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

Diagnosis: Central Nervous System/Neuromuscular Disorder. Treatment: Home Health Care. 
The insurer denied increase in personal care aide level 2 services to 14 hours per day 7 days per week for total of 98 hours.

The patient is a female with a past medical history significant for dementia, anxiety depression, chronic back pain, osteoarthritis, coronary artery disease, chronic obstructive pulmonary disease (COPD), diabetes and hypertension. The subject under review is the medical necessity for Personal Care Aide Level 2: 14 hours a day 7 days a week for a total of 98 hours per week. These services were denied based on lack of medical necessity.

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

Additional personal care aide services are not medically necessary. Her current medical needs are being met with 56 hours a week of services. Additional services would be considered supervision/companionship.
The is a patient with a past medical history significant for dementia, anxiety depression, chronic back pain, osteoarthritis, coronary artery disease, COPD, diabetes and hypertension. According to a letter from her physician and a statement from the patient's daughter who is her power of attorney, she is having progressive issues with age-related cognitive and physical decline.
A letter from her physician states that he feels that the patient requires total assistance with activities of daily living, assistance with ambulation and meal preparation.
Services were denied based upon the following. The plan previously approved 8 hours per day 7 days a week for total of 56 hours a week. The patient had a telephonic clinical assessment using New York Uniform Assessment System (UAS), noting many of her abilities to perform physical functioning and daily activity stayed the same, and some were down since her prior assessment. Abilities which stayed the same included dressing upper and lower extremity, personal hygiene, bed mobility, walking, bathing, toilet transfer, toilet use, meal preparation, medication management and ordinary housework. Physical functioning which went down included eating. Additional hours are not available for supervision/companionship or when tasks are not being performed by the aide.
The patient currently lives with her daughter and son-in-law who are involved in her care.
It was recommended the patient be referred to physical therapy. Her power of attorney, her daughter declined.
There were 3 days of log sheets available for review, noting that the patient typically goes to bed around 8 PM. She requests a glass of water later in the night and had to get up to go to the bathroom in the middle of the night one time.
Clinical services which are medically necessary are being met with the allotted time provided. The patient does appear to get up 1 time at night needing assistance which is typical for the patient's age and underlying medical conditions. The patient does not require any other nocturnal assistance such as frequent turning or positioning at night.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive Cerebellar Degeneration.
Treatment: Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week -a total of 84 hours per week.
The insurer denied the Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week -a total of 84 hours per week.
The denial is overturned. 

The patient is a male with a history of Progressive Cerebellar Degeneration. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL (activities of daily living) support.

Yes, the Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week -a total of 84 hours per week is deemed medically necessary. 

This is a male with a history of Progressive Cerebellar Degeneration. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from the patient's provider indicates that due to progressively worsening functionality and ability to perform ADLs (activities of daily living), the patient has now become total assistance required for bathing, dressing, grooming, skin care, toileting and meal preparation. Hence, the currently approved plan of 35 hours/week Personal Assistance Services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: osteoarthritis
Treatment: Consumer Directed Personal Assistance Services 
The insurer denied Consumer Directed Personal Assistance Services. The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, osteoarthritis, gait instability, and gastroesophageal reflux disease (GERD) whose primary care physician (or provider) (PCP) completed M11-Q(medical request for home care) for request for PCA (personal care assistant) services. On the same day, the patient had a telemedicine visit stating the patient's medical diagnoses and that she would benefit from light housekeeping. The patient had an assessment tool performed telephonically assessing the patient at maximal assistance with tasks of meal preparation and ordinary housework while extensive assistance with tasks of stairs, shopping, transportation, and dressing lower body. The patient was assessed at limited assistance with tasks of managing finances, managing medications, equipment management, bathing, personal hygiene, dressing upper body, transfer toilet, and toilet use while independent with tasks of phone use, walking, locomotion, bed mobility, and eating. This assessment notes stated the patient was interested in CDPAS (Consumer Directed Personal Assistance Services), used a cane to ambulate, and had an informal helper that was her partner/significant other. The Uniform Assessment System (UAS) summary of care give info and tasks estimated total task hours as 9.8 and 10.09.

