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

Diagnosis: Gender dysphoria.
Treatment: Progesterone.

The insurer denied Progesterone. The health plan's determination is upheld. 

This is a transgender patient, with a past medical history significant for anxiety, depression, autism spectrum disorder, complex post-traumatic stress disorder (PTSD) and gender dysphoria, who has been receiving feminizing hormone therapy. On sublingual Estradiol 4 milligrams (mg) every morning and 3 mg in the evening, the patient's estradiol levels when measured have been in the target range (134, 136 and 187, respectively). In addition, the total testosterone levels at those times have been on the low end (11, 4 and < [less than] 3, respectively).

Progesterone is not medically necessary for this patient.

There is limited data available looking at outcomes and safety of adding progesterone to feminizing hormone therapy. According to the 2017 Endocrine Society guidelines for Endocrine Treatment of Gender-Dysphoric/Gender Incongruent persons, although there are transgender women who do report "improved breast development, mood, or sexual desire with the use of progestogens... there have been no well-designed studies of the role of progestogens in feminizing hormone regimens, so the question is still open".  

In a more recent article by Dr. Joshua Safer, it states that "progestins are not recommended the Endocrine society because medroxyprogesterone (was) associated with both cardiovascular and breast cancer risk in older post menopausal women when used in combination with conjugated estrogens".

Unfortunately, there is no data looking at micronized progesterone used in combination with estradiol to determine benefit or risk at this time.

The addition of micronized progesterone to the patient's feminizing hormone therapy is not medically necessary, given the lack of evidence to support benefit. 

The closest trials we have available to make our clinical decisions involve patients who received medroxyprosterone in combination with conjugated estrogens, a hormone combination we now know is linked to adverse outcomes and is not commonly used in practice.

Given the patient's positive anecdotal effects of micronized progesterone and the limited data available investigating this patient's hormone regimen of micronized progesterone and estradiol, it is clear that further research in this area is needed to determine the true benefits and risks of daily micronized progesterone as part of hormone therapy in transgender patients, as well as in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Epigastric pain

Treatment: Diagnostic esophagogastroduodenoscopy (EGD)

The insurer denied coverage for diagnostic EGD.

The denial is overturned.

The patient reported epigastric pain. Upper gastrointestinal (GI) endoscopies were done in previous years. He had gastroesophageal reflux disease (GERD), gastritis, and a hiatus hernia. His medication list did not include a proton pump inhibitor (PPI) during a recent visit note. An endoscopy was performed, and the biopsies found mild gastritis and esophagitis. 

Clinical indications for performing an Upper GI Endoscopy are listed in Milliman Care Guideline (MCG) ACG: A-0203. Among the indications are having gastrointestinal reflux disease with an additional risk factor. A specific indication under this category is male 50 years or older with gastrointestinal reflux symptoms and a hiatal hernia. 

This patient was having upper GI symptoms, is within the age criteria, had previously documented GERD, and had a hiatus hernia. This met MCG criteria for having an Upper GI Endoscopy.

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

The insurer's denial of coverage for diagnostic esophagogastroduodenoscopy (EGD) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This is the case of a female with diagnoses of diabetes mellitus, and coronary artery disease, as well as abdominal pain, nausea, bilious vomiting, mild diarrhea, and concern for cholecystitis. She presented to the Emergency Department (ED) for management.

The ED documentation noted vital signs included a temperature of 36.6 Celsius, blood pressure 159/113, heart rate 86, respirations 18, and a blood oxygen saturation level (SpO2) 98% on room air. The examination revealed right upper quadrant (RUQ) and left upper quadrant (LUQ) tenderness to palpation. Lab Studies performed were generally unremarkable with only mild elevation of lipase and white blood cells 12.8. Liver function tests (LFTs) were normal. The ultrasound showed a liver demonstrating heterogeneous hyper-echogenicity suggesting hepatic steatosis/hepatocellular disease and nonspecific pancreatic ductal prominence to approximately 5 to 6 millimeters (mm). The gallbladder demonstrated no gallstones, no wall thickening, and no pericholecystic fluid. The computed tomography (CT) showed diffuse hepatic steatosis. Pancreas was unremarkable. Follow-up note by surgery noted the negative hepatobiliary iminodiacetic acid (HIDA) scan and no evidence of acute cholecystitis. No surgical intervention planned. She was discharged.

