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

Diagnosis: Dementia, Cognitive impairment

Treatment: Personal Care Aide (PCA) Level 2 services, 8 hours per day, 7 days per week for a total of 56 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2 services, 8 hours per day, 7 days per week for a total of 56 hours per week.

The denial is overturned.

This is a male patient with a past medical history of atrial fibrillation, atherosclerosis, hypertension, prostate cancer, radiation proctitis, valvular heart disease and dementia.  Per Uniform Assessment System (UAS) documentation, the patient lives alone. The patient showed minimal impairment with episodes of forgetfulness. His daughter reported that his memory has been declining over the past few years. The patient requires maximum assistance with meal preparation, ordinary housework, managing finances and managing medications. He requires limited assistance with bathing, personal hygiene and dressing himself. The patient reported that he is able to transfer to and from the toilet, but he needs supervision because of unsteadiness. Personal Care Aide: Level 2 services, 8 hours per day, 7 days per week for a total of 56 hours per week is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 

(a) Definitions and scope of services.
...1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The health plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The health plan used evaluations done in the past, and there have been changes in the patient's status since then. The patient's functional capacity has changed since the health plan's evaluation. A level of outside activity was noted then and that does not exist now. Cognitive impairment was mild then and is worse now. He used a cane then and a walker now. He was rarely incontinent then and frequently now. He needed supervision with toileting then and needs assistance now. The change in the patient's functional and cognitive capacity supports a change in hours/day from 3.5 to 8.

The carrier's denial of coverage for the requested Personal Care Aide (PCA) Level 2 services, 8 hours per day, 7 days per week for a total of 56 hours per week is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth. 
Treatment: Partial Lower Denture (D5214). 
The insurer denied the Partial Lower Denture (D5214). 
The denial is overturned. 

The patient is a female requesting dental benefits for a new cast metal lower partial denture. 

Yes, the Partial Lower Denture (D5214) is medically necessary. 

The patient is missing five lower teeth. Her remaining lower teeth are in good condition and would act as good anchor teeth for a partial denture. She is getting a new full upper denture, so getting a lower partial denture, to fill in the edentulous areas, would make chewing with a full complement of teeth easier than without the lower partial denture. Complete mastication of food is healthier for the patient then not being able to chew everything completely. The partial denture is medically necessary for health reasons.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Triple Vessel Disease

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is upheld. 

This is a male patient with Triple Vessel Disease status post Percutaneous Transluminal Coronary Angioplasty and a history of hyperlipidemia, family history of coronary artery disease, and exertional chest pain. The patient's nuclear stress testing revealed mild to moderate inferior, inferoseptal and inferoapical ischemia. The patient's coronary angiography revealed a 95% mild left anterior descending (LAD) artery lesion and a 90% diffuse lesion from the ostium to the mid right coronary artery (RCA). The patient's electrocardiogram (EKG) was normal and records indicate that the patient's troponin level was 0.00.  

The patient presented to the hospital for percutaneous coronary intervention (PCI). Three drug-eluting stents (DES) were placed from the proximal to the mid RCA, using right radial approach. The patient was admitted for staged PCI of the LAD artery, with two DES deployed in the LAD artery via right femoral approach. The patient's vital signs remained stable during and after both procedures and he had no access site complications.

Based on the review of the medical record and literature, there is no evidence that this patient required an acute inpatient level of care. Staged PCI could have been completed as two separate same day procedures at an outpatient level of care. Thus, the full admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the full hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heavy Vaginal Bleeding and Low Hemoglobin Count. 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a with a history of menorrhagia who presented to the emergency room  with complaints of menorrhagia associated with lightheadedness, fatigue, feeling faint and palpitations. 

Vital signs on admission were normal and she was afebrile. A hemoglobin was 6.3. A pelvic examination revealed minimal uterine bleeding. Two units of packed cells were transfused. The patient was admitted to the inpatient service due to symptomatic anemia as well as concern for her safety with symptoms of faint feeling and lightheadedness. A post-transfusion hemoglobin was 9.4. The patient's vital signs and electrocardiogram (ECG) were normal. The patient continued with normal vital signs. She was discharged. 

