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

Diagnosis:  Obesity.
Treatment:  Wegovy.

The health plan denied Wegovy.  The determination is upheld.

The patient is a female, who is being prescribed Wegovy for the treatment of obesity. The health plan denied coverage for the medication because she did not meet their criteria. The patient meets the body mass index (BMI) requirement of BMI greater than 30. However, the plan requires participation in a weight management program at the time Wegovy is approved, with evidence of active participation for at least the prior 3 months and continuing during treatment. The patient was enrolled in Weight Watchers previously and then discontinued her participation. Therefore, she does not meet the plan requirements for enrollment and active participation at this time.

The patient provided a letter on her own behalf in support of this appeal. She addresses the plan's assertion that she does not meet criteria. The patient participated for 8 months but was then inactive at the time she was prescribed Wegovy. She states that her visits with a physician every 1-3 months in the intervening time are evidence of counseling on her weight and should be used as evidence of an ongoing weight management program.

The patient's office visit notes were provided for review. The patient's current BMI is 37. She is being treated for hypertension.

At issue is the medical necessity of Wegovy.

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

The requested health service/treatment of Wegovy is not medically necessary for this patient.

Wegovy is one of several options that can be used to help with weight management in patients with obesity. Weight Watchers is another option which has evidence for being an effective weight management plan. The health plan requires ongoing active participation in a qualifying plan because medication treatment for obesity is best used as an adjunct to a diet and exercise program. The patient does not meet the plan criteria for prescribing Wegovy because they require active participation in a program in addition to counseling and monitoring by a doctor's office. This is a reasonable request and is in accordance with best practice standards. Therefore, the requested medication has not been demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uterine fibroids and dysmenorrhea
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with uterine fibroids and dysmenorrhea. She had a diagnostic hysteroscopy with curettage, cystoscopy with bilateral ureteral stents, laparoscopic excision of endometriosis, right oophorectomy, culdotomy and repair, myomectomy, excision rectal endometriosis, pelvic washing, right hypogastric nerve decompression and bilateral ureterolysis. She was admitted as an inpatient after surgery. Her postoperative course was unremarkable. She was discharged. At issue is the medical necessity of the inpatient admission.
The requested inpatient hospital admission is not medically necessary for this patient.
The patient was without significant comorbidities. She had a minimally invasive procedure without severe anemia and the need for blood transfusion. Her vital signs were normal and she had no hemodynamic instability. Her procedure was without complications. She had no pulmonary complications or anesthesia complications. She could have been observed after surgery in the post-anesthesia care unit (PACU) or at a lower level of care as she was discharged less than 24 hours later. There was no need for acute, inpatient monitoring as there were no complications after surgery. She had no hemorrhage, infection or poor wound healing.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease. 
Treatment: Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift). 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift). 
The health plan's determination is upheld. 

This is a case review for a female with medical history notable for Alzheimer's disease and Parkinson's disease. The patient is approved for 24-hour live-in personal care services. The patient and her care team requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift). This is the subject under review. 
The reason for the appeal is stated by the request as follows: live-in aide is not able to receive an adequate rest period at night. The request states that the patient requires toileting, changing undergarments, and turning/repositioning in bed throughout the night. They feel that the patient's live-in aide is insufficient to meet her current needs. There were no details or specifics provided on what tasks require continuous care overnight. 

The requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day (Split Shift) is not medically necessary for this patient. 
The patient is approved for 24 hour live-in care, and the request is for split-shift care. Live-in care aides are expected to receive appropriate rest each night, including the expectation of at least 5 hours of uninterrupted rest each night. 
The documentation demonstrates that the patient requires assistance with all personal care tasks. Furthermore, she is incontinent of urine and stool. She requires 5-6 diaper changes per day. This means that on average she has a diaper change every 5 hours. There were no night time logs provided detailing overnight personal care tasks. She does not have any evidence of pressure ulcers. Therefore, it has not been clearly demonstrated that the patient has personal care needs which would preclude a 5 hour rest period for a live-in aide. The increase to split-shift services has not been demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right knee osteoarthritis. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is overturned. 

This is a female patient who was diagnosed with right knee osteoarthritis. An appeal letter states that the patient was initially admitted as an outpatient; however, due to significant comorbidities, it was anticipated that a higher level of care would be necessary therefore promoting the admission to the inpatient level. The patient had a several year history of progressive bilateral knee pain, right greater than left rated 7/10. The pain was significantly impacting ability to perform activities of daily living. There was severe osteoarthritis of the medial and patellofemoral joint compartments with bone-on-bone articulation; all osteophytes in all 3 compartments. The comorbidities include hypertension, poorly controlled diabetes, morbid obesity, and peripheral venous insufficiency. The patient underwent a right total knee arthroplasty with computer-assisted navigation. The patient was discharged in stable condition with home care services. The medication log indicates that intravenous (IV) Dilaudid and acetaminophen were administered and IV Toradol was administered. Otherwise, the pain was managed with oral acetaminophen, oxycodone, Dilaudid. At issue is the medical necessity of an inpatient stay. 

