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

Diagnosis: High Blood Sugar
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient is a female with no significant past medical history who presented with dizziness, nausea, polyuria, polydipsia.

The patient's hemoglobin A1c (glycated hemoglobin) was 14% (percent). Admission day one the glucose was 609 with a sodium of 127 and an anion gap of 20 with a carbon
dioxide of 14. Serum Acetone is moderate. The BG (blood gas) showed a pH (potential of hydrogen) of 7.323, PCO2 (partial pressure of carbon dioxide) of 26.8 and a bicarbonate of 13.6. 

Yes, the Inpatient admission was medically necessary.
Hospitalization for DKA (diabetic ketoacidosis) is universally medically necessary
(1-9). Patients with diabetes and diabetic ketoacidosis (DKA) initially generally
require ICU (intensive care unit) level care (1, 3, 4, 5) until they are converted to
subcutaneous insulin and have closed their anion gaps and have no other
conditions requiring ICU (intensive care unit) level care (10, 11). Most hospitals
admit patients with DKA (diabetic acidosis) to the ICU (intensive care unit) due to
rules regarding level of service with q1h (every one hour) blood draws and nursing
rules. The patient was admitted for treatment of diabetic ketoacidosis. The patient
had hyperglycemia, ketosis and diabetic ketoacidosis based on an elevated anion
gap and a low bicarbonate. The patient could not have been safely discharged from
the emergency department, and needed admission to correct her metabolic
abnormalities and initiate subcutaneous insulin and titrate the doses. The
hospitalization is consistent with generally accepted standards of medical practice,
and is therefore medically necessary.
Urine ketones were greater than 80.

No, the health plan did not act reasonably, with sound medical judgment, and in the
best interest of the patient, as the request is medically necessary as described
above.

The patient was diagnosed with diabetic ketoacidosis and was started on an insulin
infusion. The blood gas showed a metabolic acidosis with respiratory
compensation. The progress note reveals that the patient was
transitioned to Levemir 15 units twice a day and aspart (fast-acting insulin) 4 units before meals with sliding scale. The note reveals that the patient was ready for
discharge on of Lantus 50 units daily and aspart (fast-acting insulin) 8 units before meals. The patient received diabetic education by the nursing staff.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional-Obesity
Treatment: Pharmacy/Prescription Drugs-Wegovy
The health plan denied the medication Wegovy as not medically necessary for this patient. 
The reviewer has upheld in whole the health plan's determination.

This is a patient with a body mass index of 29 kilograms per square meter (kg/m2) with prediabetes, hypertension, and hyperlipidemia. Request for Wegovy is under review. The prior request was denied as the coverage criteria requires that he has failed to lose at least 5% of body weight through at least six months of lifestyle modification alone and a body mass index of 30 kg/m2 or higher. Documentation of current height and weight were also required. The attending physician is appealing this determination as the patient has tried and failed multiple weight loss medications like Saxenda and phentermine and he is engaged in lifestyle modification intensely too. The submitted documentation includes a chart note showing that the patient is on Wegovy 0.25 milligrams (mg) weekly with a weight of 87.5 kg and height of 1.753 meters with a body mass index of 28.5. Prior body mass index 29.53.
As reviewed in a recent New England Journal of Medicine article on the management of obesity, lifestyle interventions designed to modify eating behaviors and physical activity are the first option for weight management, given their low cost and the minimal risk of complications (1). The documentation does not indicate how much weight was lost with lifestyle interventions for this patient to determine if he has failed lifestyle interventions. Wegovy has risks, including nausea and vomiting. Therefore, the requested Wegovy is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Incontinence and Increased Frequency
Treatment: Gemtesa
The insurer denied the Gemtesa.
The denial is upheld.

The patient is a female with a diagnosis of overactive bladder. She has requested coverage for Gemtesa tablets. She has tried oxybutynin. The denied coverage on the basis that the patient has not had a trial of all formulary alternatives. This is being appealed.

No, the requested Gemtesa is not medically necessary.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.

The patient has not tried all the formulary alternatives. The Plan's formulary agents are acceptable treatment alternatives with a low risk of potentially risky destabilization. Therefore, given the above, the requested Gemtesa is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spastic diplegic cerebral palsy.

Treatment: durable medical equipment, ultralight manual wheelchair.

The insurer denied coverage for durable medical equipment, ultralight manual wheelchair.

The denial is overturned.

This is a school-aged male diagnosed with spastic diplegic cerebral palsy.  He is non-ambulatory and requires a manual wheelchair for mobility.  His current wheelchair is in need of replacement.  Under review is the requested durable medical equipment, ultralight manual wheelchair.

