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

Diagnosis: History of blastic phase chronic myeloid leukemia (CML), chronic thoracic spine pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She has a history of blastic phase chronic myeloid leukemia (CML) with attainment of second chronic phase on treatment. She has been on treatment most recently with ponatinib. 

The patient is noted to have chronic thoracic spine pain with biopsy of a T5 lesion done that revealed no malignancy. She was admitted to the hospital for treatment of pain and for biopsies of the liver, T5 and sacrum. Biopsies were done. She had pain at the time of admission and was treated with ibuprofen, tizanidine, and she was also ordered intravenous hydromorphone as needed.  

The patient's pain was well controlled, mostly present in the upper back and sternal regions. No acute events had occurred since admission. As noted above, biopsies were done. She was doing well and had no pain at biopsy sites. She was discharged to home.

No, the inpatient admission was not medically necessary.

This patient was admitted to the hospital for management of chronic pain and also for two biopsies. She had unremarkable blood counts and did not require transfusion for these biopsies. Both were percutaneous needle biopsies. That kind of biopsy is routinely done in the outpatient setting, and there is no documentation in the provided records indicating that hospital admission at the acute inpatient level of care was medically necessary for her to have these biopsies. Also, there is no documentation that her chronic pain had worsened significantly to the point that she required frequent doses of intravenous (IV) pain medication and therefore could not be managed in the outpatient setting. Therefore, based on provided documentation there is no support for the medical necessity of acute care admission on the dates in question.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I malocclusion; upper and lower arch crowding; anterior crossbite with gingival attachment loss; maxillary and mandibular incisor protrusion  

Treatment: D8080 braces

The insurer denied coverage for D8080 braces

The denial is upheld.

This is a female adolescent patient who was seen for orthodontic evaluation. The orthodontist recommended comprehensive orthodontics due to class I malocclusion, upper and lower arch crowding, anterior crossbite with gingival attachment loss, and maxillary and mandibular incisor protrusion.  The orthodontist has completed the Handicapping Labiolingual Deviation (HLD) Index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and gingival recession are present. 

It is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD Index is utilized.  This index provides six specific conditions that automatically qualify for orthodontic care.  Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected.  For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  However, based on the review of the medical record, this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care.  

The clinical circumstance does not meet criteria to justify for orthodontic care.  This review supports that this patient has a score of 18 points on the HLD index (3 overjet, 4 overbite, 3 ectopic eruption, 5 anterior crowding, 3 labiolingual spread), which is below the threshold of 26 points to justify orthodontic care.

D8080 braces are not considered medically necessary for this patient.

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

The carrier's denial of coverage for D8080 braces should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of Alzheimer's dementia, chronic low back pain and macular degeneration. 
Treatment: Personal Care Aide seven (7) days per week, for two (2) twelve (12) hour split shifts. 
The insurer denied the Personal Care Aide seven (7) days per week, for two (2) twelve (12) hour split shifts. 
The denial is overturned. 

The patient is an female with a history of Alzheimer's dementia, chronic low back pain 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). 

A review has been requested to appeal the potential approval of seven (7) days a week, two (2) twelve (12) hour split shifts of personal assistance services to offer increased support for activities of daily living (ADLs). 

Yes, the proposed personal care aide, seven (7) days per week for two (2) twelve (12) hour split shifts, is deemed medically necessary. This is a female with a history of Alzheimer's dementia, chronic low back pain 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). Recent documentation received from the patient's physician indicates that due to worsening functional decline, including worsening memory, mobility and coordination, the patient requires care 24 hours per day, 7 days a week for assistance with activities of daily living (ADLs). Due to overnight toileting needs, a personal care aide for 12 hours a day, 7 days a week is inadequate due to a mandatory six-hour sleep schedule during which time the patient could sustain a fall injury or be left sitting in soiled diapers placing her at risk for skin breakdown and pressure ulcer development. For these reasons, the proposed personal care aide, seven (7) days per week for two (2) twelve (12) hour split shifts, is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, Altered mental status. 

