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

Diagnosis: dementia
Treatment: Consumer Directed Personal Assistant Services (CDPAS): 7 Days per week, 24 Hours per Day (Split Shift)
The insurer denied Consumer Directed Personal Assistant Services (CDPAS): 7 Days per week, 24 Hours per Day (Split Shift).
The health plan's determination is overturned. 

This is a female patient with a history of dementia, coronary artery disease, paroxysmal atrial fibrillation, heart failure, chronic kidney disease stage 3b, lumbar spinal stenosis with radiculopathy, polyarthritis, anxiety, depression, blindness in both eyes, bladder and bowel incontinence, and insomnia. She uses oxygen via nasal canula while she is sleeping. She lives with her daughter in an apartment.

Consumer Directed Personal Assistance Services 7 days per week, 24 hours per day (split shift) is medically necessary.

There is documentation in the UAS (uniform activity score) of the patient requiring extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the Plan failed to document a plan to meet these unscheduled and unpredictable care needs during periods that fall outside the approved personal care assistance hours. There is documentation from the patient's PCP (personal care provider) of medical necessity of increased personal care services. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in personal care services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).

The patient lives with her daughter, who is not able to provide much informal support due to her own medical conditions. In addition, per NY (New York) Codes, Rules, and Regulations section 505.14, the plan cannot assume that the informal support person can provide all needed care outside of the approved PCA (personal care assistance) hours as informal supports must be voluntary.

A live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. An aide to this patient would be unable to receive five hours of uninterrupted sleep. Overnight care logs provided by the patient's daughter show that the patient requires assistance with walking and toileting every 2-4 hours overnight. In addition, the patient frequently mistakenly removes her nasal canula due to her dementia and the status of her nasal canula needs to be monitored and replaced as needed. Therefore, split-shift care is required to meet the patient's frequent care needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pannus, Rashes
Treatment: Panniculectomy
The insurer denied the Panniculectomy.
The determination is upheld.

This is a female patient who has an abdominal pannus. The patient has lost weight. She has rashes in the folds under her pannus. A panniculectomy is planned. The records document that the patient was treated with triamcinolone for a rash. A follow-up dermatology note documents no improvement of the rash and additional prescription for ketoconazole. At issue is the medical necessity of a panniculectomy.
The panniculectomy is not medically necessary. The records document that the patient has persistent rashes in the fold under her pannus. Records document that the patient was treated with triamcinolone  for a rash. A follow-up dermatology note documents no improvement of the rash and an additional prescription for ketoconazole. The records do not document any follow-up notes that document the patient's response to ketoconazole. If the patient's rashes responded to the treatment prescribed, then the panniculectomy would not be required to manage the rashes. In addition, photos do not show the pannus elevated to illustrate the rashes.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a history of cirrhosis with ascites, diabetes, hypertension, hyperlipidemia, and bipolar disorder who presented to the hospital following a fall down steps. There was no reported loss of consciousness at the scene. The Glasgow Coma Score was 15. Evaluation revealed a 5- centimeter (cm) scalp laceration that was repaired in the emergency department (ED). Imaging identified a subdural hematoma. He also had a right intertrochanteric femur fracture that was initially managed without surgical intervention.
His hospital course was complicated by encephalopathy and hypotension that required vasopressor support. He underwent paracentesis as was his outpatient routine. He was deemed to be a poor operative risk due to his multiple comorbid health issues and was made do not resuscitate (DNR) /do not intubate (DNI), comfort care status. The trauma note states that the patient appeared comfortable and was awaiting hospice placement. The records indicate that the patient and family were agreeable to home hospice. Interventional radiology was consulted for Ascept catheter placement. This drainage catheter was placed. He was discharged to subacute rehabilitation with plans for eventual home hospice.
At issue is the medical necessity of an inpatient stay.
Continued acute inpatient admission was not medically necessary. This patient presented to the hospital following a head injury and right femur fracture that resulted from a fall. His past medical history was significant for cirrhosis with ascites, cardiovascular disease, diabetes, hypertension, hyperlipidemia, and bipolar disorder. He was determined to not. Be an operative candidate for the femur fracture due to his multiple comorbidities. The trauma note states that the patient appeared comfortable and was awaiting hospice placement. The trauma notes describe end of life planning with ongoing comfort care provided. The records indicate that the patient and family were agreeable to home hospice.
Based on the submitted medical records, the care provided did not require an ongoing acute inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #2:

Diagnosis: Hepatocellular carcinoma.