The patient presented with abdominal pain and no evidence of an acute abdominal process that required intervention. The evaluation could have been performed during observation. Acute inpatient admission was not warranted. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

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

Diagnosis: Obstructive sleep apnea.
Treatment: Outpatient sleep study.	

The insurer denied coverage for an outpatient sleep study.  The denial is upheld.

The patient has a history of morbid obesity (BMI (body mass index) = 39.1), hypertension, and obstructive sleep apnea (OSA). The patient underwent a sleep study which found:

"AHI (Apnea-Hypopnea Index) of 114.9 and associated with moderate oxyhemoglobin desaturations down to a nadir of 72%. Snoring of a mild to loud volume was noted continuously during the night. The SaO2 (arterial oxygen saturation) baseline during wakefulness was within normal limits (WNL) at 96% breathing room air. The SaO2 baseline in sleep was WNL at 94%. Average saturation during respiratory events was down to the upper 70's and the lowest SaO2 was 72%. One lead ECG (electrocardiogram) channel (modified lead 2) revealed no cardiac arrhythmias. No PLMs (periodic limb movements in sleep) were observed on this night.

These finding were consistent with severe obstructive sleep apnea (OSA). There is no information concerning the need or indication for a second sleep study in the information provided.

Based upon the information provided the health care plan acted reasonably and with sound medical judgment and in the best interest of the patient, as there was no indication that a second sleep study was needed. The one available was sufficient.

The outpatient sleep study is considered not medically necessary for this patient, as there was no information in the material provided that gave a reason for the second sleep study.

The denial of the second sleep study should be upheld, as there was no information in the material provided that gave a reason for the second study, and the initial study was sufficient.

The insurer's denial of coverage for the outpatient sleep study is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder/Anemia
Treatment: Inpatient Hospital
The health plan denied the inpatient stay as not medically necessary.
The health plan's determination is upheld.

The patient is a female with a history of heavy menstrual bleeding. She recently required a transfusion at an outside hospital for anemia. She presented to the emergency room (ER) with a 2-week history of heavy bleeding and increased fatigue. In the ER, the patient was found to have a hemoglobin of 3.1. Vitals remained within normal limits with a heart rate in the 80's beats per minute (bpm). She was incidentally found to be COVID positive, but the patient was asymptomatic. The patient was admitted to the hospital. She received 4 units of packed red blood cells with an appropriate response in hemoglobin. She was started on iron supplements. She was seen by gynecology and was started on Tranexamic acid for 5 days and Lysteda. Her hemoglobin remained above 7 for 18 hours and the patient was discharged home. There were no vital sign abnormalities. The patient had a transvaginal ultrasound ordered that I did not see the results listed in the chart, so it is unclear if it was obtained. The patient was not able to follow-up at this hospital secondary to insurance coverage, so she was set up at another hospital for follow-up.
At issue is the medical necessity for the inpatient stay.

I uphold, in whole, the health plan's determination of medical necessity.

An alternate level of care would have been medically appropriate for this patient. The patient presented to the hospital with a hemoglobin level of 3.1 which is a life-threatening hemoglobin level, but the patient was not hemodynamically unstable or actively hemorrhaging. The lack of hemodynamic instability is likely due to the extended history and a physiologic compensating process that occurs preventing anemia consequences which is well documented in the literature (i.e., tachycardia, tachypnea) (Metivier et al 2000, Alateeq et al 2021). The patient was transfused 4 units of packed red blood cells with an appropriate response in hemoglobin and delivered medical therapy to cease bleeding (i.e., Lysteda, tranexamic acid) (Mansour et al 2020). The patient was COVID positive, but she did not show overt signs of COVID, except for fatigue, which may also be from her anemia. Regardless, transfusion and initiating medical therapy for menorrhagia without evidence of shock would be expected to be managed in less than 2 midnights in the hospital. The patient was set up with appropriate follow-up. Therefore, the patient does not meet the definition for inpatient stay of being medically complex and requiring a 2 midnight stay (CMS guidelines). Care would have been appropriate at an alternate level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ehler's Danlos syndrome, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and stroke.

Treatment: home care/personal care HHC (home health care)- level 2 personal care services, per 15 minutes 84 hours per week: Mon 12 Tue 12 Wed 12 Thu 12 Fri 12 Sat 12 and Sun 12.

