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

Diagnosis: myocardial infarction
Treatment: Life Vest - Four (4) Month Rental 
The insurer denied Life Vest - Four (4) Month Rental. The health plan's determination is overturned in part. The Life Vest is medically necessary for 3 months.  

The patient is a man with a history of hypertension and diabetes who presented to the hospital complaining of dyspnea. He was diagnosed with a non-ST segment elevation myocardial infarction and congestive heart failure. Cardiac catheterization showed severe three vessel disease. By echocardiogram, his left ventricular ejection fraction (LVEF) was 25-29%. The patient underwent coronary artery bypass graft surgery. He was started on guideline-directed medical therapy for heart failure with reduced ejection fraction; he did not tolerate a beta-blocker. An echocardiogram showed an LVEF of 26-30%. He was discharged with a LifeVest wearable cardioverter defibrillator (WCD).

The Use of the LifeVest for three months was medically necessary. In a retrospective evaluation of 4958 patients with LVEFs of 35% or less after coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) from two combined databases, 809 patients who were discharged with a WCD were compared to the remaining 4149 patients. The WCD was associated with a lower 90-day mortality in patients after CABG (no WCD: 7% vs WCD: 3%) and after PCI (no WCD: 10% vs WCD: 2%). In the Wearit II registry, which included 805 patients with ischemic cardiomyopathy, the rate of potential life-threatening ventricular tachyarrhythmias was 3% over a 3 month period. All episodes that were treated by the WCD were successfully terminated, suggesting that these patients had aborted sudden death versus actual sudden death. The 2016 American Heart Association Science Advisory considers use of the WCD reasonable during the "waiting period" following myocardial infarction or revascularization, as does the 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. However, after 90 days, this patient would have been eligible for an implanted device if his LVEF remained 35% or less, unless there was a medical reason for further delay. The records provided do not document that there was such a reason. Therefore, continued use of the WCD after 3 months was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder/ADHD
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug. 
The health plan's determination is overturned.

The patient is a female diagnosed with attention deficit hyperactivity disorder (ADHD). Prior notes indicated patient's diagnosis was attention and concentration deficit, but updated information indicates her official diagnosis to be ADHD. The patient was originally denied the requested Amphetamine-Dextroamphetamine 10 mg due to it not being prescribed for a Food and Drug Administration (FDA) approved diagnosis. With the addition of the notes provided detailing the patient to be diagnosed with ADHD, she now does have an FDA approved indication for the use of the requested medication as medically necessary. The request is for Amphetamine-Dextroamphetamine 10mg for the management of ADHD concerns.

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

Yes. After review of the provided documentation, the patient is noted to have ADHD as a diagnosis (as opposed to the initial attention and concentration deficit diagnosis). As a result, ADHD is indicated as Food and Drug Administration (FDA) approved for management by the requested medication. Furthermore, this medication is noted to be an appropriate and medically necessary treatment for the management of ADHD as well.

Felt et al. note psychostimulants (e.g., methylphenidate [Ritalin], dextroamphetamine, and mixed amphetamine salts such as Dextroamphetamine/Amphetamine [Adderall]) are the most effective and safe option and are the first choice for ADHD treatment in national guidelines and reviews.[3] 

Kooj et al. note a recent systematic review and network meta-analysis on the comparative efficacy and tolerability of medications for ADHD in children, adolescents and adults showed, that the first pharmacological choice for ADHD in children and adolescents is methylphenidate, and amphetamines in adults. In fact, in adults, amphetamines were not only the most efficacious compounds, as rated by clinicians and by self-report, but also as well tolerated as methylphenidate and the only compounds with better acceptability than placebo.[4]

After review of the provided documentation, the patient is noted to have ADHD as a diagnosis (as opposed to the initial attention and concentration deficit diagnosis). This medication is appropriate and medically necessary treatment for the management of ADHD as noted in the literature above.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac/Circulatory Problems.
Treatment:  Inpatient Hospital stay.

The health plan denied the inpatient hospital stay as not medically necessary.  The reviewer has upheld the determination in whole.

