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

Diagnosis: History of cerebral infarction, weakness.
Treatment: Consumer directed personal assistance program (CDPAP): 5 hours per day- 7 days per week- total of 35 hours per week.
The insurer denied Consumer directed personal assistance program (CDPAP): 5 hours per day- 7 days per week- total of 35 hours per week.
The determination is upheld.

This is a male patient with a medical history notable for prior cerebral infarction, weakness, and difficulty walking. The patient is approved for 5 hours per day, 4 days per week (20 hours per week) of consumer directed personal assistance program (CDPAP). The patient and his care team requested an increase to 5 hours per day, 7 days per week (35 hours per week) and this request was denied by the health plan. 
The health plan notice states that they approved the patient's personal care hours for 4 days per week because the patient is in a social day care program 3 days per week. He also receives informal support from his family and spouse that live in the home.
The patient's neurologist provided a letter for this appeal. The letter lists the patient's diagnoses as prior cerebral infarction, weakness, and difficulty walking. It then states that he "needs extra home care hours for the assistance of his daily activities." There is no further information provided or discussion regarding which personal care needs are not currently being met. 
A Uniform Assessment System (UAS) was completed and was available for review. Compared to a prior assessment, he did not show a significant change in his level of function. A task tool associated with the most recent assessment recommended 18 hours per week to address his personal care needs. At issue is the medical necessity of consumer directed personal assistance program (CDPAP): 5 hours per day- 7 days per week- total of 35 hours per week. 

The requested health service of consumer directed personal assistance program (CDPAP): 5 hours per day- 7 days per week- total of 35 hours per week has not been demonstrated to be medically necessary for this patient. 
The patient has several functional limitations as outlined by the UAS. He requires hands-on assistance for most IADLs (independent activities of daily living) and some ADLs (activities of daily living). He has some informal support in his home. He did not experience any significant functional decline on his latest assessment. He is currently receiving 20 hours per week of CDPAP services, which is greater than the 18 hours recommended by the UAS task tool. It is not clear which personal care needs, if any, are not being met by his current level of personal care assistance. Therefore, it has not been clearly demonstrated that the requested increase in personal care services is medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Immunologic Disorders/Scleroderma/Tightening/Thickening of Skin
Treatment: Surgical Services/Autologous stem cell transplant
The health plan denied the requested Autologous stem cell transplant as experimental/investigational. The health plan's determination is overturned.

The case under review involves a boy with a diagnosis of systemic scleroderma (U3RNP Antibody+) complicated by multi-system involvement including moderate-severe pulmonary hypertension. He initially presented with tightness of his fingers, decreased range of motion of his shoulders, and Raynaud's Phenomenon at the time of diagnosis. He was treated with Cellcept, Rituximab, and steroids. He underwent workup for syncope in the setting of shortness of breath and chest pain with exertion and was diagnosed via cardiac catheterization with moderate- severe pulmonary hypertension requiring Intensive Care Unit (ICU) admission for treatment with a Remodulin drip. He continued outpatient treatment with Tadalafil, Nifedipine, and Ambrisentan. More recently, he was diagnosed with disease-related esophageal dysfunction. He has been followed closely and determined to have advanced disease with poor response to therapies. Given multiple risk factors, including moderate-severe skin involvement, musculoskeletal involvement, pulmonary hypertension, positive U3RNP antibody, and as a young black male, the patient was determined by his care team to be high risk for morbidity and mortality. Therefore, they have recommended autologous stem cell transplant (ASCT) therapy. The child's health plan has denied coverage for this treatment.
At issue is whether the proposed health service or treatment of an autologous stem cell transplant is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

I overturn, in whole, the health plan's determination regarding the proposed treatment.

The patient under review is an adolescent male with advanced systemic sclerosis with associated diffuse cutaneous involvement, musculoskeletal involvement, moderate-severe pulmonary hypertension, and early esophageal impairment who has had a sub-optimal response to a multitude of immunosuppressive medications and pulmonary hypertension medications. He has been classified as high risk for morbidity and his expert care team has recommended ASCT which has been shown in randomized clinical trials and multiple case series (cited above) to significantly diminish symptoms and organ damage and prolong life.
Therefore, the proposed treatment of ASCT is likely to be more beneficial than standard treatments that have already failed for the insured's life-threatening and disabling disease.
Appeal type: Medical necessity
Decision: Upheld

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


This is a male patient who presented to the hospital following a fall down three stairs. There was a brief period of confusion and disorientation. His past medical history is notable for hypertension and hyperlipidemia. The vital signs at the time of presentation were normal. A Glasgow Coma Score was 15. Evaluation revealed him to be awake and alert, moving all extremities without focal neurological deficit. There was a small acute tentorial subdural hematoma without midline shift noted on computed tomography (CT). He was admitted to the hospital and provided pain management, frequent neurological checks, pulse oximetry, Keppra 1000 milligrams (mg), and repeat CT imaging. A neurosurgical consultation was obtained. No surgical intervention was planned.
The repeat head computed tomography (CT) showed stability of the small subdural hematoma without other acute intracranial pathology. The neurosurgical consultation yielded the recommendation for no neurosurgical intervention at that time. Activity and diet were advanced and discharge planning was initiated. The patient was discharged from the hospital.
At issue is the medical necessity of an inpatient stay.