The insurer denied coverage for home care/personal care HHC- level 2 personal care services, per 15 minutes 84 hours per week: Mon 12 Tue 12 Wed 12 Thu 12 Fri 12 Sat 12 and Sun 12.

The denial is upheld.

This patient with chronic medical problems including Ehler's Danlos syndrome, COPD (chronic obstructive pulmonary disease), CHF (congestive heart failure) and stroke. She lives with her son in a 3-bedroom apartment. She currently receives 28 hours of PCA (personal care assistant) services a week. 

The Uniform Assessment System (UAS) report was reviewed. The patient cognitive status is intact. Her decisions are "consistent, reasonable and safe." She "sells jewelry online and earns some money from it (about $100/month)." She requires extensive assistance for bathing and lower body dressing. Activities of daily living (ADL) tasks such as personal hygiene and upper body dressing require only limited assistance. The patient is independent with toilet transfers/use. She is occasionally incontinent of bladder and completely continent of bowel. She ambulates with a cane or rollator; occasionally requiring contact guard assistance. The combination of patient's intact cognitive status, ability to perform much of her ADL tasks with only limited assistance and her functional mobility, do not support the medical necessity of the requested increase home care/personal care HHC(Hexahydrocannabinol)- level 2 personal care services, per 15 minutes 84 hours per week: Mon 12 Tue 12 Wed 12 Thu 12 Fri 12 Sat 12 and Sun 12. The currently approved 28 hours of PCA services a week, is clinically appropriate; allowing her the ability to continue living safely at home.
The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the home care/personal care HHC- level 2 personal care services, per 15 minutes 84 hours per week: Mon 12 Tue 12 Wed 12 Thu 12 Fri 12 Sat 12 and Sun 12 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission 
The insurer denied coverage for an inpatient hospital admission. 
The denial is overturned.

This patient is a male who presented to the hospital with chest pain and ST (interval on an electrocardiogram) segment elevation myocardial infarction. The patient reported being awoken from sleep with chest pain. Past medical history was significant for hyperlipidemia and active cigarette use. Upon arrival, vital signs were stable [Blood Pressure 121/89 mmHg (millimeters of mercury) and Pulse 61 bpm (beats per minute)]. No abnormal findings were noted on physical exam. A 12-lead electrocardiogram (ECG) revealed normal sinus rhythm with ST elevations in the inferior and lateral leads. The patient was sent for emergent cardiac catheterization. No occlusion was noted on cardiac catheterization, however it appeared as though an occluded first obtuse marginal artery had recanalized. A left ventricular angiogram demonstrated a reduced LVEF (left ventricular ejection fraction) of 40% (percent). Serum blood testing revealed a peak CPK (Creatine phosphokinase) was 371 and CK (creatine kinase) MB (cardiac marker) 24. Peak serum troponin was 5.3. The patient was admitted to the hospital following cardiac catheterization for monitoring and treatment. 

The proposed treatment was medically necessary given the patient's clinical presentation, abnormal electrocardiogram, depressed LVEF on echocardiography and elevated serum troponin levels. This patient presented with an acute ST elevation myocardial infarction with autolysis of an occluded obtuse marginal artery. Observational care in this case has a high risk of morbidity and mortality. Using the HEART (history, electrocardiogram, age, risk factors and troponin) score risk stratification schema, this patient would have a high 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. (Reference 1) In one study of patients with ST elevation MI, the average length of stay was more than six days. (Reference 2) Given the high-risk nature of the patient and his presentation, evaluation and treatment at the inpatient level of care was medically necessary and beneficial for the patient.  

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

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

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission 
The insurer denied coverage for an inpatient hospital admission. 
The denial is upheld.

This is the case of a female who presented to the hospital with chest pain. Relevant past medical history included hypertension and cigarette use. Upon arrival to the ED (emergency department), the patient had poorly controlled hypertension as BP (blood pressure) was 218/106 mmHg (millimeters of mercury). Physical examination was otherwise unremarkable. Laboratory testing demonstrated elevated no elevation in troponin (<0.012). An ECG (electrocardiogram) revealed normal sinus rhythm without ST (interval on an ECG) or T (interval on a ECG) wave abnormalities. The patient was treated with labetalol IV (intravenous), nifedipine, and metoprolol. She was admitted for additional monitoring and therapy. Her BP responded to IV and oral therapy. The patient underwent regadenoson perfusion testing that revealed an LVEF (left ventricular ejection fraction) of 57% (percent) and no significant ischemia. She was discharged the following day. 