Treatment: Continued skilled nursing facility stay. 

The insurer denied coverage for the continued skilled nursing facility stay. 

The denial is upheld. 

This is a male patient with multiple chronic medical problems including osteoarthritis of the left knee, congestive health failure, end stage renal disease on hemodialysis, obstructive sleep apnea, and depression. The patient was treated at a hospital for altered mental status and was subsequently admitted to a Skilled Nursing Facility (SNF) for physical, occupational and speech therapy due to his deficits in mobility, range of motion, activities of daily living (ADLs) and cognition. The insurer has denied coverage for continued SNF stay after one month of stay as not medically necessary. 

The clinical records do not demonstrate a level of participation or functional improvement to support the medical necessity of continued therapy/rehabilitation services at the SNF for the time period under review. The clinical records repetitively document the patient's non-compliance with rehabilitation services. The patient remained at the maximal assistance level without significant functional progress due to non-compliance and failure to participate. In addition, there were no nursing or physician notes documenting any specific complex nursing needs or acute medical issues, respectively that required ongoing inpatient skilled nursing or medical services. 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued SNF stay after one month of stay was not medically necessary. 

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

The carrier's denial of coverage for continued SNF stay after one month of stay should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Substance abuse
Substance Abuse: Inpatient

Diagnosis: Substance abuse
Treatment: Inpatient substance use rehab
The insurer denied the Inpatient substance use rehab. 
The health plan's determination is upheld. 

The patient is an adult male who following detoxification treatment was admitted to inpatient rehabilitation substance use disorder treatment of opioid (heroin) and cocaine use disorders. The patient was using three bags of heroin on a daily basis together with intermittent use of cocaine three to four days per week with intranasal administration (smoking). He had longstanding use of cocaine and more recent use of heroin for the past four years. His use of substances was causing significant risk to health and impairing his ability to function. His self-referral was prompted by an overdose and with family concerns for how his use impacted the relationship with his daughter and granddaughter.

The Inpatient Hospital Admission is not medically necessary for this patient.
The patient in this case was amenable to treatment at a lower level of care. The patient was motivated and capable of effectively continuing in substance use disorder treatment in a less restrictive treatment setting with sober supports and/or housing. The patient did not need the structure or monitoring of an inpatient setting in order to effectively participate in rehabilitation substance abuse treatment, or to participate in peer-supported recovery groups or receive other evidence-based treatment such as medication assisted treatment for the opioid use disorder.
Again, there were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and continued inpatient level services and treatment, as requested.
This answer is consistent with the application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria/Guidelines, referenced below, and in keeping with the instruction for this medical necessity review.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 
The insurer denied white glass with metal crown for tooth #10 for medical necessity. 
The denial was overturned.

The patient is a female who presented to the office of her dental provider for evaluation and treatment of tooth #10. Included for review are previous letters of appeal and denial, a narrative from the provider explaining that the crown for tooth #10 has completely fractured off, a periapical radiographic image from an unknown date, multiple radiographic images, one page of American Dental Association (ADA) claim forms, a patient narrative, and appeal documents.
Previous denials have been on the basis that tooth #10 already has a crown and that the radiographs did not show that there was decay beneath the crown making the request for a new crown unnecessary.
In question is the medical necessity of the planned treatment of white glass with metal crown for tooth #10.