The Consumer Directed Personal Assistance Services are medically necessary for this patient. The UAS assessed the patient as needing assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, stairs, shopping, transportation, equipment management, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home. This is the case for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus
Treatment: Inpatient admission

The insurer denied coverage for the inpatient admission.
The denial is overturned. 

This patient is a male child with a history of asthma who had 4 previous admissions to the hospital and 2 of those admissions were to the Pediatric Intensive Care Unit (PICU).  The patient was sick for 2 days with an upper respiratory infection (URI) and developed increased work of breathing on the day prior to this current admission. In the home, the patient was treated with Flovent but the patient's parents did not see any improvement so they brought the patient to the Emergency Room (ER). In the ER, the patient was noted to have a cough, a runny nose and dyspnea. The physician indicated that the patient was in respiratory distress with bilateral wheezing and intercostal retractions. On physical examination there was marked reduction in air entry bilaterally and wheezing.  The patient was treated with 3 doses of Duoneb, steroids, magnesium and an intravenous (IV) normal saline bolus. Since the patient continued to have wheezing, the patient was started on continuous albuterol in the ER. The patient's chest X-ray was unremarkable but the patient was tested positive for rhinovirus on a respiratory viral panel. The patient's blood testing demonstrated an elevated white blood count of 20,000 and an elevated lactic acid of 3.1. When the patient's diminished air entry and evidence of respiratory distress did not improve following this treatment, the decision was made to admit the patient to the hospital for albuterol treatment every 3 hours with a diagnosis of status asthmaticus.

Based on the review of the medical record and literature, the acute inpatient admission was medically necessary. The patient was treated appropriately in the ER for persistent wheezing and decreased breath sounds from status asthmaticus. As per UpToDate, the administration of magnesium sulfate is reserved to children with severe asthma exacerbations while in the ER or for those who require intensive care unit (ICU) care. This was the case for this patient. When the patient had persistent wheezing and evidence of airway obstruction with diminished breath sounds and increased work of breathing despite appropriate treatment for status asthmaticus in the ER, the decision to admit the patient for ongoing treatment with albuterol every 3 hours was consistent with the standard of care.  

As per UpToDate review, patients treated with continuous therapy who do not improve rapidly should be monitored closely for worsening respiratory status. The patient could not have been safely discharged to receive albuterol every 3 hours at home or at a lower level of care other than inpatient setting. 

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

The carrier's denial of coverage for the inpatient admission should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (skeletal Class I, maxillary crowding and mandibular spacing, Class II canines, excessive overjet, congenitally missing incisors and deep impinging overbite)

Treatment: D8080 Braces and D8670 monthly visits

The insurer denied coverage for D8080 Braces and D8670 monthly visits.

The denial is upheld.

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, maxillary crowding and mandibular spacing, Class II canines, excessive overjet, congenitally missing incisors and deep impinging overbite. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 11 points on review by their internal reviewers.  

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, the HLD index is utilized. This index provides 6 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 deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage, and does not support comprehensive orthodontic care. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 11 points (4 points overjet, 5 points overbite, and 2 points labiolingual spread).
 
D8080 braces and D8670 monthly visits is not considered medically necessary for this patient.  

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

The carrier's denial of coverage for D8080 Braces and D8670 monthly visits should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Open bite
Treatment: Comprehensive Orthodontic treatment and monthly visits (Braces) 
The insurer denied the Comprehensive Orthodontic treatment and monthly visits (Braces).
The denial is overturned. 

The patient is a female. The request is for dental benefits for orthodontic treatment (Braces). The clinical summary indicates that the patient has a Class I normal molar relationship with a 4mm (millimeter) severe open bite.

Yes, the Comprehensive Orthodontic treatment and monthly visits are medically necessary.

As stated in the clinical summary and evidenced in the photos and x-rays, the patient has a 4mm (millimeter) anterior open bite. The patient's upper and lower teeth do not come together when the mouth is closed.

The seal that is formed when the anterior teeth comes together is crucial for swallowing, proper speech (enunciation of certain letters-patient may develop a lisp), proper chewing function and maintaining proper alignment of the teeth in the arch.

