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

Diagnosis:  Right above knee amputation, peripheral vascular disease.
Treatment:  Continued Rehabilitation In A Skilled Nursing Facility.

The insurer denied the Continued Rehabilitation In A Skilled Nursing Facility.  The denial is overturned.

The patient is a male with history of right foot gangrene with ischemia and s/p (status post) right above knee amputation, with associated debility and general weakness.  He has relevant past medical history of peripheral vascular disease, bipolar disorder, schizophrenia, asthma, anemia, hypertension, hyperlipidemia, etc.

The patient was admitted to skilled nursing facility (SNF), requiring intravenous (IV) antibiotics for the first 14 days, requiring wound management, suture removal and requiring physical therapy (PT) towards evaluation for an above knee amputation prosthesis.

Prior to admission, the patient was homeless.  He was fully independent with all activities of daily living (ADLs).

The patient required maximum assistance for transfers, including wheelchair to bed/wheelchair to toilet, toileting, requires moderate assistance for lower body dressing, bed-mobility, requires minimum assistance for upper body dressing, grooming, is independent with feeding, wheelchair-mobility, etc.

The patient is a high-risk for falls.

Yes, the continued rehabilitation in a skilled nursing facility (SNF) is medically necessary.

This determination is based on the patient being in a clinical state and documented evidence of extent of participation with progress in physical therapy and occupational therapy.  Therefore, continued stay in SNF is medically necessary.

The records provide evidence that continued SNF stay for a length of time was reasonably expected to be health beneficial for the patient.  The patient required maximum assistance for transfers, including wheelchair to bed / wheelchair to toilet, toileting, he required moderate assistance for lower body dressing, bed-mobility, and he required minimum assistance for upper body dressing, grooming, independent with feeding, wheelchair-mobility, etc.  He was also homeless with discharge limitations and awaiting fitting for his right above knee amputation prosthesis.  The continued rehabilitation should be approved for two more weeks with re-evaluation for medical necessity at that time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Amyotrophic lateral sclerosis (ALS).
Treatment:  Radicava (generic name edaravone).

The insurer denied coverage for Radicava.  The denial is overturned. 

This male patient has rapidly progressive bulbar onset amyotrophic lateral sclerosis (ALS).  He has had worsening progressive symptoms, including slurred speech, swallowing difficulty and weight loss.  Trilogy for non-invasive ventilation, cough assist and suction machine was discussed, and the patient met with the ALS clinic team including speech and swallow therapist, physical therapist, respiratory therapist and ALS clinic nurse.  Radicava (generic name edaravone) was recommended, but it was denied by the insurer because he does not match the inclusion criteria of a key clinical trial, specifically; his respiratory function (FVC) is too low.  He does meet other criteria related to length of disease (less than 2 years) and an ALS Functional Rating Scale - Revised (ASLFRS-R) score of 26 at the start of treatment. 

Food and Drug Administration (FDA) approval of Radicava is for ALS, and the patient has clinically defined ALS.  The insurer's coverage policy for Radicava is based on the inclusion criteria for Radicava clinical trials, even though this drug is FDA approved for all patients diagnosed with ALS. 

According to the FDA, experts have pointed out that "Clinical trial inclusion/exclusion criteria are based on many factors and The clinical trial criteria employed in study 19 [of Radicava] were chosen that a signal could be detected with a modest sample size and study duration; such design considerations should not serve as the basis for insurance approvals" (1).  

The patient's disease is progressing rapidly, and Radicava is his only available treatment option according to his neurologist.  Radicava is FDA-approved for ALS. 

The use of Radicava is also supported by Up to Date (Nestor Galvez-Jimenez, MD, MSc, MHSA, FACP and associates) that states: "...received US Food and Drug Administration (FDA) approval for all people with ALS in May 2017 to treat patients with ALS in the United States.  While the evidence for the benefit of edaravone is clearest in patients with early ALS, as defined in the pivotal trial, there is no reason to believe that the population evaluated in that trial is biologically distinct from the greater ALS population." 

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

Based on the above, the medical necessity for Radicava is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Psychosis
Treatment: Mental Health Inpatient 
The health plan denied the inpatient stay.
 The health plan's determination is overturned.

The case involves an adult male admitted to acute inpatient psychiatric services for an exacerbation of a chronic psychotic disorder with mood disturbance, suicidal ideation, and acute psychosis. The patient presented for emergency services due to disruptive behavior at his shelter that included disrobing and aggressive behavior. The patient reported increasing symptoms of depression in the context of symptoms of psychosis that included paranoid thought content and acute grief with the recent death of his mother such that he wanted to die. The patient presented with active substance use with alcohol, tobacco and cannabis class substances of abuse affirmed with drug and alcohol screening.