Treatment: internal radiation therapy outpatient services (37242 X 1, 37243 X 2).

The insurer denied coverage for internal radiation therapy outpatient services (37242 X 1, 37243 X 2).  The denial is overturned.

This case involves an adult female seeking coverage for selective internal radiation therapy (SIRT) utilizing yttrium-90 microspheres. The patient presented for hematology/oncology evaluation for initial visit.  The patient had been admitted to the hospital with severe hypokalemia and nausea.  Imaging revealed massive hepatomegaly with large bi-lobar masses without evidence of metastasis in the chest.  Magnetic resonance imaging of the brain revealed pituitary macroadenoma.  Biopsy results revealed liver masses to be hepatocellular carcinoma with moderate to poor differentiation.  

The patient was seen for an evaluation related to hepatocellular carcinoma.  The patient reported quite a bit of nausea with occasional vomiting.  There was consideration for local therapy with radioembolization or possibly chemoembolization.  

A computed tomography (CT) angiography of the abdomen and pelvis noted marked hepatomegaly.  There were multiple hepatic masses.  Inferiorly in the right lobe, the largest mass measured 16.5 x 10.1 centimeters (cm).  The largest left lobe mass measured 12.1 x 7.8 cm.  There were at least 10 small enhancing masses that had become more apparent since the prior study.  These are scattered throughout the right and left lobes of the liver.  The largest 1 showed arterial enhancement with central lucency.  This measured 3 cm in diameter.  The right kidney was slightly compressed by the hepatic mass in the right lobe.

In this case, the patient has advanced multifocal hepatocellular carcinoma without hepatic vein or inferior vena cava involvement.  The provider recommended radioembolization.  Based on the current literature, radioembolization may be considered in select cases.  

Scientific evidence in peer-reviewed literature supports improvement in health outcomes comparable to standard treatments.  

The requested services have final approval from the appropriate regulatory bodies for the patient's diagnosis.  

There were decreased adverse effects noted with SIRT over traditional systemic therapy.  While outcomes are not superior to systemic treatment, there is evidence of improved safety profile with SIRT and the patient's clinical presentation.  Thus, the requested treatment is likely to be more beneficial than standard treatments for the patient, the treatment is the best available treatment for the patient at the current time, and the patient is a good candidate for the outpatient services.  As such, the denial of coverage for outpatient services (37242 X 1, 37243 X2) is overturned.

In summary, the denial of outpatient services (37242 X 1, 37243 X2) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Reviewer #1:

Diagnosis: Hepatocellular carcinoma.

Treatment: internal radiation therapy outpatient services (37242 X 1, 37243 X 2).

The insurer denied coverage for internal radiation therapy outpatient services (37242 X 1, 37243 X 2).  The denial is overturned.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome.

Outpatient services (37242 X 1, 37243 X 2) have final approval from the appropriate regulatory bodies for this diagnosis. This is Food and Drug Administration (FDA) approved treatment.

This patient is a good candidate for outpatient services (37242 X 1, 37243 X2).

Outpatient services (37242 X 1, 37243 X2) are the best available treatment for this patient at this time.

The adverse risks are NOT increased over standard treatment/services.

The requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The National Comprehensive Cancer Network (NCCN) guidelines version 2.2018 for Hepatocellular Cancers (HCC) states that all HCC irrespective of their location in liver may be amenable to Radioembolization.

During the past five years, multiple peer reviewed publications demonstrating the effectiveness of radioembolization in the treatment of primary HCC have been published.

This treatment is well tolerated.

The nontumorous liver appears more tolerant to Selective internal radiation therapy (SIRT) than external beam radiation.

Selective internal radiation therapy (SIRT) has very little morbidity compared to cytotoxic chemotherapy.

Episodes of acute liver failure is much less compared to chemoembolization.

There is no need for inpatient hospitalization.

