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

Diagnosis:  Dementia.
Treatment:  Personal care assistance 24 hours a day, 7 days per week (Split Shift).

The insurer is denied coverage for personal care assistance 24 hours a day, 7 days per week (Split Shift).  The denial is overturned. 

This is a female patient, who has physical and cognitive impairment, which results in significant decline in her ability to perform most daily activities.  Many daily tasks can be managed within the current 12 hours of personal care assistance (PCA) services per day.  However, the patient needs assistance with transfers, walking and toileting, which occur at various, unscheduled times throughout the day and night.  Therefore, it is medically necessary for the patient to have caregiver assistance for these activities of daily living (ADLs) throughout the day and night.  It is reported that the patient usually gets up to use the toilet on average of 3 times per night.  The specific times probably vary, and the frequency may not allow a live-in aide to have at least 5 uninterrupted hours of sleep per night, as required by New York State regulations for live-in aides.  In addition, due to dementia and nighttime confusion, the patient may have other unpredictable reasons for wanting to get up at night, and assistance is needed for transfers and walking each time she wants to get out of bed.  Therefore, it is medically necessary and in the best interest of the patient to have PCA 24-hour continuous services (split shift) to ensure a caregiver is present throughout the night to provide assistance with mobility/ADLs when needed.  

It was noted in a letter from the patient's relative and the UAS that the patient does not have local informal caregivers who can provide assistance on a regular basis.  Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  When informal caregivers are not available to provide care on a consistent basis, then personal care services are indicated to provide the necessary assistance with daily activities, including ADLs that occur throughout the day and night.

Due to medical conditions causing physical and cognitive impairment, the patient needs assistance to ensure proper and safe performance of all daily activities and to decrease the occurrence of adverse health and safety events.

Personal Care Assistance services 24 hours per day, 7 days per week, split shift is medically necessary.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for Personal Care Assistance 24 hours a day, 7 days per week (Split Shift) is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Class I occlusion 
Treatment: Braces
The insurer denied Braces. The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with deep overbite and appropriate overjet. She has minor maxillary and mandibular spacing. She is treatment planned for 18-24 months of orthodontics to correct her malocclusion. 

Braces are not medically necessary for this patient. There is no medical reason to correct her malocclusion with braces. While the patient has minor spacing, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. If her teeth were aligned, it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment with braces is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Problems. 
Treatment:  Dental/Orthodontic Procedure. 

The insurer denied dental implant for tooth # 18.  The denial is overturned in whole.

The patient is a female, who presented to the office of her dental provider for evaluation and treatment of tooth #18.  Included for review are previous letters of appeal and denial, a letter from the treating provider, and narrative explaining the need for #18 to be replaced, full mouth panoramic radiographic images, one periapical film, two pages of American Dental Association (ADA) claim forms, a patient narrative, and health plan language.  In question is the medical necessity of the planned treatment of implant placement (6010) for #18.

The health plan's determination is overturned in whole.

Yes, the requested health service/treatment of Dental Implant for tooth #18 is medically necessary in order to treat the diagnosis of partial edentulism and diminished posterior support.  Based on the provided documentation, tooth #18 had suffered from extensive decay leading to the need for its extraction.  After the extraction, the patient had the diagnosis of partial edentulism as well as diminished posterior support.  With the diagnosis of partial edentulism as well as diminished posterior support the only therapy capable of addressing both diagnosis is that of implant therapy, as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis.  Fixed partial dentures do not offer additional support and actually depend on the residual dentition to replace the missing tooth simply putting additional load on the residual teeth without replacing the loss. Removable partial dentures are tissue supported prosthesis and do not offer any support to the dentition, as they are designed to become passive upon load.  After the implants have integrated, they will require restorations in the form of abutments and crowns in order to complete the tooth replacement.  This is standard in tooth replacement involving implants.  Hence, the treatment of dental implant placement (6010) for site #18 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac circulatory problems 
Treatment: DME 

The insurer denied Flexitouch pneumatic compression device for both legs. The denial is upheld in whole. 

