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

Diagnosis: Atrial fibrillation s/p cardiac pacemaker placement, hypertension, breast cancer and macular degeneration. 

Treatment: Increase of personal care aide services to seven days per week, 24 hours per day/split shift. 

The insurer denied the Increase of personal care aide services to seven days per week, 24 hours per day/split shift. 

The denial is overturned. 

The patient is a female with a history of atrial fibrillation s/p (status post) cardiac pacemaker placement, hypertension, breast cancer and macular degeneration. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of seven days per week, 24 hours per day/split shift personal assistance services to offer increased ADL support. 

The increase of personal care aide services to seven days per week, 24 hours per day/split shift is medically necessary. 

The patient is a female with a history of atrial fibrillation status post cardiac pacemaker placement, hypertension, breast cancer and macular degeneration. Recent documentation from the patient's physician indicates that due to worsening visual acuity, insomnia, frequent nighttime trips to the bathroom, gait ataxia and generalized weakness; she has sustained numerous overnight falls. For these reasons, the currently approved plan of seven days per week, 12 hours per day for a total 84 hours per week is insufficient to meet the patient's current needs, as she needs 24/7 supervision to prevent overnight falls and to assist with ambulation and toileting needs. For these reasons, the proposed treatment seven days per week, 24 hours per day/Split shift personal assistance services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cytomegalovirus (CMV).  
Treatment: Letermovir (Prevymis) 480MG OR TABS. 
The insurer denied the Letermovir (Prevymis) 480MG OR TABS. 
The denial is upheld. 

The patient in this case has acute myeloid leukemia (AML). She underwent allogeneic transplantation and was on preventive therapy with letermovir.  While on that treatment, cytomegalovirus (CMV) polymerase chain reaction (PCR) rose and she required treatment with valganciclovir.  Following that treatment, she was to resume treatment with letermovir. 

No, the proposed treatment with letermovir (Prevymis) is not medically necessary. 

This patient was started on letermovir for prevention of CMV (cytomegalovirus) reactivation.  This is a standard treatment to prevent CMV (cytomegalovirus) reactivation.  Standard use of this agent indicates that it is indicated for prevention through day 100.  There is no evidence that continued use beyond 100 days post-allogeneic transplantation improves outcomes compared to stopping after day 100.  Given that lack of evidence the proposed continued use of letermovir in this patient is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  History of coronary artery disease, chronic obstructive pulmonary disease (COPD) and diabetes mellitus.
Treatment:  Personal Care Aide (PCA) Level II - 12 hours per day, seven days per week - a total of 84 hours per week.

The insurer denied the Personal Care Aide (PCA) Level II - 12 hours per day, seven days per week - a total of 84 hours per week.  The denial is overturned. 

The patient is a female with a history of coronary artery disease, chronic obstructive pulmonary disease (COPD) and diabetes mellitus.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of 84 hours per week personal assistance services to offer increased activities of daily living (ADL) support.

Yes, the proposed treatment of 84 hours per week Personal Assistance Services is deemed medically necessary. 

This is a female with a history of coronary artery disease, chronic obstructive pulmonary disease (COPD) and diabetes mellitus.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  Furthermore, recent documentation was received from the patient's provider, which indicated that due to worsening gait ataxia, frequent falls, generalized weakness/fatigue and chronic dyspnea requiring supplemental oxygen therapy, the currently approved plan of 59.5 hours per week Personal Assistance Services is insufficient to meet the patient's current needs.  For these reasons the proposed treatment 84 hours per week Personal Assistance Services is deemed medically necessary to offer increased ADL (activities of daily living) assistance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal-Other/panniculectomy-hernia
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld the health plan denial in whole.

This is a patient with an abdominal pannus after weight loss surgery. The patient underwent abdominal panniculectomy, excision of hip rolls, and umbilical hernia repair. Estimated blood loss was 200 cubic centimeter. The patient  was admitted to inpatient for deep vein thrombosis (DVT) prophylaxis and monitoring. Vital signs and laboratory values were reviewed. Hospital records were reviewed. The following day the patient's vital signs were stable; the patient was doing well and had no complaints. Examination revealed - no collection, drains with serosanguinous drainage. One day later the patient was deemed medically stable and discharged home.
The Inpatient Stay was not medically necessary for this patient.