This patient presented to the hospital as a trauma patient following a fall. He was neurologically intact at presentation and there was no surgical plan for acute neurosurgical intervention. The patient remained stable during the period of monitoring. The initial head CT in the morning and the follow up head CT in the afternoon demonstrated a stable small subdural hematoma without mass effect. He was deemed stable and neurosurgically nonoperative. The care and treatment provided could have been rendered without an inpatient level of care. This would have permitted ongoing evaluation and neurological checks as he was determined to be neurologically and hemodynamically stable and non-operative.
Admission is indicated for head injury and one or more of the following: Hemodynamic instability, altered mental status that is severe or persistent, post-resuscitation or presenting Glasgow coma score of less than (<) 13, worsening neurologic function, new signs or symptoms, new focal signs on neurologic examination, evidence of increased intracranial pressure, new intracranial pathology on imaging, cerebrospinal fluid (CSF) leak, inpatient wound care needed, skull fracture, that is basilar, open or depressed, intracranial infection, cerebral vasospasm identified or suspected, recurrent seizures, significant respiratory abnormalities secondary to the brain injury, increased intracranial pressure or cerebral edema monitoring. In this case, none of these neurological criteria were present to warrant an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

This case involves an adult male who presented to the emergency room complaining of dizziness and left-sided numbness.  The patient's blood pressure was 150/50.  He had a history of taking aspirin with his primary assessment noting that he did not appear to be in acute distress.  The patient had a history of hyperlipidemia and prior angioplasty.  He claimed that the left-sided numbness began 1 hour prior while resting and was not associated with trauma, vomiting, chest pain, shortness of breath, facial droop, slurred speech, or arm drift.  The patient claimed to not feel right, felt anxious, and stated that he used cannabidiol (CBD) and thought it might have been laced with something.  During neurological examination, the patient had numbness to the upper and lower extremity with a heart rate at 104.  He was described as mildly anxious but scored a 0 on the National Institute of Health (NIH) stroke scale.  Laboratory testing and imaging was ordered.  Glucose via fingerstick was elevated at 205, creatinine kinase was elevated at 287, glucose via comprehensive metabolic panel was elevated at 217, with lipase elevated at 101.  Prothrombin time was also reduced to 12.3. Computed tomography (CT) of the head was negative for acute intracranial pathology.  The patient was admitted to telemetry for further work-up. 

According to the Milliman Care Guidelines (MCG) regarding Neurology, the patient did not require inpatient level of care for presenting symptoms.  While he reported dizziness and left-sided numbness, he was not found to have a condition that required hospital admission and could have had his care rendered safely and effectively on an observational basis or outpatient basis.  Laboratory testing and diagnostic imaging could have been obtained under observation.  The patient had no escalation in symptoms and responded favorably to the provided treatment.  

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:  Pneumonia.
Treatment:  Inpatient admission.

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

This patient is an adult female with a history of obesity, schizophrenia and bipolar disorder, who presented to the hospital with shortness of breath and productive cough with yellowish sputum for 1 week.

At presentation vital signs were: Temperature 98.3 degrees F, respiratory rate 44, pulse 99 and blood pressure 154/85, and oxygen saturation of 89 percent on room air. The patient was placed on 4 liters (L) of oxygen via nasal cannula raising the oxygen saturation to 95 percent. Increased respiratory effort was noted, and the patient was found to have wheezing on lung exam.

White blood cell (WBC) count was 15.9, blood urea nitrogen (BUN and creatinine (Cr) were within normal limits. Venous blood gas (VBG) was 7.42/42/40. Chest X-ray revealed bilateral ground-glass opacities. Computed tomography (CT) was negative for pulmonary embolism (PE). The imaging was consistent with Pulmonary Edema versus Infectious/Inflammatory process.

Viral panel was positive for Rhinovirus.

The patient was initially treated with steroids, bronchodilators and placed on Ceftriaxone and Azithromycin, and she improved with treatment initiated in the emergency department. She was alert and oriented x 3, speaking in full sentences, tolerating oral food and fluids and was in no apparent distress. Vitals stable with oxygen saturation at 93 percent on room air. Scheduled to follow up with Pulmonary Specialist.

Presentation was consistent with viral pneumonia, and this patient did not need 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, heart disease, osteoarthritis and depression
Treatment: Personal Care Aide (PCA): 12 hours per day - 7 day(s) per week; 12 hours per day- 7 day(s) per week (split shift) - a total of 168 hours per week
The insurer denied coverage for Personal Care Aide (PCA): 12 hours per day - 7 day(s) per week; 12 hours per day- 7 day(s) per week (split shift) - a total of 168 hours per week
The denial is overturned

This is an elderly person with chronic medical problems including dementia, heart disease, osteoarthritis and depression. The patient lives alone in a private residence. The insurer approved personal care aide (PCA) live-in per diem - 1 day - 7 days per week - a total of 7 days per week. The request is for Personal Care Aide (PCA): 12 hours per day - 7 day(s) per week; 12 hours per day- 7 day(s) per week (split shift) - a total of 168 hours per week.