Comprehensive Orthodontic treatment and monthly visits are medically necessary in order to correct the patient's open bite.

If the patient's condition is left untreated, it will become progressively worse over time. The patient may develop flaring of the teeth, speech problems, difficulty chewing, premature posterior tooth wear and the inability to swallow effectively.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems-Teeth spacing problem/crowding
Treatment: Dental/Orthodontic Procedures-Braces
The health plan denied the service of braces as not medically necessary for this patient. 
The reviewer has overturned the determination in whole.

The patient in question  has a Class II malocclusion with protrusive maxillary incisors. The patient has severe maxillary and mandibular crowding. She is treatment planned for 24 months of orthodontics to correct this malocclusion.

Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, this patient's overjet is greater than 6 millimeter (mm). Overjets of this magnitude are shown to negatively affect the oral health quality of life. For these reasons treatment of Braces and monthly visits is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attempted Suicide
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This male with a history of depression and inpatient psychiatry admission was admitted after overdosing on 15 diphenhydramine tablets.  Vital sign (VS) were as follows:  temperature 36.7, heart rate 103, respiratory rate 16, blood pressure 129/83, and oxygen saturation 100%.  The patient's exam was remarkable for blunted affect, fluent speech and intermittently losing train of thought.  Labs revealed the following: white blood cell (WBC) count 7.4, hemoglobin/hematocrit (H/H) 17.1/49.4, platelets (Plt) 227, sodium (Na) 137, potassium (K) 3.7, blood urea nitrogen/creatinine (BUN/Cr) 12/1, and Electrocardiogram corrected QT interval (QTC) 583.  

The patient was treated with emetic therapy in the emergency room (ER).  He was admitted. Plan of care included one to one (1:1) monitoring, intravenous fluids (IVF), and telemetry.  The next day, vital signs were stable (VSS).  The patient was irritable and agitated.  Electrocardiogram revealed improved QTC interval.  Telemetry was discontinued.  Risperdal was restarted and Lorazepam was to be given as needed.  The following day, the patient was medically cleared for discharge to inpatient psych.  He was awaiting a bed; the psych bed became available a few days later.  

No, the proposed inpatient admission was not medically necessary.

This patient, with a history of depression, was admitted after an intentional antihistamine overdose.  The patient was hemodynamically stable.  He was awake and alert.  There were no findings of end-organ damage.  Electrocardiogram (EKG) showed mildly prolonged QTC interval.  Treatment of antihistamine overdose is supportive care.  The patient was treated with intravenous (IV) fluids.  Telemetry was discontinued on day #2 and he was cleared for transfer to inpatient psych on day #3.  Discharge was delayed pending bed availability.   

Medically necessary services are typically those which are:

1) safe 2) effective 3) generally accepted national standard of medical practice 4) not provided primarily for convenience of the patient or the practitioner 5) the least intensive and/or most appropriate alternatives among diagnostic and treatment options.

Inpatient admission was not medically necessary because the patient was clinically stable.  He did not have extreme drowsiness, confusion, seizures, or vomiting.  The patient had not failed a lesser level of care.  He did not receive intervention that required an acute inpatient level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 

The insurer denied inpatient hospital admission. The denial is upheld.

The patient is a male who presented to the hospital for scheduled cardiac catheterization. The patient reported one year of exertional dyspnea. Myocardial perfusion imaging showed moderate sized reversible inferolateral and anterolateral defects. The left ventricular ejection fraction was 52%. The patient's medical history was remarkable for hypertension, hyperlipidemia and obesity. Upon presentation the patient denied chest pain. His electrocardiogram was normal. Coronary angiography showed severe multi-vessel disease. The procedure was uncomplicated. Post-procedure the patient was admitted to the hospital. Coronary artery bypass graft surgery was recommended. This was initially planned the next day. However, the patient's adenosine diphosphate receptor (P2Y12) level was low. A hematology consultant recommended sending blood out for platelet function tests. Since the results would take several days, the patient was discharged with plans for surgery the following week. Medical necessity for an inpatient admission is at issue.