The two most common abdominal contouring procedures performed by plastic surgeons are abdominoplasty and panniculectomy. Although the two procedures share similarities, abdominoplasty, or "Tummy Tuck" is considered a purely cosmetic procedure (Aherra et al, Sati et al). A panniculectomy is typically performed in patients after massive weight loss with a symptomatic abdominal pannus that is unresponsive to conservative measures. These abdominal contouring surgeries are typically performed at a lower level of care unless there are compelling reasons for an inpatient stay.
For this patient, the objective documentation did not demonstrate a need for admission at the acute inpatient level of care. The estimated blood loss was moderate (200 cc). Postoperative, the pain was well controlled, vital signs were stable, the patient had unlabored breathing, no respiratory distress, and tolerated a diet. Postoperative chemoprophylaxis does not require an inpatient stay for monitoring. Postoperative clinical care could have been safely performed at a lower level of care
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Seizure.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a man with a history of asthma, seizures and alcohol abuse who presented to the hospital. He presented with a chief complaint of a seizure. He reported last drinking on the prior day. After losing consciousness, he awoke laying on the floor. He denied shortness of breath, nausea, vomiting and diarrhea. He reported drinking 2 pints of vodka daily. Vital signs showed blood pressure 153/78, heart rate 102, and temperature 98.3 Fahrenheit. On physical examination, there were tongue fasciculations and tremors. Heart was regular and abdomen was soft and nontender. There was no cranial nerve deficit reported. Labs showed white blood cell (WBC) 4.65, hemoglobin 12.5, creatinine 0.69, sodium 132, and potassium 3.8. Alanine aminotransferase (ALT) was 204, aspartate aminotransferase 280, alcohol level was negative, and lactate 8.8. Head computed tomography (CT) was negative for acute abnormalities. CT of the cervical spine was negative for fractures. The patient was admitted for alcohol withdrawal with seizure. The plan of care included telemetry, Neuro checks, Clinical Institute Withdrawal Assessment (CIWA) protocol, benzodiazepines, thiamine, multivitamin, folic acid, intravenous (IV) fluids, trend lactate, and monitor electrolytes.

The inpatient care was medically necessary. The reason is that the patient presented with seizure in the setting of suspected alcohol withdrawal. While it is correct that he had an unremarkable hospital course and responded to benzodiazepines, IV fluids, and multivitamins, his history of alcohol abuse and presenting symptom of a seizure in the setting of withdrawal increased his risk of a serious adverse outcome, such as delirium tremens. It would not be appropriate to manage a patient at this degree of increased risk at a lower level of care. The patient was at increased risk for recurrent seizures, other symptoms of acute alcohol withdrawal, development of infection and sepsis, and transfer to the Intensive Care Unit (ICU). Monitoring him more closely with Neuro checks and telemetry, while maintaining him on a CIWA, was appropriate and required an increased intensity of care given his presenting seizure.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Type 2 diabetes, hypertension, and coronary artery disease.
Treatment:  Pharmacy/ Prescription Drugs (Janumet).

The insurer denied Janumet.  The health plan's determination is overturned in whole. 

This is a male with type 2 diabetes, hypertension, and coronary artery disease.  He has been on Humalog.  He was on Lantus which he stopped due to hypoglycemia.  He has tried and failed metformin.  He was on Janumet in the past.  He has tried and failed Jentadueto.  Request for Janumet is under review.

The health plan's determination is overturned in whole.

The formulary alternatives will be or have been ineffective.  The documentation indicates that the patient has tried and failed Jentadueto.  It is not appropriate to have the patient trial Jentadueto in this clinical situation, as the patient has already tried and failed Jentadueto.  Without Janumet, this patient is at risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Inpatient hospital

Diagnosis: Dental Abscess
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a boy who presented with right sided facial swelling. He was well until 3 days prior to presentation when he developed a tooth ache. He was seen by a dentist at that time and was prescribed clindamycin. However, his symptoms persisted and he subsequently developed right sided facial swelling. The swelling continued to worsen despite the antibiotics, and therefore he was brought to an outside emergency department and subsequently referred to Mount Sinai for further care. His past history is significant for a previous root canal on the same tooth approximately 7 years ago.
On physical examination, he was found to have right sided lower facial swelling that was minimally tender to palpation. Laboratory values were drawn and a Maxillofacial computed tomography (CT) was obtained which revealed buccal space cellulitis and swelling.
He was diagnosed with buccal cellulitis and was admitted for intravenous clindamycin and intravenous fluids. 