The patient has a history of psychiatric treatment and multiple hospitalizations for schizophrenia and depressive disorder. He had a history of medication non-adherence and co-occurring substance use disorders with alcohol and cannabis, as noted.

The patient was homeless and unemployed with ongoing substance use as noted.  The patient refused a long-acting injectable antipsychotic medication but was amenable to oral medications that included resumption of his psychotropic regimen and the addition of Fluphenazine titrated as clinically appropriate.

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

Yes, the requested health service/treatment of Behavioral Health Inpatient stay was medically necessary for this patient.
The patient's admission and the continued hospital stay for treatment of and exacerbation of a psychotic and mood disorder with co-occurring substance use disorder did require the continued inpatient level services, structure, and monitoring through discharge. The patient's severity of symptoms, and inability to benefit from treatment at a lower level of care, functional decline, and safety issues related to persistent symptoms of psychosis and mood disturbance were clinical factors and treatment dimensions that necessitated acute inpatient hospital care, structure, and monitoring as proposed through discharge. 
The patient's admission and continued treatment was reasonable and in the best interest of the patient; he had severe symptoms of depression and psychosis complicated by substance abuse and medication non-adherence and decline in functioning. He had deteriorated to the point that he was a safety risk with intrusive thoughts that included suicidal ideation, and aggressive behavior that had prompted his presentation for treatment. Moreover, the patient's co-occurring substance use disorder was moderately severe, and the patient had acute grief in the context of a violent death of his mother.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Neck, back, and shoulder pain.
Treatment:  Reduction Mammaplasty.

The insurer denied the Reduction Mammaplasty.  The denial is upheld. 

This female patient presented to her plastic surgeon requesting smaller and perkier breasts.  She complains of back, neck and shoulder pain.  Her surgeon recommended bilateral breast reduction.  The planned weight of the reduction is not documented in the plastic surgeon's notes. 

No, the proposed reduction mammoplasty for date of service was not medically necessary.

The patient's cervical spine x-rays showed severe scoliosis.  The patient had neck pain, but it is unclear that her neck and back pain were due to her breast size rather than her profound scoliosis.  Moreover, the plastic surgeon's consultation note indicates that the patient wanted smaller and perkier breasts.  The note documents that the patient had back and shoulder pain and it is stated that, "exercise and physical therapy are medically advisable."  Photographs of the patient's breasts to confirm the diagnosis of macromastia were not provided for review.  Finally, the plastic surgeon's notes do not document the amount of breast tissue to be removed; a small weight of breast tissue removed is unlikely to have any impact on her back and neck symptoms.  Regardless of this information, the reduction mammoplasty was not medically necessary, as the etiology of the patient's pain was not clear, more conservative treatment was advised, and the patient's request for smaller/perkier breasts would be cosmetic in nature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache, Dizziness And Blurred Vision
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She presented to the emergency ward with the complaint of right sided headache and dizziness.  

At presentation, the patient's neurological examination was normal (except for a positive Romberg which is nonspecific), and CT(computerized tomography) scan was negative for acute pathology. She was admitted and MRI(Magnetic resonance imaging)was negative for acute stroke. She was treated for migraine and discharged. 

No, the Inpatient admission was not medically necessary.

At presentation, the patient had minimal deficits and negative neuro-imaging.  Risk stratification guidelines for TIA (transient ischemic attack) do not support acute inpatient admission here. The diagnosis of migraine does not require acute inpatient evaluation. The diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Infusion Therapy

Diagnosis: Smoldering multiple myeloma
Treatment: Therapeutic Apheresis or Plasmapheresis 
The insurer denied the Therapeutic Apheresis or Plasmapheresis. The health plan's determination is upheld. 

The patient is a woman with a diagnosis of smoldering multiple myeloma. The patient developed back pain. A magnetic resonance imaging (MRI) of the thoracic spine was ordered and demonstrated a T2 signal abnormality in the anterior aspect of the spinal cord from the level of T2 to T8. There was enhancement of the nerve roots from T9 through T12 bilaterally. A lumbar puncture showed oligoclonal bands. The patient was diagnosed with transverse myelitis. The patient underwent 5 days of intravenous Solu-Medrol. Serum protein electrophoresis was performed and showed an M (monoclonal) spike of 1.1. A bone marrow aspiration was performed  which showed a plasma cell neoplasm with the plasma cells comprising 15-20% of the marrow elements. Neurology attributed the transverse myelitis to multiple myeloma as no other cause was found. Treatment with plasmapheresis is being requested and is under review.