The patient is a female that suffers from bilateral lower extremity swelling that extends to the groin that resulted after motor vehicle accident (MVA). The patient is reported as having suffered from cellulitis in the past. The patient reports pain. She has tried elevation and limited exercise. Compression stockings have not been tried due to poor fit and inability to obtain custom stockings in setting of the COVID-19 pandemic. Bilateral leg venous study performed documented no deep vein thrombosis (DVT) and no venous reflux bilaterally. Given this study, she was documented as suffering from bilateral lower extremity lymphedema. 

The subject under review is the medical necessity for the Flexitouch pneumatic compression device for both legs. 

The health plan's determination is upheld in whole. 

The requested Flexitouch pneumatic compression device for both legs is not medically necessary for this patient. The Flexitouch device is a multi-compartment pneumatic compression device providing programmable calibrated gradient pressure. The medical documentation being provided to support the request for the Flexitouch device is limited and consists of a short office note from the treating provider and a short letter from the provider. The office note documents that the patient suffers from, "moderate bilateral leg swelling." There is limited information provided in this office note on the degree or extent of the leg swelling (i.e. calf or thigh circumference measurements). 
Based on the standard of care more conservative treatment is required first. Based on Warren et al. (referenced below), compression garments are the first line of treatment. For this patient, there is no documentation that compression bandages or a Velcro compression garment has been tried for this patient. 

Based on this, the requested health treatment of the Flexitouch pneumatic compression device for both legs is not medically necessary based on the medical documentation provided.
Appeal type: Medical necessity
Decision: Upheld

Trauma/injuries
Inpatient hospital

Diagnosis: perineum laceration
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a child who was jumping on a couch and fell and lacerated her perineum. She was seen at an OSH and transferred to Cornell. She underwent a perineal laceration repair. In the op note it reflects that the injury was 4 centimeter (cm) superficial going from the fourchette to the anoderm. The introitus and anus were patent and without injury. There were no signs of non-accidental trauma (NAT).

The inpatient hospital admission was not medically necessary. The physicians and medical center followed standard of care in treating this child. Literature review suggests that any child less than 10 y/o should have an EUA (examination under anesthesia). (2)
Perineal injuries that require surgical repair occur predominantly in patients less than 10 years of age who sustain blunt perineal trauma from a variety of causes, but rarely MVC (motor vehicle collision). Thus, such patients should undergo aggressive evaluation, including EUA, especially if they present with perineal bleeding, hematoma, or swelling. Furthermore, perineal injuries in children under 4 years should raise the suspicion of abuse.
In this case, the child had the appropriate evaluation and testing, which could all have been done at a lower level of care. The injury was 4 centimeter (cm) superficial going from the fourchette to the anoderm. The introitus and anus were patent and without injury. There were no signs of non-accidental trauma.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. Treatment: Substance Abuse: Inpatient. The insurer denied inpatient stay. The denial was overturned in whole. 

The patient is a male who was admitted following medical screening to acute inpatient level services for detoxification and withdrawal management of severe sedative-hypnotic-anxiolytic (benzodiazepine), cannabis and opioid (heroin) use disorders. 

The patient was admitted to acute inpatient level care and placed on a detoxification regimen with a phenobarbital and methadone protocol, vitamin replacement therapy, and medical monitoring.

The patient was initially ambivalent about treatment and required motivational techniques and ongoing counseling including case management to work toward a safe and clinically appropriate discharge plan and disposition. The patient was discharged with recommendations for clinically appropriate aftercare and referred to outpatient substance use disorder treatment, as well as recommendations for continued involvement in 12-step recovery meetings with Alcoholic and Narcotics Anonymous (AA and NA). He was discharged with continued use of medication assisted treatment with Suboxone. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is overturned in whole.

The requested health service/treatment of inpatient stay for detoxification treatment, withdrawal management and stabilization is medically necessary for this patient.

The proposed inpatient services and detoxification treatment and withdrawal management for severe polysubstance use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. This patient's substance use disorders and clinical features and treatment dimensions 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. 
Thus, the patient in this case scenario 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.

Medical necessity for the admission and the continued inpatient services, is met in this case, and is consistent with prevailing standards of medical practice, published practice guidelines, and American Society of Addiction Medicine (ASAM) Criteria, as well as the appropriate application of the NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria and Guidelines, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dental Disorder
Treatment: Full cast base metal crown, post and core for tooth #11.
The insurer denied a full cast base metal crown, post and core for tooth #11.
The determination is upheld.

