that with so much stenosis, the only safe way to decompress would be to sacrifice the facet joints. The patient underwent a posterior lumbar interbody fusion at L2-L3 with bilateral posterior lateral fusion at L2-L3.

The scientific evidence in peer-reviewed literature does not support a result of improvement in health outcome, as there is no indication of instability, deformity or listhesis of at least 4mm or more at L2-3 on preoperative imaging to necessitate fusion. Removal of medial facets can be done safely without a need for fusion.

Jette et al noted "Positive clinical change was greatest in patients undergoing fusion for
spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Re views number, CRD42015020153)."

Back surgery (percutaneous or endoscopic spinal decompression and fusion), does not in this case need final approval from the appropriate regulatory bodies for this diagnosis.

This patient is not a good candidate for back surgery (percutaneous or endoscopic spinal decompression and fusion) as there is no indication of instability, deformity or listhesis of at least 4mm or more at L2-3 on preoperative imaging to necessitate fusion. Removal of medial facets can be done safely without the need for fusion. 

The requested surgical procedures are not likely to be more beneficial than any standard treatments or procedures.

The carrier's denial of coverage for back surgery (percutaneous or endoscopic spinal decompression and fusion) should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Spinal Stenosis at L2 -L3, L4-L5
Treatment: Back surgery (percutaneous or endoscopic spinal decompression and fusion
The insurer is denied coverage for back surgery (percutaneous or endoscopic spinal decompression and fusion.
The denial is overturned.

This is a male patient who consulted a neurosurgeon for complaints of back pain and bilateral leg pain from spinal claudication. The patient could not walk more than a short distance without experiencing. The MRI revealed severe spinal stenosis at L2 -L3, less so at L4-L5 and because of the distribution of pain in the lateral thigh and anterior thigh. The patient reported having a fall a few days prior to his consultation with the provider. fell. The provider suggested a laminectomy from L2-L5 decompressing both levels. In a follow-up visit the provider noted that the patient had classic spinal claudication. 

The patient underwent a decompressive lumbar laminectomy at L2-L3, L3-L4, and L4-L5 with subsequent fusion with no need to remove the facets at L2-L3 to decompress the sac with subsequent fusion at L2-L3 and 60-degree fusion at L2-L3 using fluoroscopy, microscopy, and neuromonitoring. The patient also underwent a posterior lumbar interbody fusion at L2-L3 using the K2 M titanium interbody cage device with its medullary portion filled with local autogenous bone graft. The patient also underwent a bilateral posterolateral fusion at L2-L3 using local autogenous bone graft. There was bilateral pedicle screw instrumentation at L2 -L3 using the K2 M Everest pedicle screw system.

The carrier's denial of coverage for back surgery (percutaneous or endoscopic spinal decompression and fusion) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back, neck and shoulder pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult female.  She underwent bilateral breast reduction.  She had back, neck and shoulder pain.  She had an uneventful postoperative course.  Following surgery, she was treated with Dilaudid IV push and oxycodone.  PACU (post anesthesia care unit) nursing notes document pain of 0 on a 0-10 scale.  Transfer to floor note documents patient resting comfortably.  Progress note documents pain control with oral medication.  The patient was discharged the following day in good condition.

According to the records, the patient was hospitalized primarily for pain control and monitoring of her JP drains.  The medical literature indicates that breast reduction can safely be performed as an outpatient procedure, particularly when On-Q pumps or intraoperative sensorcaine are used. 

According to a large series by Stevens and colleagues, "Complication data derived from this series are comparable to previously published studies and thus support the safety and efficacy of outpatient reduction mammaplasty performed in an accredited facility." According to a study by Short et al, "The data confirms that reduction mammaplasty is a safe and effective procedure when performed on an outpatient basis."  A 2012 study by Blaine et al found that over 2/3 of reduction mammoplasty procedures are performed on an outpatient or observational level of care. The authors concluded, "Reduction mammaplasty is a common procedure that is safe when performed on an outpatient basis." 

This patient could have been safely managed at a lower level of care or as an outpatient. Her pain was well-controlled, and she was drinking adequately to maintain hydration. She did not have significant nausea or vomiting.  Her vital signs were stable, and her dressings were dry. She did not require management of clinically significant co-morbidities. Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System/Neuromuscular
Home Health Care