The Therapeutic Apheresis or Plasmapheresis is not medically necessary for this patient.

Acute idiopathic transverse myelitis is initially treated with high-dose intravenous glucocorticoid treatment for patients with acute idiopathic transverse myelitis. Glucocorticoid treatment should be initiated as soon as possible as there are relatively few contraindications. The preferred regimen is 1000 milligrams (mg) daily of methylprednisolone for 3-5 days. Continuing treatment with glucocorticoids or more aggressive regimens is based upon the clinical course and radiographic parameters. Intravenous corticosteroids are considered the standard of care and first-line therapy in acute transverse myelitis. Plasma exchange may be effective for acute central nervous system demyelinating diseases that fail to respond to high-dose glucocorticoid treatment. But in addition to high-dose glucocorticoid therapy, treatment with plasma exchange for patients who have acute transverse myelitis with motor impairment is often recommended. The preferred regimen is 5 treatments each with exchanges of 1.1-1.5 plasma volumes every other day for 10 days.

In this particular case, evidence is lacking that the transverse myelitis is acute. The patient initially developed symptoms 9 months ago. At the time of this writing, it is uncertain that the patient has acute transverse myelitis. In the documentation provided, there is no documentation of a worsening appearance on imaging. Furthermore, the regimen of 2 sessions x 4 weeks followed by 1 session x 4 weeks does not fit the recommended treatment schedule. Therefore, the requested treatment is not indicated at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Short stature.
Treatment:  Humatrope.

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

The patient is a male, who is seeking growth hormone (GH) treatment under the indication of idiopathic short stature (ISS).  His mother's height is 62'' and father's height is 71''.  His mother was late in puberty and reached menarche at the teenager age.  He was initially evaluated in the pediatric endocrinology clinic.  At that time, his height was 116 centimeter (cm) (7th percentile:-1.5 standard deviation (SD)) while his weight was 18.64 kg (2nd percentile -2.0 SD).  His evaluation, including complete blood count (CBC), erythrocyte sedimentation rate (ESR), comprehensive metabolic panel (CMP), TFT's (thyroid function tests), IGF-1 (insulin like growth factor one), insulin-like growth factor binding protein-3 (IGFBP-3), celiac screen, chromosomes, and SHOX gene analysis, was normal.

Humatrope is not medically necessary.

Although this patient's growth velocity was 4 cm per year, growth velocity decreases prior to the onset of puberty (peripubertal growth deceleration) and growth spurt occurs towards the end of puberty in boys and commences at 10 ml testicular volume (genitalia stage 3 to 4).  As boys attain a peak growth velocity at 12 ml testicular volume, growth of a boy, who enters puberty late, will continue to decelerate for years until the growth spurt starts much later than average.

Based on this patient's pubertal staging, he has not achieved peak growth velocity, and his growth velocity is expected to improve with the progression of puberty.  Based on his bone age, his adult height prediction was within 1 SD of his mid-parental height (about 67 +/- 2''), which was reassuring.  Despite that, GH treatment under ISS was recommended, which is not medically necessary.

The US Food and Drug Administration (FDA) has approved injectable somatropin (Humatrope) for the treatment of idiopathic short stature (ISS), also called non-GH-deficient short stature, defined by height SDS <=-2.25 and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients for whom diagnostic evaluation excludes other causes of short stature that should be observed or treated by other means.  This patient clearly does not meet the above criteria for ISS, as his height has never been 2.25 SD below the mean for age.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Left elbow injury.
Treatment:  Inpatient hospital stay.

The insurer denied the inpatient hospital stay.  The health plan's determination is upheld. 

This case describes a female patient, who sustained a fall resulting in a left elbow injury.  She was evaluated in the Emergency Department where an evaluation and plain radiographs confirmed a left elbow fracture-dislocation.  The patient was admitted to the hospital for definitive treatment.  Left elbow surgery was performed for a radial head replacement, coronoid process open reduction and internal fixation and a lateral collateral ligament repair.  The surgery was successful, and the patient was subsequently discharged home. 

The Inpatient Hospital Admission was not medically necessary for this patient.  The patient with a medical history significant for hypothyroidism sustained a left elbow fracture-dislocation.  Surgical intervention was performed with no complications.  The care rendered in this case was consistent with the recommendations of the current, peer-reviewed orthopedic literature on the topic of elbow fracture-dislocations, as documented by Zaidenberg and colleagues in the Shoulder and Elbow Journal and by Zhang and associates in the Journal of Orthopedic Trauma.  The dictated operative report and the post-operative progress note states that the patient was resting comfortably, and her pain was well controlled.  The plan at that time was for the patient to be discharged home.  Thus, the provided medical records in this case do not justify the medical necessity of the inpatient hospital stay for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal Care Assistant (PCA) Services: 7 Days x 24 Hours per Week (Continuous Services). 