The patient presented for evaluation and treatment of tooth #11. Provided for review are previous letters of appeal and denial, a narrative from the patient's daughter, radiographic images , case notes, and health plan language. The services were previously denied on the basis that the tooth can be extracted since the treating doctor did not provide a reason why it could not be extracted medically. At issue is the medical necessity of the planned treatment of a full cast base metal crown, post and core for tooth #11. The Plan has approved one post and core, and the porcelain fused to base metal crown for tooth # 11.
In this case the porcelain fused to base metal crown for #11 is the more appropriate procedure, as the facial allows for the appearance of a tooth and the lingual portion of the tooth allows for adaptation with the rest seat, and guide plane of the removable partial denture as porcelain would not allow for this.
The first set of porcelain fused to base metal crown and the associated buildup is the only medically necessary procedure for the patient.  Any additional base metal crown for tooth #11 or associated buildup for #11 beyond the first approved procedure is redundant and not medically necessary. Hence, since the plan has already approved the porcelain fused to base metal crown and associated post and buildup, the request for a second buildup and the full cast base metal crown for #11 are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder
Treatment: Home Health Care
The insurer denied: Consumer Directed Assistant Services
The denial is: Overturned in whole

The patient is a male with severe autism, developmental disability, chromosomal abnormality, and anxiety disorder. He is documented to have safety concerns, aggression, and undressing behaviors. He receives speech and occupational therapy (OT) services twice weekly through school. The patient lives with his father, who currently assists with the patient's needs, but is disabled due to injury and requires assistance. The patient's uncle also assists when available. At issue is the medical necessity for Consumer Directed Personal Care Assistance Services (CDPAS).

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

The requested Consumer Directed Personal Care Assistance Services are considered medically necessary for this patient. This is a male with moderate to severe developmental delays and behavioral dysregulation related to autism with underlying chromosomal anomaly. According to the documentation provided by this child's developmental-behavioral pediatrician, this child has Level 3 Autism which requires very substantial support.

According to the Uniform Assessment System-NY Comprehensive Assessment Report, the patient requires extensive to total assistance with activities of daily living (ADL) and Instrumental activities of daily living (IADL) due to developmental disorder related to autism. He requires PCA services for activities of daily living and to ensure the safety of himself and others. The patient's father is disabled and requires assistance.
Appeal type: Medical necessity
Decision: Upheld

This patient presented to the emergency room with abdominal pain and a positive pregnancy test. An ectopic pregnancy was diagnosed and she had a laparoscopic right salpingectomy and evacuation of hemoperitoneum. She received two units of packed red blood cells. After the procedure she was stable and vital signs were appropriate. She was meeting all postoperative milestones and she was discharged home the same day. The health plan's determination is upheld.
The patient had an ectopic pregnancy with uncomplicated laparoscopic surgery and was discharged the same day as she was admitted. The provided medical records do not support the need for inpatient hospital admission prior to discharge. She was seen in the emergency room with stable vital signs. She had an ectopic pregnancy and laparoscopic surgery was performed without complications. She was given two units of red blood cells to correct anemia. Vital signs after the procedure were normal and there were no complications. She had no infection, continued hemorrhage, cardiovascular compromise nor postoperative complications. She had no severe anemia and was meeting all postoperative milestones including voiding and pain control. She was discharged shortly after surgery demonstrating her excellent course. There was no need for inpatient management. She could have received care at a lower level without the need for acute, inpatient monitoring as there was no acute, high level condition present.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The treatment with Dupixent is not medically necessary.

Summary:
The patient is a woman with atopic dermatitis for whom Dupixent is requested. She has moderate to severe chronic atopic dermatitis affecting the hands. She has failed three high topical steroids as well as Eucrisa. For coverage the Health Plan require she tried and failed or cannot tolerate one topical calcineurin inhibitor.