No, the proposed inpatient admission was not medically necessary. 

The medical records and medical literature were thoroughly reviewed. The patient presented to the emergency room with complaints of vaginal bleeding and dizziness. The patient was admitted to the emergency room with documented anemia and a complaint of menorrhagia. Her medical history was significant for anemia and uterine fibroids. On admission to the emergency room the patient had normal vital signs with a normal blood pressure and pulse of 80. She exhibited no signs of dizziness or syncope and was noted to be normal in appearance. Her pelvic examination was normal except for minimal blood staining on speculum examination. There was no evidence of hemodynamic instability or symptomatic anemia. There was no evidence of active vaginal bleeding.  She did not have significant co-morbidities to support inpatient admission. Therefore, there was no evidence that the patient required inpatient admission. The patient was therefore stable and could have been transfused blood in an ambulatory setting within the facility, with observation, at the time and subsequent to emergency room admission. Transfer to an ambulatory unit or an intermediate patient observation unit would have been within the standard of care. Therefore, the inpatient admission was not medically necessary. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient stay. 
The denial is upheld in whole.

The patient is a male with a history of hypertension and methadone dependence, presented to the emergency department (ED) with asymptomatic bradycardia. The day prior his heart rate at his methadone clinic was 39 beats/minute. An electrocardiogram showed sinus bradycardia and he was advised to go the ED. In the ED the patient was in no distress. Upon questioning he reported several years of exertional dyspnea with walking one block. His blood pressure was 150/90 millimeters of mercury (mmHg) with a heart rate of 51 beats/minute. His physical exam was unremarkable. An electrocardiogram showed sinus rhythm at 55 beats/minute without acute changes. His brain natriuretic peptide (BNP) level was normal. Chest x-ray showed cardiomegaly and mild pulmonary vascular congestion. The patient's serum creatinine level was 1.63 milligrams per deciliter (mg/dl). He was treated with intravenous fluid and admitted to the hospital. Prior to admission he had been on carvedilol, which was stopped. His resting sinus rate ranged from the 40s-50s; with walking his heart rate increased to the 80s. The next day the patient's creatinine level was 1.18 mg/dl. Review of his prior medical records indicated that he had been evaluated in 2010 and again in 2014 for asymptomatic bradycardia. He was discharged. Medical necessity for an inpatient admission is at issue.

The health plan's determination of medical necessity is upheld in whole.

This patient was admitted to the hospital with asymptomatic sinus bradycardia. The most likely underlying etiology was intrinsic sinus node dysfunction, exacerbated by treatment with carvedilol, a beta-adrenergic blocker. He was hemodynamically stable, without signs of myocardial or cerebral ischemia. His initial serum creatinine was elevated but normalized with intravenous fluids, and then remained stable. No particular treatment for his bradycardia was provided while he was hospitalized, nor was it indicated. According to current guidelines, while it would be reasonable to assess this patient's chronotropic response to exercise at some point, no immediate intervention or inpatient hospitalization was warranted. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

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

This is a male with a history of intravenous (IV) drug abuse and alcohol abuse.  He presented to the Emergency Room with complaints of dark urine and jaundice. The patient was admitted to the hospital with jaundice. 

The patient presented with jaundice.  He was afebrile and the vital signs were stable.  There was no abdominal rebound or guarding.  A recent hepatitis A test was positive. He was also treated for cellulitis. There was a history of IV drug abuse.  IV hydration and anti-emetics were given. The patient's International Normalized Ratio (INR) level was 1.2.  He was able to tolerate a diet.

Clinical indications for admission for Liver Disease Complications include hepatic encephalopathy, hemodynamic instability, peritonitis, infected ascites or a markedly prolonged INR value. The patient did not have these conditions. He also did not have severe vomiting, severe dehydration, or an inability to maintain oral hydration.

This patient had hepatitis but did not have acute liver failure. His INR level was 1.2 and he was able to tolerate a diet.  IV hydration and antiemetics could have been given in the Emergency Room with observation status. He did not meet Milliman Care Guidelines (MCG) guidelines for Liver Disease Complications.  An inpatient hospitalization was not medically necessary.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

Diagnosis: autoimmune breast implant disorder.
Treatment: Removal of Breast Implants.
The insurer denied the Removal of Breast Implants. 
The health plan's determination is upheld. 