The Inpatient Hospital Admission was medically necessary for this patient.
This is a teenage boy who presented with a dental abscess and cyst. His symptoms were progressing despite appropriate oral antibiotic treatment as an outpatient. At the time of presentation, he had worsening swelling of his face and was referred in for care. His CT scan revealed swelling and cellulitis. He required inpatient admission for prompt initiation of parenteral antibiotic treatment and intravenous fluids in preparation for surgery the following day.
The most important treatment for odontogenic infections is surgical drainage and removal of necrotic tissue. Parenteral antibiotic therapy can help prevent further local spread of infection and hematogenous dissemination. This is important because odontogenic infections can extend to potential fascial spaces in the orofacial area or deep in the head and neck and cause substantial morbidity.
The decision making at the time of admission for this patient was consistent with his young age, the presence of a dental abscess and cellulitis that was worsening with failed outpatient therapy, and the need for prompt and intensive treatment with parenteral antibiotics, intravenous fluids, and surgical intervention to prevent further morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/Injuries. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole.

This is the case of a male who presented as a level II trauma after a motorcycle crash. The patient was helmeted and had no loss of consciousness. After a thorough workup, his injuries consisted of a friction burn to the face and bilateral upper extremities and a scaphoid fracture. He was admitted with consultations from orthopedic surgery and trauma surgery. The scaphoid fracture was managed non-operatively and the patient was observed for possible internal injuries given the mechanism of his crash. He improved and was discharged. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld. 

An inpatient stay was not medically necessary for this patient. This patient had some abrasions of the face and upper extremities, as well as a scaphoid fracture. He required no inpatient surgery. The patient had no hemodynamic instability and did not have any interventions that required inpatient treatment. While a period of monitoring for possible internal injuries would be appropriate, a full inpatient admission is not warranted. The computed tomography (CT) scans were thorough and have a sensitivity for blunt abdominal trauma of at least 95%. It is more than appropriate to admit at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Ear/Nose/Throat
Surgical Services (All)

Diagnosis: sleep complaints
Treatment: Uvulopalatopharyngoplasty (UPPP) 
The insurer denied Uvulopalatopharyngoplasty (UPPP). 
The health plan's determination is upheld.

This is a female with a history of "sleep complaints". These include snoring, daytime somnolence, fatigue, and frequent napping. Nocturnal gassing and apneas have been witnessed. A home sleep study revealed an apnea hypopnea index (AHI) of 7. Exam revealed enlarged tonsils, and a redundant soft palate and uvula. Endoscopy demonstrated retropalatal narrowing and mild lingual enlargement. The patient declined a trial of continuous positive airway pressure (CPAP) as she stated that she has a history of claustrophobia with face coverings. She elected uvulopalatopharyngoplasty (UPPP) with tonsillectomy, which is under review.

The requested uvulopalatopharyngoplasty is not medically necessary for this patient. According to Adil (2017), if a patient is unable to tolerate CPAP therapy, then surgery can be considered. General indications for surgical intervention include mild obstructive sleep apnea with excessive daytime fatigue, an apnea-hypopnea index of 15 or more, oxyhemoglobin desaturation less than 90%, and/or cardiac arrhythmias associated with obstructions. These criteria are not met. In a review of the literature by Stuck 92018), the authors concluded that uvulopalatopharyngoplasty with tonsillectomy reduces respiratory events and daytime sleepiness in adult patients with obstructive sleep apnea and was superior to non-treated controls in this regard. The authors called for further research to establish the long-term benefit, the impact on cardiovascular morbidity and the role of these procedures in variety of available treatment options for obstructive sleep apnea. Based upon the clinicals provided, uvulopalatopharyngoplasty is not clinically appropriate and is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neuropathic pain
Treatment: Lidocaine Patch
The insurer denied the Lidocaine Patch.
The denial is overturned. 