This physician agrees the requested ultralight manual wheelchair is clinically appropriate and medically necessary.  According to the clinical records several standard manual wheelchairs were tried.  "He cannot propel a standard non-adjustable wheelchair as it is too heavy, and the wheels are placed too far back for him to reach."  In addition, a standard light weight wheelchair "cannot have transit brackets, cannot grow with the child and cannot achieve the necessary seat angles for safe positioning and efficient propulsion."  However, the requested ultralight weight wheelchair allows him to use his limited strength and function most efficiently.  The required ultralight manual wheelchair for this patient with spastic diplegic cerebral palsy is also the most appropriate durable medical equipment (DME) in this particular circumstance.  

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

From a Physical Medicine & Rehabilitation/Pain Management perspective, as well as within a reasonable degree of medical certainty, based on the documentation available for review, the requested durable medical equipment; ultralight manual wheelchair is medically necessary.  

The insurer's denial of coverage for durable medical equipment; ultralight manual wheelchair is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperlipidemia. 
Treatment: Repatha SureClick 140 milligrams per milliliter. 

The insurer denied the Repatha SureClick 140 milligrams per milliliter. 
The denial is overturned. 

The patient is a female with history of hyperlipidemia. There is documented intolerance to multiple statins and Zetia as well as full work up to confirm intolerance of these medications. 

Yes, the proposed Repatha is medically necessary. 

Per guidelines, indication for a PCSK9 (Proprotein convertase subtilisin/kexin type 9 serine protease) inhibitor would be intolerance or failure of statins and Zetia to reach goal in patients with hyperlipidemia. This patient meets these criteria and use is consistent with community practice. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

Treatment of hyperlipidemia as requested is appropriate care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiomyopathy. 
Treatment: Durable medical equipment (K0606RR) x (times)1, life vest. 

The insurer denied coverage for durable medical equipment (K0606RR) x1, life vest. 

The denial is upheld. 

This is the case of a male with dilated cardiomyopathy. Past medical history was significant for heart failure with reduced ejection fraction 20% despite guideline directed medical therapy. Left ventricular ejection fraction (LVEF) remained depressed on consecutive echocardiographic studies performed three months apart. Implantable cardiac defibrillator (ICD) was recommended, and the patient refused. 

American Heart Association/ American College of Cardiology/ Heart Rhythm Society (AHA/ACC/HRS) guidelines recommend ICD implantation for patients that have an LVEF less than 36% treated with guideline directed medical therapy. (1) Current American Heart Association Science Advisory regarding wearable life vest therapy recommends that external life vest defibrillators may be beneficial in situations where implantable defibrillators cannot be utilized or when there is a heightened risk of sudden cardiac death that is expected to resolve over time. (2) 

In this case, the patient had a clear indication for an implantable cardioverter-defibrillator (ICD) upon initial presentation. 

The health plan acted reasonably and with sound medical judgement and in the best interest of the patient. This patient should undergo ICD placement. 

The insurer's denial of coverage for the durable medical equipment (K0606RR) x1, life vest is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulpitis
Treatment: root canal therapy (3310) for tooth #11.
The insurer denied root canal therapy (3310) for tooth #11.
The determination is overturned. 


The patient presented  for evaluation and treatment of tooth number (#)11 with root canal treatment (3310). Provided for review are previous letters of appeal and denial, a narrative from her provider explaining radiographic bone levels and pulpal diagnosis of tooth #11, full mouth radiographic and single periapical images from unknown dates, one page of American Dental Association (ADA) claim forms, periodontal indices, and clinical notes. At issue is the medical necessity of the planned treatment of root canal therapy (3310) for tooth #11.
The requested service of nerve treatment on front tooth #11 is medically necessary for this patient. In any situation where the patient has the diagnosis of irreversible pulpitis, as long as the tooth is restorable, as it is here, there is the requirement to treat the pulpitis through removal of the infected nerve, artery, vein, as well as the canal tooth structure, irrigate with sodium hypochlorite, and fill with gutta percha medicament as this is the only therapy that will treat the diagnosed pathology. This is a root canal. If the therapy is not done, the pulpal infection can spread to the surrounding bone, which can lead to the presence of an abscess, with an array of sequential systemic sequela. Therefore, based on the diagnosis of irreversible pulpitis alone, the therapy of root canal therapy is indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis.

Treatment: Inpatient admission.

The insurer denied coverage for an inpatient admission.

The denial is upheld.

According to the appeal letter, the patient was admitted with acute appendicitis. The patient underwent a laparoscopic appendectomy and was discharged on the same day. Admission may be necessary for patients with severe systemic illness (e.g., sepsis), poorly controlled comorbidities (e.g., chronic heart failure), or complications from the procedure (e.g., infection, bleeding) that require more than 24 hours of postoperative care [1-3]. Patients with a perforated appendix are noted to have a longer inpatient stay [4]. Peer-reviewed literature indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis [1-3]. As there are no medical records, there is no indication of complications that would require inpatient admission. The records were requested from the appealer and the patient in writing and telephonically to date they have not been provided. Based on the submitted documentation, the acute inpatient stay is not medically necessary.  