In summary, the denial of outpatient services (37242 X 1, 37243 X2) and coverage for the requested treatment should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Deep vein thrombosis.
Treatment:  Inpatient Admission.

The insurer denied Inpatient Admission.  The denial is overturned.

The patient is a female, who was admitted to the hospital after a diagnosis of bilateral lower extremity deep vein thrombosis (DVT). History was notable for morbid obesity and gastric sleeve placement one month prior to this admission, complicated by deep vein thrombosis. She was placed on anticoagulation (AC) but suffered hemoptysis. For this reason, she underwent inferior vena cava (IVC) filter placement. On the current visit, her providers wanted to again treat her with anticoagulation, but they were concerned about the prior bleeding episode. She was started on anticoagulation and was admitted to watch for bleeding complications. Coverage for the admission was denied on the basis that the patient had no medical features that required hospital admission. 

The requested health service is medically necessary.

This patient had recently suffered bleeding, specifically hemoptysis, while on anticoagulation. Her medical condition, recurrent deep vein thrombosis (DVT), warranted use of anticoagulation, and her providers were appropriately concerned about the potential for bleeding. The patient was admitted, so that she could be observed on anticoagulation. This is an accepted indication for hospital admission when anticoagulation is initiated. Therefore, the health service (inpatient hospital stay for one day) was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a woman with anxiety who was admitted to the hospital with syncope. The syncope was associated with lightheadedness and falls. Duration of symptoms was 1 to 2 months, with associated anorexia and poor oral intake, and in the process, lost 20 pounds of weight. Medical history reveals psychiatric hospitalizations for starvation. Arrival vital signs included a normal temperature, pulse rate of 92 respirations of 18. Examination showed a masticated young female with a normal cardiopulmonary exam soft, nontender abdomen. Laboratory studies showed stable hemoglobin and white blood cell count. Urinalysis showed no evidence of urinary tract infection (UTI). Urine pregnancy was negative. 

The inpatient hospital admission was not medically necessary. Based on the provided documentation, the patient began stabilizing with the appropriate treatment and was noted to be eating at least 50% of her meals by the dates in question. The Neurologic work-up was negative. She was not suffering from dizziness, near syncope, or syncopal episodes. The time spent in the hospital on the dates in question was due to awaiting placement at a psychiatric facility and not due to medical necessity. The catatonic state resolved. The laboratory studies were stable, vital signs were stable, and the patient was improving her mental state. Adjustments and titration of psychiatric medications do not need to be completed in an inpatient hospital setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is a school aged male. He had abdominal pain, vomiting, and diarrhea and was hospitalized. Brief summary of hospital stays shows his emergency department note and discharge summary state he was seen in the emergency department for abdominal pain, vomiting, diarrhea, and decreased oral intake. Surgery was consulted. He was admitted for intravenous fluids and serial abdominal exams. It was likely acute gastroenteritis. A progress note on the next day stated he still had diarrhea, but no more nausea and vomiting. He tolerated oral intake and was discharged home.

The requested health service was not medically necessary.

As documented in clinical notes, this patient had acute abdominal pain, vomiting, diarrhea, and decreased oral intake. Initial abdominal X-ray showed air fluids, but surgery consult ruled out bowel obstruction. The patient was suspected to have acute gastroenteritis. During the hospital stay, the patient received intravenous fluids and oral intakes. The patient stopped vomiting after admission and tolerated oral intake. There was no documentation of any acute events. Thus, the acute inpatient care is not medically necessary. Acute infectious gastroenteritis may require intravenous fluids for dehydration and can be managed at observational level of care (1-3).
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Personal Care Aide: 168 Hours per Week (24 Hours, 2 Split Shifts)
The health plan's determination is upheld. 

This is a case review for a female with medical history notable for incontinence, mobility issues, and heart failure. The patient and her care team requested Personal Care Aide: 168 Hours per Week (24 Hours, 2 Split Shifts).