This 63-year old woman presented to the hospital for scheduled cardiac catheterization.  The procedure was recommended to evaluate her complaints of persistent fatigue, intermittent chest pain and exertional dyspnea after a Covid-19 infection.  Her medical history was remarkable for diabetes, hypertension, and hyperlipidemia, stage 4 chronic kidney disease and kidney cancer.  Upon presentation she was hemodynamically stable.  Her blood sugar was 443 mg/dl (milligrams per deciliter); this high level was attributed, in part, to steroid premedication for a contrast allergy.  Her serum creatinine level was 2.37 mg/dl, which was her baseline.  Her potassium level was 6.0 mmol/L (millimoles per liter).  She was treated with intravenous fluids and insulin.  A repeat potassium level was 5.1 mmol/L.  Coronary angiography showed a significant stenosis in the posterior descending coronary artery that was successfully treated with a stent.  The procedure was uncomplicated.  The patient was discharged the following day.  Medical necessity for an inpatient admission is at issue.

An inpatient level of care was not medically necessary.  This patient presented for elective cardiac catheterization and subsequently underwent coronary artery stent implantation.  The procedure was uncomplicated.  While some period of observation/monitoring immediately following percutaneous coronary intervention is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients.  In fact, in the report by Shroff et al., a literature review of randomized clinical trials, observational studies, meta-analyses guidelines, and consensus statements showed that same day discharge after percutaneous coronary intervention (PCI), as compared to overnight hospitalization, was not associated with an increase in adverse events (bleeding, repeat coronary procedures, death, or rehospitalization).  The Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes.  Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications.  This patient did not meet these criteria.  Given her kidney disease and hyperkalemia, overnight monitoring was reasonable and prudent at a lower level of care.  However, it did not require an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied treatment with braces. 
The denial is upheld.

The patient is a female with Skeletal Class I occlusion. She has moderate maxillary spacing and mild mandibular crowding. She has a severe overjet and moderate overbite. The subject to be determined is the medical necessity for braces.

The health plan's determination is upheld in whole.

The requested treatment of braces is not medically necessary for this patient. Since the patient displays a Skeletal Class I occlusion with moderate maxillary spacing, mild mandibular crowding, severe overjet and moderate overbite, according to the standard of care, braces in this case would not be considered medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied braces and monthly visits x 12. 
The denial is upheld.

The patient is a female with maxillary and mandibular crowding and retained teeth C and H. The orthodontist mentioned in the diagnosis that #6 and #11 are impacted. The patient is treatment planned for comprehensive orthodontics with maxillary canine exposures and ligations, but the plan was denied due to lack of medical necessity.

The health plan's determination is upheld.

Braces and monthly visits is not medically necessary for the patient at this time. The patient is in the mixed dentition phase of development. Neither #6 nor #11 appear to be erupting at a poor angle on the radiograph. The angle of canine eruption can affect spontaneous eruption of teeth where the steeper the eruption angle, the higher risk of impaction.1and it is too early to determine if it will require an exposure as maxillary canines usually erupt at 11-12 years of age.2 There is still much time to see if #6 and/or #11 will erupt successfully on their own without orthodontic intervention. She is in the process of losing her remaining primary teeth as they are replaced with permanent teeth. Research indicates the following risk factors for impacted canines in patients over 10 years of age 3:

1)  If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph and photographs.)
2)  The canines cannot be palpated, and occlusal development is advanced. (The canines can quite obviously be palpated on the labial.)
3)  The lateral incisor is proclined and tipped distally (Photographic evidence does not indicate proclined lateral incisors.)
4)  On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided.)
The patient does have maxillary and mandibular crowding and treatment may be indicated in the future. However, the patient does not exhibit any of the criteria to suspect these canines are, in fact, impacted. For this reason, orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Orthopedic/Musculoskeletal-Femur Fracture/Break.
Treatment:  Physical Therapy (2 additional visits).

The plan denied physical therapy (2 additional visits) as not medically necessary.  The reviewer has overturned in whole the health plan determination of medical necessity.