This female complained of autoimmune breast implant disorder and Hashimoto's thyroiditis. She also has breast implant capsular contractures. Her surgeon performed breast implant removals and capsulectomies. Under review is the medical necessity for the removal of breast implants.

The breast implant removals were not medically necessary. The patient complained of deterioration in health that she attributed to her breast implants. According to a 2016 study by Balk et al: "The evidence remains inconclusive about any association between silicone gel implants and long-term health outcomes. Better evidence is needed from existing large studies, which can be reanalyzed to clarify the strength of associations between silicone gel implants and health outcomes."
According to a 2019 review by Rohrich et al: " To the best of our body of scientific knowledge to date, there have not been any concrete or evidence-based studies or peer-reviewed data concerning the formation of a new syndrome: "silicone implant illness." Lastly according to the Food and Drug Administration (FDA), "There is no apparent association between silicone gel-filled breast implants and connective tissue disease, breast cancer, or reproductive problems."
Peer studies do no support removal of this patient's implants and capsulectomies to prevent or treat a systemic inflammatory condition. Using the American Society of Plastic Surgeons (ASPS) position paper on reoperation for implants placed for cosmetic augmentation, the medically necessary conditions for reoperation are broken or failed implant, infection, implant extrusion, siliconoma or granuloma, interference with the diagnosis or treatment of breast cancer.
The ASPS position paper goes on to say that insurance carriers "respond thoughtfully and with compassion on an individual basis" for several other conditions including "mastodynia (painful breasts) and medically significant capsular contracture (capsular contracture that produces pain, disfigurement and/or interferes with mammography)." Capsular contracture is a benign condition. Although contractures can be painful, they do not pose a health risk or danger. Surgery will make the patient more comfortable and will improve the appearance of her breasts, but it is not necessary to prevent a disease or illness or to treat a functional problem.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital.
The insurer denied inpatient admission for medical necessity. The denial was overturned. 

This patient is an infant female with congenital ptosis who presented to the emergency department (ED) with stiffening and color change at home. She presented to an outside hospital with a brief resolved unexplained episode (BRUE) at home with concern for seizure. The episode did not respond to physical stimulation and lasted a couple minutes before resolution. Emergency Medical Services (EMS) was called, and the infant was back to baseline by the time of arrival. The child was transported to the outside ED where initial evaluation was performed. Neurology consultation recommended transfer to the children's hospital for further work-up and monitoring.
Admission note vital signs were a temperature (T) at 37.5C, heart rate (HR) was 139, respiratory rate (RR) was 38, blood pressure (BP) was 97/73, oxygen (O2) saturation was 100% on room air. Her weight was 14 lbs, 14 ounces. The physical exam noted baseline left sided ptosis and was otherwise normal for her age.
Given the concern for possible seizure, blood work was obtained, and a lumbar puncture was performed to rule out infection. Cell counts were reassuring. The white blood cell count (WBC) was 10.6 with 11% segs and 78% lymphs. She had a normal basic metabolic panel (BMP), and the electrocardiogram (EKG) was normal.
The infant was admitted to the hospital for an electroencephalogram (EEG), neurology consultation and management. A magnetic resonance imaging (MRI) scan of the head was recommended but refused by the patient's parents. The work-up (EEG, lumbar puncture [LP], labs) was benign and the baby had no further episodes while inpatient. The patient was discharged home to follow up with neurology as an outpatient. Discharge diagnosis was a BRUE.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is overturned in whole.

The inpatient stay was medically necessary for this patient.
This infant presented to the hospital after an episode of stiffening and redness at home of unclear duration. According to the medical documentation provided, there was concern for possible seizure activity, which could be related to infection or underlying neurological abnormality. This is a young early term infant with history concerning for seizure activity. The patient does not meet the BRUE criteria for lower risk activity given the duration of episode estimated to be greater than (>)1 minute and the baby's young corrected gestational age.
This infant did not meet low-risk criteria for BRUE, and therefore an inpatient stay was appropriate for the clinical situation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain, headache, dizziness.
Treatment: Inpatient admission.
The insurer denied the inpatient admission. The denial is overturned. 