This is a patient with a past medical history of Alzheimer's dementia, transient ischemic attack (TIA), atrial fibrillation on chronic anticoagulation, hypertension, osteoarthritis, permanent pacemaker and congestive heart failure who was hospitalized with subsequent transfer to rehabilitation. The patient had an assessment indicating supervision for toilet transfer and bed mobility. Limited assistance was recommended for toilet use, eating and walking. The patient required extensive assistance with dressing upper extremity/lower extremity (UE/LE), personal hygiene and maximal assistance with bathing and medication. Total assistance was needed for meal preparation, shopping, housework, managing finances and transportation. The patient's daughter provided overnight care because the patient's personal care aides were provided for 13 hours per day. Notes from rehabilitation stated the patient had hallucinations, delusions, excessive agitation and verbal aggression related to Alzheimer's dementia.
The patient was seen in the emergency room for chest pain and a malfunctioning pacemaker, respectively. The patient was admitted to the hospital with syncope. She had fallen times two (x 2) while attempting to get into bed. The patient had another assessment and required supervision for eating and limited assistance for personal hygiene bed mobility. The patient was assessed to need extensive care for dressing UE/LE, locomotion, transfer toilet and walking. Maximal care was recommended for bathing, medication and toilet use. Total care was recommended for shopping, meal preparation, housework, managing finances and transportation. The health plan's determination is overturned.
The personal care aide 7 days times two 12 hours split shifts is medically necessary. The patient has moderate Alzheimer's disease with an increase in wandering and sundowning at night. Due to the patient's dementia, she does not recall/remember safe walking and locomotion with walker and needs to have assistance when she is up at night. The patient recently had 2 falls at home. The assessment tool indicated the patient required maximal assistance with toilet use and had previously needed limited assistance. The patient also required extensive assistance with toilet transferring and had needed only supervision. The patient needed contact guarding assistance with ambulation with queues to use her walker. The patient requires help overnight with these activities of daily living (ADLs). In a letter, the patient's primary care provider noted personal care aide services are medically necessary 24 hours per day, 7 days per week. The patient had been hospitalized due to missing medication in the evening hours. In summary, personal care aide services are medically necessary at 24 hours per day in split shifts, 7 days per week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Parkinson's disease, brain meningioma
Treatment:  Increase in personal care services to 24 hours day, 7 days/week, split shift (Health plan's approval is for 12 hours/day, 7 days/week)

The Increase in personal care services to 24 hours day, 7 days/week, split shift is not medically necessary.

The patient is a Russian-speaking female.  She lives with her son in a large studio apartment in an elevator-accessible building.  During recent nursing assessments, the patient found to be well-groomed and well-nourished.  The patient is under the care of a neurologist, who she sees on a regular basis.  The patient also has primary care physician.  The patient's medical conditions include Parkinson's Disease and brain meningioma.  Meningioma was removed previously.  The patient has a history of falls but none within the last 90 days.  She experiences urinary incontinence, and she uses pull-ups.  Dentures are available and effective.  She experiences no problems with chewing or swallowing.  She had recently completed eight weeks of physical therapy. Her son and two daughters are very supportive.  The patient requires assistance with preparing meals, housekeeping, laundry, shopping, dressing, bathing, personal hygiene and toileting.  

Based on uniform assessment system, the patient's current personal care aide hours of 12 hours a day 7 days per week, total 84 hours per week, meet medical needs, based upon medical records and supporting documents presented for review.  

The health plan's approved 12 hours/day, 7 days/week of personal care assistance meet the patient's needs on a daily basis.  The approved services provide a level of assistance to perform all of the patient's ADL (activities of daily living) needs and IADL (instrumental activities of daily living) needs.  There is nothing documented in the records to indicate that an Increase in personal care services to 24 hours day, 7 days/week, split shift is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to the emergency department with cellulitis. She was well until 2 days prior to admission when she was playing in the grass and sustained some insect bites. She developed lesions on her skin and was treated with Loratadine at home, but there was no improvement. She then developed increasing redness, swelling, itchiness, and pain of her left forearm and the back of her left foot. She was taken to her primary doctor and was found to have a tactile fever and worsening erythema. There was concern for progressive cellulitis versus an abscess, and therefore she was referred to the emergency department for further evaluation and care.

In the emergency department, her physical examination revealed erythema and swelling of the left forearm surrounding an insect punctum, with tenderness to palpation moving proximally and streaking, as well as erythema and swelling on the dorsum of her foot moving proximally to the mid foot. An ultrasound was performed to evaluate for abscess. There was no abscess noted, however, cobblestoning was present which was felt to be suggestive of cellulitis. She was given a dose of intravenous Vancomycin as well as Diphenhydramine and was admitted for ongoing treatment with intravenous Clindamycin.

After admission, she continued to receive intravenous Clindamycin. Significant improvement was noted and she was felt to be stable for discharge with continued treatment with oral Clindamycin and follow-up with her primary doctor.
The health plan's determination is overturned.

This is a young girl who presented with rapid progression of cellulitis in 2 locations of her body. She had some streaking of the redness as well as tenderness to palpation. An ultrasound supported the diagnosis of cellulitis. Hospitalization is indicated for children with skin and soft tissue infections who have rapid progression of erythema, in order for them to receive appropriate parenteral antibiotics and monitoring with further treatment and evaluation as needed. She required prompt initiation of intravenous Clindamycin along with close monitoring to ensure appropriate response to therapy.

The decision making at the time of admission for this patient was consistent with her young age, the rapid progression of cellulitis in 2 different locations, and the need for prompt initiation of aggressive treatment with close monitoring for potential deterioration of clinical status.