The insurer denied of Personal Care Assistant (PCA) Services: 7 Days x 24 Hours per Week (Continuous Services).  The health plan's determination is overturned. 

The patient is a female with past medical history of dementia, incontinence and hypoxemia who has been assigned Personal Care Assistant (PCA) services 24 hours/day, live-in, 7 days/week.  On The patient's last in person Uniform Assessment System (UAS), the patient was assessed at total assistance for tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, bathing, dressing lower body and toilet use, while needing maximum assistance with tasks of equipment management, walking, locomotion, transfer toilet and bed mobility.  The patient was assessed at extensive assistance with tasks of managing medication, phone use, personal hygiene and dressing upper body while limited assistance with task of eating. There was a request to change/increase Personal Care Assistant (PCA) Services: 7 Days x 24 Hours (Continuous Services) per Week.

There is documentation from the PCA service night log that patient required assistance with activities of daily living (ADL) at least every 2-3-1/2 hours, which would not allow a PCA to obtain 5 hours of uninterrupted sleep.  The assistance with ADLs did not include the assistance provided to help reposition continuous positive airway pressure (CPAP) mask.  Scope of practice for Home Health Aid (HHA) vs. PCA in NY state is that a home health aide may apply CPAP mask, and it is unclear by legal definition if a PCA may.  Nonetheless, excluding the placement of CPAP mask, the patient still requires assistance with ADLs such as drinking, positioning, repositioning, turning, and toileting in the overnight hours at least every 2-3-1/2 hours.  In addition, there is documentation that there is not a separate room for the PCA to sleep.  Overnight PCA needs are not solely for supervision but to assist the patient with ADLs and Instrumental activities of daily living (IADL).  Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.  The requested PCA services, 7 days 24 hour per week (continuous services) are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Disorder.
Treatment:  White glass with metal crown for tooth #22.

The insurer denied the White glass with metal crown for tooth #22.  The determination is overturned.

The patient presented for evaluation and treatment of tooth number (#) 22.  Provided for review are previous letters of appeal and denial, a narrative from the patient, a single peri-apical radiographic image of tooth #22, full mouth radiographic images, and one page of American Dental Association (ADA) claim forms.  A white glass with metal crown was denied on the basis that the tooth does not have enough structural loss to require a crown.  From the documentation, the tooth has had root canal therapy, as well as removal of 2/3 of the internal tooth structure.  At issue is the medical necessity of the planned treatment of white glass with metal crown for tooth #22.

The requested health service/treatment of white glass with metal crown for tooth #22 is medically necessary for the patient.  From the provided documentation, the tooth has lost a significant amount of tooth structure resulting in undermining of the clinical crown.  As this is the case and as the tooth is involved in functional load as well as guidance during mastication and phonation, the tooth will undergo high amounts of stress and is at high risk of fracture without cuspal coverage; with the amount of lost tooth structure, a direct restoration cannot replace the missing tooth structure and support the remainder of the crown.  Therefore, the requested crown is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Acute diverticulitis.
Treatment:  Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.  The denial is upheld.

This is a female patient with a history of rheumatoid arthritis, hypertension, hyperlipidemia, and asthma who presented to the Emergency Department (ED) with left lower quadrant (LLQ) abdominal pain.  The patient was afebrile, and her vital signs were stable.  On examination, there was no abdominal rebound or guarding.  The patient was admitted with acute diverticulitis.  The patient's computed tomography (CT) scan was consistent with diverticulitis.  However, there was no abscess or perforation.  The patient was treated with intravenous antibiotics.  She was able to tolerate a diet.  As per Gastroenterology consult, the patient was stable and was recommended for an outpatient colonoscopy.

As per Milliman Care Guideline (MCG), the clinical indications for admission for acute diverticulitis include hemodynamic instability, peritoneal signs, active gastrointestinal bleeding, or a complicating factor seen on imaging studies.  This would include a fistula, obstruction, perforation, or an abscess.  In this case, the patient did not have these conditions.  The patient did not have bacteremia, severe vomiting, or an inability to maintain oral hydration that persisted after observation care.

This patient had an uncomplicated diverticulitis that was amenable to treatment with a course of oral antibiotics as an outpatient.  As per imaging, there was no fluid collection or perforation associated with her diverticulitis that required inpatient level of care and intervention.  The patient did not meet the MCG criteria for an acute care inpatient admission.  Thus, inpatient hospital 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 inpatient hospital admission should be upheld.  The medical necessity is not substantiated.