A full admission was medically necessary for this patient. The inpatient admission meets the plan criteria for the inpatient surgical setting in this case. The health plan supports the acute inpatient surgical setting when current postoperative requirements are of such intensity and/or duration that cannot be met in an observation or outpatient surgical setting or if the anticipated postoperative care requirements cannot be met, even initially, in an observational surgical setting due to the complexity, duration, or extent of the planned procedure and/or substantial preoperative patient risk. In this case the provider recommended the inpatient level of care due to the substantial preoperative patient risk due to the significant comorbidities of hypertension, poorly controlled diabetes, morbid obesity, and peripheral venous insufficiency. While there were no postoperative complications reported, the inpatient admission meets the plan criteria for the inpatient surgical setting due to substantial preoperative patient risk.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion.
Treatment: D8080 braces.

The insurer denied coverage for D8080 braces.  The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified anterior crossbite among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary, as the clinical circumstance does not meet the requirements of the HLD index attaining 20 points by internal reviewers when 26 points are required for approval.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Reverse denial, as the clinical circumstance as presented does meet and substantiate the medical/dental necessity of orthodontic care, as it meets the accepted criteria for approval.

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

D8080 braces is considered medically necessary for this patient.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for D8080 braces is substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: syncope
treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female who presented to the emergency department (ED) with near syncope, left eye vision loss for 5-7 minutes and left sided head pressure for 1 week. The patient reported that she was standing at the sink when all of a sudden she felt lightheaded, had tunneling of her vision and then was not able to see out of left eye. Within several minutes her vision returned to baseline. She also had a mild left sided headache for the last week.

The inpatient hospital stay was not medically necessary. The patient presented with loss of vision in her eye. The patient previously had neurologic events and intervention. During hospital stay, she underwent a work up which was negative for recurrent event, and there was no stroke or acute thrombosis of cerebral vessels. The patient's condition remained stable. Her vitals were stable, and she did not have new cardiac complaints. Her medications were unchanged.
Based on the above, the inpatient level of care was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned.

The patient is an adult female. She presented to the Emergency Department (ED) with worsening left lower quadrant abdominal pain. The evaluation was suggestive of ovarian torsion. The patient was admitted and taken to the operating room, where she underwent an open laparotomy with findings of a ruptured ovarian cyst. A left ovarian cystectomy was performed. 
She did well postop and was discharged home on the next day. 

The Inpatient Hospital Admission was medically necessary. 

This patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in the hospital for 48 hours. 
On postoperative day 1, the Foley catheter is removed, the patient is encouraged to get out of bed and ambulate, and clear liquids are started. 
On postoperative day 2, if the patient is passing flatus, and tolerating a regular diet she is discharged home. 
The standard of care was followed in this case, with the patient able to be discharged a day earlier.  

The admission was medically necessary and is standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


The patient is an adult female who presented to the emergency department with complaints of seizures. She had a past history of Lambert-Eaton myasthenic syndrome and Tourette syndrome. She had a witnessed seizure or seizure-like episode at a train station. She had a seizure in the past with a negative electroencephalogram (EEG). She was unresponsive and appeared to be in an active seizure on presentation to the emergency department. This resolved with administration of lorazepam. A head computed tomography (CT) scan was performed on presentation that revealed no acute changes. Other workup included a brain magnetic resonance imaging (MRI) that was negative for any pathology including mesial temporal sclerosis. The electroencephalogram (EEG) was negative. The chest X-ray was also negative. There is no evidence that she was placed on an antiepileptic. Her mother informed the staff that her symptoms were similar to a bad Tourette tic, and she was discharged without any treatment for epilepsy.