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia

Treatment: D6010 surgical placement of implant body; endosteal implant to tooth 4, 18, 19, 20, 21, 30, and 31

The insurer denied coverage for D6010 surgical placement of implant body; endosteal implant to tooth 4, 18, 19, 20, 21, 30, and 31

The denial is upheld.

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, narrative letter from the dentist in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants and is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. As regards to endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment.  

Therefore, as removable dentures (full and partial removable) remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary.

The health care plan did act reasonably and with sound medical judgement and in the best interest of the patient. Surgical placement of endosteal implant teeth is not considered medically necessary for this patient.

An appropriate alternative standard of care treatment would be convention removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate, and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary.

The insurer's denial of coverage for D6010 surgical placement of implant body; endosteal implant to tooth 4, 18, 19, 20, 21, 30, and 31 is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle Cell Crisis
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient in this case is a woman with sickle cell anemia and a history of pulmonary embolism. She presented to the emergency department with pain in her back and legs noted to be typical of sickle cell crisis pain. She took Tylenol and oxycodone at home without any improvement. Her hemoglobin was 6.9g/dl (grams per deciliter) and she was not transfused. She had tachycardia at the time of admission. She was treated with IV (intravenous) Dilaudid, total of six doses, and felt better so was discharged the next day. She was also treated with IV (intravenous) fluids during admission.

No, the Inpatient admission was not medically necessary.
This patient had tachycardia without hypotension, hypoxia or active infection. There was also no documentation of cardiac ischemia or any other organ ischemia. She was treated with pain medication and IV (intravenous) fluids and felt better within the first 24 hours. Based on this information she did not require acute care inpatient admission. She could have been safely managed at the observation level of care.

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, decreased mobility

Treatment: coverage for increase of Home Care / Personal Care HHC (Home Health Care) - Level 2 Personal Care Services per 15 minutes, 49 hours per week

The insurer denied coverage for coverage for increase of Home Care / Personal Care HHC - Level 2 Personal Care Services per 15 minutes, 49 hours per week

The denial is upheld.

This patient has a history of hypertension, gastroesophageal reflux disease, insulin dependent diabetes mellitus, iron deficiency, and osteoarthritis. She is noted to have problems with mobility and gait. She receives Personal Care Services/CDPAP (consumer directed personal assistance program) at 35 hours per week. The request is for increased hours.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse. ..."

Also: "...s previously advised, social services districts are NOT required to allot time for safety monitoring as a separate task as part of the total personal care services hours authorized.  However, districts are reminded that a clear and legitimate distinction exists between "safety monitoring" as a non-required independent stand alone function while no Level II personal care services task is being provided, and the appropriate monitoring of the patient while providing assistance with the performance of a Level II personal care services task, such as transferring, toileting, or walking, to assure the task is being safely completed."

The patient has been receiving 35 hours per week services for at least the last 8 months. There is no documentation that there has been a change in functional capacity. It is not apparent what the basis would be for any increase in hours. The plan's decision is upheld. 

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

Based on the above, the medical necessity for the increase of Home Care / Personal Care HHC - Level 2 Personal Care Services per 15 minutes, 49 hours per week is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld in whole. 

The patient is a female who was transferred to the hospital from an outlying emergency department where she had presented with chest pain that was precipitated by emotional distress. She was treated with aspirin and enoxaparin and transferred to the hospital for admission to rule out acute coronary syndrome (ACS). Her medical history was remarkable for hypertension, diabetes, chronic obstructive pulmonary disease (COPD), heart failure, obesity, and bipolar disorder. Upon admission her blood pressure was 178/96 millimeters of mercury (mmHg) with a heart rate of 56 beats/minute. Her room air oxygen saturation was 100% (percent). Her physical exam was remarkable for left chest wall tenderness. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin and brain natriuretic peptide (BNP) levels were normal. A repeat troponin level was again normal. Per the admission history and physical exam, the likely etiology of patient's pain was thought to be musculoskeletal. The next day the patient was in no distress. The following day she reported improvement in her pain but had persistent tenderness on exam. An echocardiogram showed a left ventricular ejection fraction of 45% with inferolateral hypokinesis. There was mild pulmonary hypertension. The patient remained stable and was discharged. The subject under review is the medically necessity for the inpatient stay.

The health plan's determination is upheld in whole. 

This patient, with multiple cardiac risk factors, presented with atypical symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no acute ischemic electrocardiographic changes. She did not require intensive monitoring or continuous infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be both safe and is in accordance with current guidelines, including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. The patient could have been managed at a lower level of care status.