The Personal Care Aide: 168 Hours per Week (24 Hours, 2 Split Shifts) has not been demonstrated to be medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5 hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate.
There is insufficient documentation that the patient meets medical necessity criteria for 24-hour split shift care. There is no documentation of a pressure ulcer which requires turning and repositioning every 2 hours overnight. There are no overnight personal care logs which demonstrate that the patient has personal care needs of such high frequency to preclude adequate rest from a live-in care aid. Live-in personal care is not intended to be for 13 hours followed by 11 hours of uninterrupted care. Rather, it is intended for 24-hour care but with sufficient rest periods allowed for the caregiver. There is insufficient evidence that a living care aide would not be able to receive adequate rest while still providing for the patient's occasional overnight care needs.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: overdose.
Treatment: inpatient stay.
The insurer denied an inpatient stay.
The health plan's determination is upheld. 

The patient is an adult male with a history of substance abuse, hepatitis B, and hypertension who initially presented to the emergency department with concerns about loss of consciousness and bystander cardiopulmonary resuscitation (CPR). Additional history included "snorting a bag" of heroin in the morning with a dose of naloxone being provided with clinical improvement before arrival. Initial vital signs revealed a temperature of 97.6, heart rate (HR) of 77, blood pressure (BP) of 141/98, respiratory rate (RR) of 13, and oxygen saturation of 94%. Initial examination documented the patient as somnolent but awakens to verbal stimuli, and oriented x 3 with pinpoint pupils bilaterally. Urine drug screen was positive for opiates, methadone, and benzodiazepines. 

The inpatient hospital stay was not medically necessary. The patient was observed to lose consciousness shortly after snorting heroin resulting in bystander CPR and naloxone administration. Initial examination documented the patient as somnolent, hemodynamically stable, and with a SpO2 of 89%. Initial evaluation revealed leukocytosis, elevated troponin, and a drug screen positive for opiates, methadone, and benzodiazepines. Two electrocardiograms did not reveal acute significant abnormalities. Additional naloxone was given with significant clinical improvement. Following emergency department care, the patient was documented as alert, oriented, hemodynamically stable, and without hypoxia. Treatment thereafter included cardiac monitoring, serial troponins, and consultations. Cardiology consulted, ruled out acute coronary syndrome, and recommended outpatient follow-up. Following observation care, the patient returned to baseline and no active inpatient intervention was being performed. No other issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion 
Treatment: Full Braces and Monthly Brace Adjustment Visit
The insurer denied Full Braces and Monthly Brace Adjustment Visit
The health plan's determination is upheld. 

The patient in question is a young male with a Class I occlusion with 4 millimeter (mm) overbite and 4 mm overjet. He has moderate maxillary and mandibular crowing. He is treatment planned for Full Braces and Monthly Brace Adjustment Visit to correct his malocclusion.

Full Braces and Monthly Brace Adjustment Visit are not medically necessary for this patient.
The patient has moderate crowding but no teeth are impacted. His overbite is deep but there is no indication of damage to the incisors in the photographs. His cephalometric radiograph shows the lower incisors are contacting the maxillary teeth, not the palate, in occlusion. There is no indication from the photographs that there is severe soft tissue damage (or any soft tissue damage) on this patient. There are no anterior or posterior crossbites present.
There is no medical reason to correct his malocclusion with braces. While the patient has crowding, 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 his teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient has a 4 millimeter (mm) overjet but this amount of overjet does not affect oral health related quality of life. If his teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer.
Treatment: Proton Beam Therapy.
The insurer denied the Proton Beam Therapy.
The determination is overturned.

This is a female patient with a history of node-positive left breast cancer status/post (s/p) systemic therapy and surgical resection. She had internal mammary lymph node involvement visualized on imaging. There is a request for proton beam radiation therapy in the postoperative setting. At issue is the medical necessity of the proton beam therapy.
The requested proton beam radiation is medically necessary. The treating provider supplied a proton/photon plan comparison which shows that the photon radiation plan is unable to adequately protect the patient's heart. If delivered, the photon plan would lead to an unnecessary and unacceptable risk for cardiac morbidity/mortality. The proton radiation plan was able to significantly minimize the patient's cardiac exposure within known safe tolerance limits. Proton radiation is expected to minimize the risk for serious/life-threatening toxicity and is supported by the American Society for Therapeutic Radiology and Oncology (ASTRO) Model Policy as the provider has shown that photon radiation cannot meet nationally accepted treatment planning objectives.