This patient presented with a seizure or seizure-like episode. An acute intracranial process required exclusion. An acute intracranial process was excluded using a computed tomography (CT) scan and subsequently a brain magnetic resonance imaging  (MRI). Her mental status returned to normal after presentation. Once an acute intracranial process was excluded, the patient could have been discharged (either with or without an antiepileptic) with plans for further evaluation on an outpatient basis. In this case, the patient's mental status had improved, and there was no specific medical necessity for admission for neuro-checks or electroencephalogram (EEG) monitoring. There was no evidence of any hemodynamic instability or hypertension requiring monitoring. There were no cardiac arrhythmias or any need for cardiac monitoring. There were no pulmonary abnormalities requiring pulmonary monitoring. The patient could therefore have been discharged from the emergency room or from observation status. Once acute pathology was excluded, there was no need for acute inpatient hospitalization.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a past medical history of alcohol use including binge drinking who presented with a seizure and altered mental status. Per the report, Emergency Medical Services (EMS) observed bilateral arm stiffening and administered 5 milligrams (mg) of Versed intramuscularly followed by an additional 5 mg of Versed intravenously to abort the seizure-like activity. 
It was also reported that the patient had pinpoint pupils and received Narcan with minimal response. In the emergency department, the patient was loaded with Keppra 1500 milligrams (mg), and a computed tomography head scan was performed and reported as a negative study. 
The inpatient hospital stay was not medically necessary. 
The review of the medical records clearly demonstrated that at the time of admission and during the entire hospital stay the patient remained hemodynamically stable. There was no evidence that the patient had status epilepticus. The imaging studies did not reveal the presence of brain disorders such as tumors, edema, trauma, or hydrocephalus. There was no mention that the patient's seizures were associated with an infectious process such as encephalitis or meningitis. 
There was no evidence that the seizures were the result of drug toxicity or withdrawal. Specifically, there was no documentation that the patient had experienced alcohol withdrawal symptoms. 
There was no mention that the patient had any cardiac arrhythmias of immediate concern. The physical exam did not reveal new focal neurologic deficits. Laboratory evaluation was not consistent with clinically significant metabolic abnormalities. After having two seizures at the time of admission, in the hospital the patient remained seizure-free. 
Furthermore, there was no mention that the patient had increased intracranial pressure or cerebral edema. Therefore, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient hospital admission
The health plan denied: Inpatient hospital admission
The determination is: Overturned.

The patient is a female who presented to the emergency department (ED) via Emergency Medical Services (EMS) complaining of chest pain, nausea, and lightheadedness. She was treated with aspirin en route to the ED. Her medical history was remarkable for hypothyroidism. In the ED, her blood pressure was 130/84 millimeters of mercury (mmHg) with a heart rate of 59 beats per minute. Her room air oxygen saturation was 99 percent (%). An electrocardiogram (EKG) showed sinus rhythm with nonspecific ST segment changes. Her serum troponin T level was 126 and rose to 156 when re-measured. A brain computed tomography (CT) scan showed no acute pathology. The patient was treated with acetaminophen and clopidogrel and was admitted to the hospital. Dual antiplatelet therapy, a beta-adrenergic blocker, a statin, and heparin were prescribed. The next day, the patient complained of less severe but persistent pain. Her troponin T level was 536. An echocardiogram showed a left ventricular ejection fraction of 45% with segmental wall motion abnormalities. Urgent cardiac catheterization was performed and showed a spontaneous dissection of the ramus intermedius coronary artery. Conservative management was recommended. The patient was monitored continuously post-procedure. She remained in sinus rhythm with rare ventricular ectopy.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient hospital admission was medically necessary for this patient.
This patient presented with a non-ST segment elevation myocardial infarction due to spontaneous coronary artery dissection (SCAD). SCAD is an important cause of acute coronary syndrome, myocardial infarction, and sudden death, particularly among young women and individuals with few conventional atherosclerotic risk factors. Early complications, including recurrent myocardial infarction, shock, and malignant arrhythmias, occur in 5% to 10% of conservatively managed patients, mostly related to extension of dissection within the first seven days after an acute episode. Current guidelines recommend inpatient monitoring for at least three to five days after the initial event.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Heart disease, anal cancer and dementia. 
Treatment: Customer Directed Personal Assistance Services 7 days per week live-in. 

The insurer denied coverage for Customer Directed Personal Assistance Services 7 days per week live-in. 

The denial is modified. 

This is an elderly patient with medical problems including heart disease, anal cancer and dementia. He lives with his family in a private residence. His 3 children and a friend are the paid caregivers. The insurer reduced his Customer Directed Personal Assistance Services (CDPAS) from 7 days/week (live-in) to CDPAS 56 hours/week. The request is reinstatement of the CDPAS 7 days/week (live-in). 

The Uniform Assessment System (UAS) report was reviewed. According to the report, "Member lives with his son and family in a private house." The patient's cognitive skills are described as minimally impaired. He is reportedly totally dependent to maximal assistance for much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. Extensive assistance is reportedly needed for bathing, dressing, locomotion, toilet transfer/use and ambulation (uses a walker). Limited assistance is reportedly needed for personal hygiene and bed mobility. Eating requires supervision. He is reportedly frequently incontinent of bladder and infrequently incontinent of bowel. 

The patient's functional ability is much the same (if not slightly improved) when compared to the prior UAS report. The patient's medical condition, cognitive deficits and physical limitations are not at the level or unpredictable as to require the requested CDPAS 24 hours/day live-in; particularly in the context of living with family. This physician would agree that given the patient's reported general debility and cognitive deficits, he may benefit from additional safety monitoring. However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the records reviewed, reducing his CDPAS from 7 days/week (live-in) to CDPAS 56 hours/week is excessive. This physician recommends CDPAS 84 hours/week. The patient's functional needs are more appropriately provided and maintained with CDPAS 84 hours/week, shared household responsibility of other adults living in the home and informal care from family. 

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Customer Directed Personal Assistance Services 7 days per week live-in from Personal Touch Home Care of NY Inc services is not substantiated. However, CDPAS 84 hours/week is medically necessary.