The patient is a male. At the time of admission to the hospital, he had a past medical history significant for hypertension (HTN), dyslipidemia, tobacco abuse, coronary artery disease (CAD) status post (s/p) myocardial infarction (MI) (non-ST-elevation myocardial infarction [NSTEMI]) five months prior to this admission, status post (s/p) two vessel percutaneous coronary intervention (PCI).  The patient presented for evaluation in the emergency room (ER) due to complaints of chest pain, headache, dizziness, blurry vision and nausea for two days duration. The patient was found to have severe hypertension with blood pressure (BP) of 204/131 millimeters of mercury (mmHg). The rest of vital signs were unremarkable. 

The patient admitted to non-compliance with medical regimen. Chest x-ray revealed no acute cardiopulmonary disease. Electrocardiogram (ECG) revealed sinus rhythm with no acute ischemic changes. Troponin was mildly elevated. Computed tomography angiogram (CTA) of the chest was performed, revealing an ascending aortic aneurysm of 4.5 centimeters (cm) with no dissection and descending thoracic aortic mural thrombus with no associated dissection or aneurysm. 

The patient was treated in the ER with intravenous (IV) anti-hypertensives, nitroglycerin and Fioricet for headaches and IV Zofran for nausea. His BP remained severely elevated and he was admitted for treatment of hypertensive urgency, malignant hypertension, as well as to rule out acute coronary syndrome (ACS). The patient was seen in consultation by cardiology and oral anti-hypertensive therapy was initiated. His BP remained elevated and IV hydralazine was administered as well. Head CT scan was negative for cerebral vascular accident (CVA) or hemorrhage. His chest pain, headaches and the mild troponin leak were felt to be due to hypertensive urgency and no further ischemic work-up was planned. His dual antiplatelet therapy was restarted. His BP gradually improved and his symptoms resolved; he was discharged home with a plan for outpatient follow-up.

Yes, the proposed inpatient admission was medically necessary.

The patient presented with complaints of chest pain, as well as headache, blurry vision, nausea, and mild troponin leak, in the setting of severe hypertension, suggestive of hypertensive emergency. His presentation, as well as clinical findings were consistent with end-organ damage, including hypertensive encephalopathy and hypertensive heart disease. The patient had a known history of coronary artery disease, including a recent myocardial infarction (MI), requiring percutaneous revascularization. Given the presentation, uncontrolled hypertension, as well as clinical presentation consistent with hypertensive emergency, it would be consistent with the current standard of care that this patient be managed in an inpatient setting, and therefore the requested inpatient admission was medically necessary in this clinical setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chronic pain.
Treatment:  Oxycontin (oxycodone) Extended Release.

The insurer denied coverage for Oxycontin (oxycodone) Extended Release.  The denial is upheld. 

This is a male patient with a diagnosis of chronic pain, untreated hepatitis C virus (HCV), immunocompromised condition, and polysubstance abuse.  The patient was admitted to the hospital due to skin abscesses and pneumonia.  It was noted that the patient "cheeked oxycodone" and signed out against medical advice (AMA) repeatedly.  There is no documentation of urine toxicology or an opiate maintenance agreement.  There is no formal opiate risk assessment. 

As per review of the submitted documentation, there are several alternatives on the insurer's formulary including Embeda, which is a morphine/naltrexone combination.  This medication too, is abuse deterrent and will not cause a reaction if taken as directed. Given this patient's history of polysubstance abuse including opiates, oxycodone immediate-release (IR) or oxycodone extended-release (ER) is not consistent with clinical practice guidelines.  The Department of Veteran Affairs and the Department of Defense (VA/DoD) guidelines state:  "We recommend against long-term opioid therapy for pain in patients with untreated substance use disorder."

As per Cheatle et al., "Individuals engaged in substance abuse and addiction place the physician at risk for diversion of their prescriptions because this implies contact with the illicit drug trade."

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

Based on the review of the medical record and literature, the medical necessity for Oxycontin (oxycodone) Extended Release is not substantiated.  The insurer's denial should be upheld.