The health plan's determination is upheld in whole.

An inpatient hospital admission was not medically necessary. This patient presented for scheduled cardiac catheterization for exertional chest pain. The records provided do not document rest pain or pain with minimal exertion. Upon presentation the patient was in sinus rhythm with a normal electrocardiogram. His cardiac catheterization was uncomplicated. The patient remained stable overnight post-procedure. He did not require intensive monitoring or intravenous infusion and titration of cardioactive medications. He was deemed stable for discharge the day after the procedure. Treatment at a lower level of care status would have been appropriate. In patients with chest pain, in the absence of hemodynamic instability, dynamic electrocardiographic changes or elevated cardiac biomarkers, care at a lower level status is endorsed by the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients with Non-ST-Elevation Acute Coronary Syndromes. An inpatient level of care was not medically necessary in this instance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain.
Treatment: Lumbar Epidural Steroid Injection.
The insurer denied the Lumbar Epidural Steroid Injection.
The denial is overturned. 

The patient is a male with low back pain and neurogenic claudication (pain in the low back and legs with walking and standing). He has failed PT (physical therapy), home exercise, and various medications. 

Yes, the proposed treatment is medically necessary.

The patient is a male with chronic low back pain that starts in his low back and radiates down his bilateral lower extremities. He complains of paresthesias in the bilateral lower extremities.  He has done PT (physical therapy), he continues with home exercise. He has tried various medications including opiate medications. He has a recent MRI (magnetic resonance imaging) that shows severe spinal stenosis at L4-5 (fourth lumbar spine vertebra- fifth lumbar spine vertebra), which is consistent with his symptoms.  It is medically necessary to consider an epidural steroid injection, as his other options would involve much more invasive procedures, including surgery. It is reasonable to consider an ESI (epidural steroid injection) prior to consideration of more invasive methods.  

The patient was initially approved for an epidural steroid injection; however, this injection was never performed due to the Coronavirus pandemic situation.  Therefore, a requirement of two months of relief is not applicable, since the patient never had an initial injection.  This would be the first epidural steroid injection for this patient. 

Epidural steroid injections have been shown to effective in spinal stenosis, low back pain, and neurogenic claudication.  As such, given the above, the requested epidural steroid injection is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: PCOS (polycystic ovarian syndrome)
Treatment: Ovarian Hyperstimulation and Intrauterine Insemination (IUI) (58322, 89260, 89261) 
(Pre-Service)
The insurer denied the Ovarian Hyperstimulation and Intrauterine Insemination (IUI) (58322, 89260, 89261) 
(Pre-Service).
The denial is overturned.

The patient is a  female with a diagnosis of PCOS (polycystic ovarian syndrome). According to the provider, the patient has failed Clomid treatments but conceived following controlled ovarian hyperstimulation. She underwent repeat treatments and conceived a twin gestation. She has undergone five cycles of controlled ovarian hyperstimulation with timed intercourse but did not conceive. Semen analysis showed oligospermia with a motile sperm of 4.8 million sperm. The provider plans to proceed with controlled ovarian hyperstimulation with intrauterine insemination.

Yes, the Ovarian Hyperstimulation and Intrauterine Insemination (IUI) (58322, 89260, 89261) are medically necessary.

This patient has failed treatments back with oral agents (Clomid). She conceived three times following controlled ovarian hyperstimulation (one miscarriage, one delivery of a singleton, and one delivery of twins). The plan is to proceed with the same treatment. However, because the patient has failed timed intercourse and there is evidence of an abnormal semen analysis, the plan is to proceed with intrauterine insemination.

It is unclear why the requested services are being denied. This patient has anovulation and has failed prior induction of ovulation with oral agents. She has been successful three times previously with controlled ovarian hyperstimulation. Going back to using oral medications that did not work would not be consistent with the standard of care. So, ovarian hyperstimulation is standard of care and medically necessary for this patient.

In addition, this patient has a significant male factor, as the motile sperm count is less than 5 million. Again, based on the standard of care, an intrauterine insemination is medically necessary for this patient.