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as "severely impaired." The patient requires total dependence and maximal assistance for much of the Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient requires maximal assistance for bathing, personal hygiene, dressing, bed mobility, locomotion, toilet transfer and ambulation.  The patient requires extensive assistance for eating and requires total dependence for toilet use. The patient has a Foley catheter for bladder management and is frequently incontinent of bowel. There have been no reported falls over the prior 90 days. The patient's functional ability has reportedly declined over the prior 90 days.   

The patient's cognitive and functional deficits are at a level or unpredictable as to require the requested PCA services 24 hours/day (split shift).  Based on the records reviewed, a live-in PCA would not be appropriate as they are unlikely capable of providing for the patient's functional needs and have the ability to consistently obtain uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home by the provision of Personal Care Aide (PCA): 12 hours per day - 7 day(s) per week; 12 hours per day- 7 day(s) per week (split shift) - a total of 168 hours per week.

From a physical medicine and rehabilitation perspective, the requested approval for PCA services is medically necessary.      

Based on the above, the insurer's denial must be overturned. 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 Personal Care Aide (PCA): 12 hours per day - 7 day(s) per week; 12 hours per day- 7 day(s) per week (split shift) - a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Braces (comprehensive orthodontic treatment visit). 

The insurer denied coverage for braces (comprehensive orthodontic treatment visit). 

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, this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, ectopic eruption, and anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index attaining 27 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 12 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) 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, New York State requires, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria is considered by 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 completes the second portion of the index arriving at 27 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which exceeds the threshold of 26 points to support orthodontic care. 

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. This is confirmed by several referenced studies (1, 2, 3). Each of these peer reviewed articles concludes that 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. 

Based on the above, the insurer's denial must be overturned. 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 braces (comprehensive orthodontic treatment visit) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cyclic vomiting syndrome. 
Treatment: Inpatient Hospital Admission. 

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

This adult female patient with a history of schizophrenia and anxiety presented with 19 days nausea, vomiting and inability to tolerate oral (PO) intake. She reported symptoms after menstrual period that usually resolve. The patient's vital signs were stable, and she was afebrile. Her complete blood count (CBC) and comprehensive metabolic panel (CMP) were unremarkable. Abdominal/pelvic computed tomography was normal. Her exam was unremarkable. The patient was admitted, and the plan of care included Zofran, Pepcid, intravenous fluids, and regular diet. On Day #2, it was noted the patient was unable to tolerate oral intake due to vomiting. Current management was continued and Klonopin was to be considered if the patient was unable to tolerate dinner. On Day #3, the patient continued to have symptoms. Gynecology was consulted for cyclical vomiting syndrome and starting oral contraceptive pills (OCP). There was no significant change. and the patient was discharged on Day #6. 

The proposed treatment was not medically necessary. 

This patient was admitted cyclic vomiting syndrome. The Plan denied admission because the medical records document that the patient's clinical condition, combined with the scope and intensity of diagnostic and therapeutic services rendered, do not exceed the health-plan utilization review guidelines. At time of admission, the patient was hemodynamically stable and afebrile. Electrolytes and renal function was normal. She was not 'nothing by mouth' (NPO). Treatment included intravenous fluids and antiemetics. The patient remained clinically stable with no significant 
change in her management. Medications were adjusted around mealtimes to manage nausea and vomiting. The patient's condition and the management provided did not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hindfoot Repair
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Upheld

The patient is a female who presented to the hospital for elective hindfoot repair. Her preoperative diagnosis was posterior tibial tendon insufficiency, foot deformity, and an equinus contracture. On the day of presentation, she underwent multiple surgical procedures including a double osteotomy of the calcaneus, bone grafting, and a tendon transfer.
According to her discharge summary, the patient had an "orthopedically uncomplicated hospital course." Included for review are medical records, and denial and appeal documentation.
This review involves denial of a full admission for a patient who underwent an elective hindfoot reconstruction. In the postoperative period, the patient was put on full inpatient status. This was denied by the insurance company as the care provided was thought to be able to be provided at a lower level of care.
The subject under review is the medical necessity for the full hospital admission.

The requested full hospital admission was not medically necessary for this patient.
The patient had comorbidities including smoking, hypothyroidism, anxiety and a family history of deep vein thrombosis (DVT), there was no exacerbation of any of these pre-existing medical conditions. The care provided the patient was pain control and physical therapy for mobilization. She was able to be discharged to home safely and had done well in physical therapy. All of the care provided can be done at a lower level of care status and does not require a full admission.
As described in the text box above, the patient had a routine orthopedic follow-up. She needed to stay at the hospital for pain control and physical therapy for a couple of days postoperatively, but did not have any exacerbation of premorbid conditions or develop new complications that required for intensive monitoring. The patient could have been safely managed at a lower level of care status.