For coverage of Dupixent, both of the following are required: First, the patient has a diagnosis of chronic atopic dermatitis that has been determined to be severe based on physician assessment. Secondly, the patient has a history of failure, contraindication, or intolerance to one topical calcineurin inhibitor* [e.g., Elidel (pimecrolimus), Protopic (tacrolimus)]: (document drug, date of trial, and/ or contraindication to medication).

There is no documentation that the patient has history of failure, contraindication, or intolerance to one topical calcineurin inhibitor or that justifies the medical necessity of Dupixent over the plan's alternatives. Presence of atopic dermatitis on the hands does not preclude use of a topical calcineurin inhibitor.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign intracranial hypertension

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission. The denial upheld.

This patient is a female with a history of headaches with papilledema and severe stenosis of the occipital sinus.  Her diagnoses were benign intracranial hypertension.  She presented to the hospital for an angiogram, venogram, venous manometry and venous sinus stent placement.  The preoperative testing showed a low white blood cell count at 4.22 K.  Postoperative orders included vital signs, neurological assessment, puncture site checks extremity pulse checks and intake/output checks every 15 minutes x4, every 30 minutes x2, every hour x3 and then per floor protocol.  No bending right leg or wrist for five hours.  Neurosurgery orders for every 2 hours neurological assessment and intake/output, intravenous normal saline at 75 cc/hr until taking oral fluids, oral oxycodone and Tylenol for pain as needed, Dexamethasone intravenous every eight hours, and Ketorolac intravenous every six hours, ondansetron intravenous x1 dose.  Intraoperatively her right wrist puncture site was found to have a weak pulse and dusky color of extremity.  Postoperatively her right wrist pulse was strong with dusky color with improvement after air removed from the band.  Her vital signs were stable and within normal limits.  Neurological checks were within normal limits postoperatively.  Neurosurgery progress note noted a normal exam.  Continue neuro checks and pulse/groin checks.  Dexamethasone was administered every eight hours overnight to transfer to Medrol dose pack, Toradol overnight, pain control, and advance diet as tolerated, anticipate discharge tomorrow.  Her right wrist TR band was removed.

She was transferred to the floor.  She received IV ketorolac for 6/10 pain and Tylenol. Her neuro checks continued every two hours.  Neurosurgery progress note stated she complained of headaches and right forearm pain overnight.  Her exam was within normal limits.  She was discharged to home.

The healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.  This patient's care could have been provided at an Observational level of care.  Post-operatively she had improvement in her right arm symptoms after removal of her band.  Her vital signs and neurological assessments were stable.  She was treated for her pain with intravenous medication and oral medication.  She was able to ambulate, void, and take oral fluids/meals the next day.  She had no significant neurological deficit or uncontrolled pain that needed an inpatient admission according to criteria. (1)

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

Diagnosis: Poor dentition
Treatment: Implants on teeth 2, 3, 4, 5, 12, 14, 15, 18, 19, 20, 21, 29, 30, 31

The implants on teeth 2, 3, 4, 5, 12, 14, 15, 18, 19, 20, 21, 29, 30, 31 are not medically necessary. 

The treatment requested is only considered when "alternative treatment options are not possible". The treating dentist must explain why other covered functional alternatives for prosthetic replacement will not correct the patient's dental condition and why the patient requires dental implants. There is nothing from a dentist explaining that alternative prosthetic treatments would not be possible. This patient has upper and lower teeth in her anterior regions. A set of upper and lower, well-fitting partial dentures can be constructed that will allow the patient to eat properly. This basic, common dental procedure was not even discussed as a viable alternative to try. Based on the documentation submitted, this alternative treatment is appropriate for this patient and will allow proper chewing of food for nutrition.  The requested implants are not medically necessary as there are alternative treatments available that are appropriate for this patient.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Periodic paralysis
Treatment: Whole exome sequencing 
The health plan should cover the whole exome sequencing.

The available medical records support that the patient has otherwise failed extensive previous evaluation for the condition. Standard treatments for the presumed diagnosis have not provided any meaningful improvement per the records. Determination of the underlying disorder would help guide treatment as all other measures have been exhausted. The lack of precise diagnosis is leading to persistent dysfunction for the patient and treatment options cannot be guided further without a diagnosis.

Whole exome screening would be medically indicated in order to diagnose and guide further treatment of the patient.