Hypertensive emergency is defined as BP > (greater than) 180/120 with target organ damage. (Reference 1) In this patient, serum brain natriuretic peptide and troponin levels were not elevated. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing consequence of rapid BP correction. (Reference 2) This patient's BP immediately responded to therapy, and she did not require continuous intravenous therapy for blood pressure control. She also had a low risk for myocardial infarction. Utilizing the HEART (history, electrocardiogram, age, risk factors, and troponin) risk score, this patient would have a low risk of for major adverse cardiac events [ST-segment elevation myocardial infarction (MI), non-ST-segment elevation MI, unstable angina, percutaneous coronary intervention, coronary artery bypass grafting, significant stenosis (> 50%) treated conservatively, or death due to any cause]. (Reference 3) In conclusion, this patient presented with poorly controlled hypertension and chest pain that was easily controlled with medical therapy. She had no evidence of target organ damage and did not have a hypertensive urgency or emergency. She could have been managed at a lower level of care. An acute inpatient admission was not medically necessary. 

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

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

Diagnosis: Lumbar radiculopathy, osteoarthritis, chronic pain.
Treatment: Increase Consumer Directed Personal Assistant Services 6 Hours Per Day, 3 Days Per Week, A Total of 18 Hours Per Week.
The insurer denied the Increase Consumer Directed Personal Assistant Services 6 Hours Per Day, 3 Days Per Week, A Total of 18 Hours Per Week.
The denial is overturned.

This female has conditions including lumbar radiculopathy, osteoarthritis, chronic
pain, and limited range of motion. She lives alone. She is appealing denial of increase consumer directed personal assistant services (CDPAS) 6 hours per day, 3 days per week, a total of 18 hours per week. Uniform Assessment Systems (UAS) evaluation completed previously shows modified independent cognition and functional status: maximal assistance with housework; extensive assistance with meal preparation; limited assistance with managing finances and medications, bathing, and dressing; and independent with phone use, personal hygiene, walking, locomotion, toilet, bed mobility and eating. She uses a cane for ambulation.

The Uniform Assessment Systems evaluation completed most recently shows a functional
decline with personal hygiene and dressing.

An appeal statement from the provider notes the member has difficulty with activities of daily living due to back and joint problems. Recommends an increase in hours of assistance.

Yes. The proposed treatment is medically necessary.

No. The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Consumer Directed Personal Care Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs). The member has several chronic conditions including chronic low back pain and limited range of motion. She is appealing denial of increase consumer directed personal assistant services (CDPAS) to 6 hours per day, 3 days per week, a total of 18 hours per week. Uniform Assessment Systems (UAS) evaluation completed on shows the member requires assistance  housework; extensive
assistance with meal preparation; limited assistance with managing finances and medications, bathing, personal hygiene, and dressing. Compared to Uniform Assessment Systems evaluation completed previously there has been a functional decline with personal hygiene and dressing.

An appeal statement recommends an increase in consumer directed personal assistant services hours due to difficulty with activities of daily living due to back and joint problems. The information provided shows there has been a decline in the member's functional status between Uniform assessment systems evaluations. Based on the progression of this member's physical limitation, the proposed increase consumer directed personal assistant services to 6 hours per day, 3 days per week, a total of 18 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 comprehensive orthodontic treatment and D8670 monthly visits.
The insurer denied coverage for D8080 comprehensive orthodontic treatment and D8670 monthly visits.
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, ectopic eruption, and anterior crowding and posterior crossbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index, attaining 28 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements, attaining only 23 points on the HLD index by internal reviewers.

Upon review of the submitted documentation (study models were not provided for review), 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, New York State requires the use of an orthodontic index, the Handicapping Labio-Lingual Deviation Index Report (HLD New York State Medicaid program) modeled after Handicapping Labio-Lingual Deviation index. 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 completes the second portion of the index arriving at 28 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care.

Regarding the validity of the HLD index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

The healthcare plan did not act reasonably, with sound medical judgement, or in the best interest of the patient. D8080 comprehensive orthodontic treatment and D8670 monthly visits is considered medically necessary for this patient.

The insurer's denial of coverage for D8080 comprehensive orthodontic treatment and D8670 monthly visits is overturned. Medical necessity is substantiated.