The patient has a history of bilateral knee degenerative joint disease (DJD) and left femur fracture status/post (s/p) open reduction internal fixation (ORIF).  She was seen by her Orthopedic provider and was using a walker to ambulate.  She noted her range of motion and condition is improving.  She rated her pain as 6/10 with activity.  On physical exam of the left lower extremity her incisions were well healed with minimal swelling.  Her knee range of motion was 5-120 degrees with no tenderness to palpation and was neurovascularly intact.  Range of motion was greater in the right knee than left.  Sensation and motor was intact bilaterally.  Assessment included knee pain and femur pain s/p left distal femur ORIF, weight bearing as tolerated, knee cortisone injection was discussed and performed.  Physical therapy for knee range of motion and knee pain was prescribed.  Left knee and femur X-rays were also obtained, which showed demineralization, mild to moderate tricompartmental osteoarthrosis, small osteochondroma and partially healed fracture of the distal femoral shaft s/p ORIF.  The professional rehabilitation and physical therapy progress notes were also reviewed, and it was noted that she was compliant with physical therapy treatments and was slowly progressing towards her goals.  She continued to have left leg and knee pain but was making slow improvement and was walking with a walker and having less pain.  She continued to have weakness in the left leg muscles, and additional physical therapy was recommended.

The requested 2 additional visits of physical therapy are medically necessary for this patient, given the new report provided.  The patient was seen by her orthopedic surgeon and continued to have pain and physical dysfunction.  The patient had new X-rays which showed demineralization, mild to moderate tricompartmental osteoarthrosis, small osteochondroma and partially healed fracture of the distal femoral shaft s/p ORIF.  She had a steroid injection to her left knee, and additional physical therapy was prescribed.  The additional information from the X-rays justifies the need for additional physical therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ambulatory Dysfunction
Treatment: Personal Care Aide Level 2 Services - Live in per day
The insurer denied Personal Care Aide Level 2 Services - Live in per day.
The determination is upheld.

The patient has a past medical history significant for chronic obstructive pulmonary disease (COPD), coronary artery disease, diabetes, cerebrovascular disease and ambulatory dysfunction.

The patient is currently approved for 8 hours a day 7 days a week for a total of 56 hours a week. Additional services, 168 hours a week, 24 hours a day 7 days a week live-in aide are being requested.

At issue is the medical necessity of the requested services.

The requested health service is not medically necessary for this patient.
This is a patient with multiple medical problems including ambulatory dysfunction who is dependent on services for all instrumental activities of daily living (IADLs) and most activities of daily living (ADLs).

The patient's health plan denied the additional services noting this level of care is not justified for this member. Review of the most recent documents do not support there has been a significant change. No skilled needs are noted at night. There is no evidence of wounds which will require frequent turning and repositioning.

The patient currently lives in a senior housing facility in a one bedroom apartment. She was in a care facility. It appears that the evaluation was done while the patient was in the facility. Evaluation was compared to a previous evaluation done a month prior. There are no significant changes in the patient's abilities.

The question is whether the patient needs can be met with 8 hours a day 7 days a week of services versus 24 hour a day live-in services. The patient's IADLs can be met with 56 hours a week of services. The patient is dependent on caregivers for the majority of ADLs. However, these services can be provided in the allotted time. There are no specific nocturnal needs noted which would necessitate additional service hours at night such as frequent turning or other skilled care for skin wounds. The patient is noted to be incontinent of urine and supplies have been provided for management of this condition. Additional services in addition to the 56 hours a week of services would be considered companion/safety monitoring which are not typically provided by the plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient presented to the hospital with a history of progressively worsening abdominal pain of 1-day duration. Comorbid health conditions included hyperlipidemia. His evaluation included a physical exam, labs, and computed tomography (CT) scan. He was without a fever at the time of presentation. Lab data identified a white blood cell count (WBC) count of 7.6 thousand (K). The CT scan yielded the diagnosis of appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. A surgical consultation was obtained.

The patient underwent a laparoscopic appendectomy. The clinical notes and the anesthetic record indicate an uncomplicated appendectomy with findings of acute appendicitis without abscess. He was provided IV fluids and perioperative antibiotics. Vital signs remained normal throughout the hospitalization without a fever. The diet was advanced and pain management was converted to oral medications. He was discharged home following the initial recovery period.

At issue is the medical necessity of an inpatient stay.

Inpatient stay was not medically necessary for this patient.

This patient presented with abdominal pain. The evaluation with examination, lab data, and CT scan supported the diagnosis of appendicitis. The initial treatment appropriately included nothing by mouth (NPO) status, IV fluid, and the appendectomy. The early post-surgical course was uncomplicated and the patient was hemodynamically stable and tolerating a diet on the first post-surgical day. 