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

The service of white glass with metal crown, tooth #10 is medically necessary for this patient.
The restoration previously was a porcelain fused to metal crown and as it has failed based on the radiographic documentation, it requires replacement in order to be returned to function. Based on the documentation, the radiographs show decay under the current margin of tooth #10, and the additional radiograph without a date shows that after some type of treatment, the previous post is now missing. The documentation provided clearly shows decay under the crown of #10 which on its own necessitates removal of the crown and fabrication of a new restoration.
Hence, the procedure of white glass with metal crown for tooth #10 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is status/post (s/p) laparoscopic right colectomy for stage IIB goblet adenocarcinoma of the appendix. He was started on adjuvant therapy of capecitabine and oxaliplatin. He developed abdominal pain and was evaluated in the emergency department. A computed tomography (CT) scan showed possible twisting of the hepatic flexure and the white blood cell count was elevated at 16. The patient was admitted to the hospital for observation and started on a clear liquid diet. He did have some improvement in his symptoms although he developed blood in his bowel movements. The blood in the bowel movements ultimately resolved and the patient was advanced to a regular diet and was felt to be stable for discharge to home. At issue is whether the inpatient stay was medically necessary.
Inpatient level of care was not medically necessary as the care provided (e.g. advancement of diet, pain control, serial labs) could have been administered at lower level of care . In addition, this also matches the assessment of his doctor who recommended admission for observation since the symptoms were already improving at the time of his evaluation. The patient had abdominal pain after a laparoscopic colectomy with possible twisting of the colon on a CT scan. He had significant improvement in his symptoms by the time his doctor evaluated him and recommended a clear liquid diet and observation overnight since the symptoms were resolving. The patient meets criteria for a lower level of care based on Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care 23rd edition (General Criteria: Observation Care and Abdominal Pain: Observation Care) given the gastroenterological problem of evaluation for possible obstruction and the possible twisting of hepatic flexure seen on CT scan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Covid Pneumonia.
Treatment:  Skilled Nursing Facility Admission for Sub-Acute Rehabilitation.

The insurer denied Skilled Nursing Facility Admission for Sub-Acute Rehabilitation.  The health plan's determination is overturned. 

The patient is a female with past medical history of chronic obstructive pulmonary disease (COPD), Covid pneumonia, diabetes mellitus type 2, gastroesophageal reflux disease (GERD), and nicotine dependence, who had been admitted to sub-acute rehabilitation following a hospitalization for Covid pneumonia.  The patient was admitted and was dependent on oxygen.  Physical therapy (PT) and occupational therapy (OT) were provided 5-6 days per week.  The patient had a change in vital signs with temp of 100.3, blood pressure of 97/60 and had diarrhea.  A C.diff test and Covid test were sent, and the patient was placed on intravenous (IV) fluids and started on Zosyn IV following a chest x-ray showing diffuse interstitial infiltrates unchanged.  The patient received 7 days of IV Zosyn.  The patient had noted PT/OT goals upon admission to rehabilitation and PT and OT.  The summary notes from PT and OT indicate the patient met those rehabilitation goals.  The patient was seen by psychiatry, psychologist, dietary, social work and palliative care during her rehabilitation stay.  The patient resided in a shelter prior to hospitalization and rehabilitation and was returning to the shelter.  Oxygen was able to be weaned prior to discharge from rehabilitation.

The Skilled Nursing Facility Admission for Sub-Acute Rehabilitation Services was medically necessary for this patient. 

The patient was hospitalized with Covid pneumonia with underlying tobacco abuse and COPD.  The patient also has diagnosis of diabetes mellitus type 2 and bipolar disorder.  During her rehabilitation stay, the patient developed low grade fever with diarrhea requiring further evaluation with labs and x-rays.  The patient was then started on IV fluids and IV antibiotics.  The patient did have rehabilitative services with OT/PT on a routine basis.  Skilled care is nursing and therapy care that can only be safely and effectively performed by, or under the supervision of, professionals or technical personnel.  It is health care given when the patient needs skilled nursing or skilled therapy to treat, manage, and observe the patient's condition, and evaluate the patient's care.  The rehabilitative therapies the patient was provided were used to treat a recent documented decline in functional status due to Covid pneumonia in the setting of underlying COPD.  There was the expectation that the patient's functional capabilities would improve significantly in a reasonable and predictable period of time, as documented by the patient's PT and OT notes.

The patient required close monitoring of oxygen and vital signs, administration of IV fluids and IV antibiotics during her rehabilitation stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skin Disorders/Dermatitis. 
Treatment: Pharmacy/Prescription Drugs/Dupixent. 