The patient is a female with neuropathic pain who has been prescribed Lidocaine 5% patch.

Yes, the treatment with Lidocaine 5% patch is medically necessary.

The patient is a female with low back pain and lumbar radiculopathy, a neuropathic type pain, who has been prescribed lidocaine patches. This is a continuation of therapy. The patient has been on this in the past. She has tried and failed multiple options. She cannot take NSAIDs (nonsteroidal antiinflammatory drugs) due to anti-coagulation. She has failed Gabapentin and Cymbalta. She cannot take Tylenol due to liver issues. Chronic opiates are generally not recommended. She has used this medication in the past with good results. Lidocaine patches have been shown to be effective in the treatment of chronic low back pain in the literature. It is the least invasive option, and it tends to have low side effects.  She has tried lidocaine jelly, but she develops a rash. The options are limited. Given the above, the requested lidocaine patches are medically necessary,  

The risks of the alternatives far outweigh the benefits. The patient has failed most conventional and common modalities. 

Lidocaine patches have been used for numerous pain complaints outside of PHN (postherpetic neuralgia), including low back pain. This has been shown in the literature, and is considered standard of care in the treatment of many pain complaints aside from PHN.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral Palsy
Treatment: Physical Therapy 10 visits
The insurer denied the Physical Therapy 10 visits.
The determination is upheld.

The patient has a diagnosis of cerebral palsy, bilateral perisylvian polymicrogyria, and left sided hemiplegia. She had a total of 148 physical therapy visits. The available records include a prescriptions for physical therapy (PT) and physical therapy progress notes. At issue is the medical necessity of physical therapy 10 visits.

The requested treatment is not medically necessary for this patient.

The patient's therapy progress note documentation does not support medical necessity for the requested physical therapy. The patient has a chronic lifelong condition for which the use of physical therapy is appropriate at times subject to the standards of care and medical necessity. Transition to a home exercise program is appropriate when patients have reached a plateau which is the case for this patient. Skilled physical therapy is not necessary when a plateau has been reached, though the home exercise program can and should be continued. For physical therapy to be medically necessary the patient must have identifiable short and long term goals which can be accomplished during an established time frame and progress towards these goals must be demonstrated and this is not the case for this patient.

The patient's clinical documentation indicates that she has received 148 sessions. Comparison of the goals as documented in the oldest progress note available with the most recent progress note in which goals are documented indicates no significant progress towards goals. For the following goals, no improvement has been made: primary functional limitation of inability to complete activities of daily living (ADLs) with left upper extremity (LUE); shoulder external rotation strength; tolerance of repetitive upper extremity activity which is 1 minute or less. For the following goals minimal improvement has been made: Disabilities of the Arm, Shoulder and Hand (DASH score), dynamometer grip strength. For the following goals regression has occurred: shoulder abduction strength and elbow extension strength. Transition to a home exercise program rather than skilled physical therapy is appropriate for this patient given the lack of progress towards goals.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia; Schizophrenia. 
Treatment: Increase Consumer Direct Personal Assistance (CDPAS) Services From 20 Hours To 41 Hours Per Week. 

The insurer denied the Increase Consumer Direct Personal Assistance (CDPAS) Services From 20 Hours to 41 Hours Per Week. 
The denial is overturned. 

The patient is a male with a history of dementia and schizophrenia. Due to impairments related to these conditions, he requires assistance for completion of many of his activities of daily living (ADLs). An appeal review was requested for potential approval of 41 hours/week Personal Assistance Services to offer increased ADL support.

Yes, the increase home care/personal care home health care - level 2 personal care services, per 15 minutes to 41 hour(s) per week is medically necessary. 

This is a male with a history of dementia and schizophrenia. Due to impairments related to these conditions, he requires assistance for completion of many of his activities of daily living (ADLs). Recent documentation from the patient's medical providers indicate that due to the patient's worsening mental status, progressive dementia and worsening anxiety and agitation; the currently approved plan of 20 hours/week personal assistance services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 41 hours/week personal assistance services is deemed medically necessary.