The submitted clinical documentation does not support the need for an inpatient admission for this patient. The patient presented with abdominal pain and underwent an uncomplicated appendectomy. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
   
The patient was clinically stable at the time of presentation and remained so during the course of care. Presurgical assessment, serial examination, operative treatment and post-surgical monitoring could have been provided at a lower level of care than inpatient.

Generally accepted guidelines state that the goal length of stay is ambulatory or 1 day postoperative. These guidelines indicate that in the absence of hemodynamic instability, sepsis or toxicity, significant electrolyte imbalance, bleeding, gastrointestinal (GI) obstruction or surgical complications, the procedure may be performed with an ambulatory level of care. In this case, the patient tolerated oral hydration, diet and medication and pain was well controlled.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for the inpatient hospital admission. 

The denial is upheld. 

This is a male patient with a history of asthma who presented to the Emergency Department (ED) with complaints of chest tightness, wheezing and cough secondary to asthma exacerbation. Vital signs at triage included: blood pressure (BP) 142/84; heart rate (HR) 123; respiratory rate (RR) 25; and oxygen saturation (O2 sats) 98%. The patient denied any chest pain (CP). As per the ED Note, the patient was in no acute distress. No respiratory distress was noted; lung exam revealed bilateral (B/L) wheezing. The patient was awake and alert X 3. The neurological exam was non focal. 

The patient was treated with DuoNeb, intravenous (IV) steroids and IV Magnesium. As the patient was still wheezing he was given subcutaneous (SC) Terbutaline. Chest x-ray did not reveal any infiltrates. His electrocardiogram (EKG) was essentially normal. Peak expiratory flow (PEF) was 220. His best PEF was 300. The patient was admitted to the hospital for further management. Vital signs as per the history and physical were: temperature 98.3; RR 20; BP 144/85; HR 113; and O2 sats 100%. Lung exam revealed B/L wheezing. The patient was continued on bronchodilators (BD), steroids, and Inhaled Corticosteroid/Long Acting Beta Agonist (ICS/LABA). He remained stable after admission. He was medically cleared for discharge on oral medications: steroids, bronchodilators, and ICS/LABA later in the evening on the day of admission. 

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. He remained stable after admission, was in no acute distress, and his PEF improved with treatment. The patient did not have any hypoxia. The patient remained afebrile and hemodynamically stable and was tolerating oral intake. The patient was stable to be kept in Observation status and discharged later that evening without need for inpatient hospitalization. 

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

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

Diagnosis: Substance Abuse.
Treatment: Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services.
The insurer denied Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services. 
The health plan's determination is overturned. 

The patient is an adult male who was admitted to acute inpatient level services for detoxification and withdrawal management of opioid (heroin), stimulant (cocaine), and alcohol use disorders. The patient was using up to 6 bags of heroin daily with intravenous (IV) administration. The patient was also using small amounts of alcohol intermittently, and up to $120 of cocaine on a daily basis. The patient had experienced severe opioid withdrawal in the past when attempting to cut down and he had received detoxification and rehabilitation services in the past with the most recent occurring five years prior to presentation. He presented with mild to moderately severe withdrawal at the time of admission with sweats, nausea and diarrhea, abdominal cramp, yawning, aches and rhinorrhea, as well as anxiety, irritability and restlessness with a Clinical Opiate Withdrawal Scale (COWS) score of 11.

The Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services is medically necessary for this patient.

The proposed inpatient services and detoxification treatment and withdrawal management for severe poly-substance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The adult inpatient treatment of this patient's substance use disorders did warrant the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the substance use disorders with multiple substances of abuse, and the associated psychosocial stressors and presence of chronic medical conditions. Withdrawal symptoms were managed with tapering dosages of methadone requiring monitoring and prn (pro re nata) medications, as well as the availability of Ativan for alcohol withdrawal and comfort medications and nicotine replacement and vitamin replacement therapy to prevent the onset of encephalopathy. Seizure and fall precautions were provided. Counseling and educational sessions with motivational techniques together with case management services were appropriately provided to motivate the patient's transition to rehabilitation substance use disorder treatment. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review with associated substance use disorder treatments, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.

This answer is consistent with the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.