The health plan denied Dupixent as not medically necessary. The health plan determination is overturned in whole. 

The patient has moderate to severe atopic dermatitis. The patient has tried and failed topical triamcinolone, oral methotrexate, and prednisone, intramuscular Kenalog, and the biologic agent Taltz. The patient's hands are significantly affected, which makes the patient's job (mechanic) more difficult because the patient needs to use  hands much at work. 

For a patient with moderate to severe atopic dermatitis, including the significant hand involvement noted in this patient, and who has failed systemic steroids and methotrexate, further treatment with topical agents (such as Protopic or Eucrisa) are more likely than not going to result in further treatment failure. At this time, having failed topical steroids and oral agents, Dupixent is indicated as per all dermatology literature reviews. Accordingly, at this particular time, Dupixent is medically necessary to treat this patient's particular clinical scenario. 

After failing topical, intramuscular, and oral steroids, as well as oral methotrexate (an immunomodulator), no other reasonable option exists to treat this patient's symptoms and functional impairment of the hands. Dupixent is therefore standard of care and medically necessary, consistent with all modern dermatology literature reviews  for this patient's particular clinical scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Right Hip Pain.
Treatment:  Physical Therapy.

The health plan denied the request for physical therapy.  The health plan's determination is upheld.


This is a male patient.  The patient is diagnosed with right hip pain.

A physical therapy evaluation indicated the patient to have complaints of right hip pain.  It was noted there was pain in the right low back region down the back of the hip to the lateral knee and into the right heel.  Pain was rated at rest at 3/10 and could increase up to 7/10 when trying to sleep or with certain standing and walking activities.  It was noted that the patient had struggled with right leg pain that started along his knee and progressed to include the hip and low back with radiating, numbness and tingling symptoms.  It was noted he has had one physical therapy session around four years ago and has tried massage therapy, and both had minimal to no relief.  He has done some stretching and yoga, but certain positions make the symptoms worse.  Examination showed decreased range of motion and diminished motor strength in the lower extremities.  It was recommended the patient undergo physical therapy to include therapeutic exercise, manual therapy.

Records indicate that physical therapy was denied, and that determination was appealed.  On appeal it was noted that physical therapy services were upheld as not medically necessary, noting that the information did not show that the treatment was being used to help with a loss of function due to illness, injury, loss of a body part, or disorder from birth.

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

No, the requested health service/treatment of physical therapy services is not medically necessary for this patient.  The patient is noted to have a  history of pain in the right hip, buttock, low back, knee, likely symptoms of sciatica.  There was no indication of specific injury, illness, loss of body part or disorder from birth.  Records provided do not show the treatment has been used to help with a loss of function due to illness, injury, loss of a body part, or disorder from birth.  Physical therapy services are, therefore, excluded from coverage as not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Continued skilled nursing facility (SNF) stay
The insurer denied coverage for the continued skilled nursing facility (SNF) stay.
The denial is upheld.

This is a female patient with chronic stable medical problems including anemia, epilepsy and osteoarthritis. The patient was status post right total knee arthroplasty and was admitted to a skilled nursing facility (SNF). The insurer has denied coverage for continued SNF stay effective on day 126 of admission and beyond.

The clinical records do not demonstrate a level of functional impairment to support the medical necessity of continued therapy/rehabilitation services at the SNF for the time period under review. A progress note stated that the patient "has made substantial progress and has reached highest functional level." According to the Physical and Occupational Therapy Discharge Summary notes, the patient had "reached maximum potential with skilled services." In addition, there were no nursing or physician notes documenting any specific complex nursing needs or acute medical issues, respectively that required ongoing inpatient skilled nursing or medical services for this patient.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued SNF stay effective on day 126 of admission and beyond was not medically necessary. The health plan acted reasonably with sound medical judgment and in the best interest of the patient. (Taken under consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations). 

The carrier's denial of coverage for continued SNF stay effective on day 126 of admission and beyond should be upheld. The medical necessity is not substantiated.