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

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Pharmacy/Prescription drugs. 
The insurer denied Opsumit. 
The denial is overturned in whole. 

The patient is a female born with hypoplastic left heart disease, intact atrial septum and left pulmonary vein stenosis. She underwent Hybrid stage I, followed by a comprehensive stage II repair along with a stent placed in the right pulmonary artery. she underwent cardiac catheterization where her right pulmonary artery (RPA) stent was dilated along with coil placement in 2 veno-venous collaterals. She had dilation of coarctation of aorta and a repeat dilation of RPA stent. Most recently she underwent cardiac catheterization when it was shown there is no flow to left lung and the RPA stent was patent without obstruction. However, her Glenn pressures were 15 millimeters of mercury (mmHg) with a pulmonary vascular resistance of 2.43 wood unit (WU).
The subject under review is the medical necessity for Opsumit in this patient.

The health plan's determination is overturned in whole.

The patient in question has a single ventricle and single lung physiology both of which are ominous with high pulmonary artery pressure, and 15 mmHg is a significantly high pressure in such a patient and can lead to significant decrease in cardiac output if not reduced.
In this patient with single ventricle physiology pulmonary flow is passive without the help of the pumping action of heart. Therefore, in such patients any slight elevation of pulmonary artery pressures are not tolerated well and can decrease cardiac output.
Studies have shown that patients have better outcomes if their pulmonary vascular resistance is less than (<) 2 WU and the pulmonary artery pressures are less than 15 mmHg. (1) Studies also have shown that pulmonary vasodilators improved cardiac output. Opsumit has shown improvement in the REPAIR study in these patients.
Opsumit is medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Narcolepsy without cataplexy.
Treatment: Xyrem.

The insurer denied coverage for Xyrem. The denial is overturned.

This is a male patient with a past medical history of chronic headaches and narcolepsy without cataplexy. The patient was seen for follow-up of narcolepsy. The patient had been on armodafinil 150 milligrams (mg) and it was changed to Provigil 400 mg daily.  There was some improvement in the patient's brain fog. The patient was still sleepy and he wanted to nap. The patient used a cortisol supplement in the mornings. The assessment noted that the patient had an improvement with alertness with the medication, but he still had an inadequate clinical response. The provider recommended starting Xyrem at night to improve the patient's nocturnal sleep quality and daytime alertness.

Based on a literature review and a review of the patient's medical record, Xyrem is considered medically necessary for this patient. For this patient's daytime sleepiness, Xyrem is an approved treatment with good results. Trying a stimulant has an addiction potential. The patient had tried 2 other medications with little success. Xyrem is well-known to help with daytime sleepiness in narcolepsy without cataplexy.

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

Based on the above, the medical necessity for Xyrem is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Home Health Care

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

The patient is a boy who has been diagnosed with Lennox-Gastaut syndrome (medically intractable epilepsy), expressive and receptive language delay, autism spectrum disorder, insomnia, and thalassemia minor. Records reviewed included a communication evaluation, neuropsychology evaluations, and letters from his pediatrician and child neurologist. Documentation from the health plan including a Uniform Assessment System New York Comprehensive Pediatric 4-7 Assessment Report, and a letter from the patient's mother.

The patient was receiving speech and language therapy 5 times per week. He was working on matching objects/pictures. He was noted to have severely impaired expressive and receptive communication skills, with limited use offing/gesture, verbal output and poor sound imitation skills. He was noted to have slightly low muscle tone in his trunk and legs. He had inconsistent gait length and cadence. The evaluator recommended use of a low-tech non-electronic communication system, and an iPad with app programs for access to voice output.

A letter from the pediatrician described that he was on the ketogenic diet, and required supplemental oxygen and a heart rate monitor for seizures. He had been admitted to intensive care and had required intubation due to status epilepticus. More recent hospital admissions were not documented. The physician recommended supervision 24 hours per day, 7 days per week.

The requested Consumer Directed Personal Assistance Services: 24 hours per day, 7 days per week (Total of 168 Hours per Week) is not medically necessary for this patient. The 98 hours per week of Consumer Directed Personal Assistance Services approved by the health plan appears appropriate given the patient's health needs. He requires limited assistance with walking, locomotion, toilet transfers and bed mobility. He does not require turning at night. But without additional medical issues, this patient does not require 24/7 services. 

Although he requires constant adult supervision for safety, the approved hours of Consumer Directed Personal Assistance Services provided appear adequate for his medical needs. Consumer Directed Personal Assistance Services are not provided for safety supervision.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal 
Treatment: Surgical Services. 
The insurer denied fat grafting into jaw space. 
The denial is overturned in whole.

The patient is a female with history of progressive degenerative joint disease (DJD) in her left mandibular condyle, glenoid fossa, and joint meniscus secondary to an assault injury which occurred 3 years ago. According to the provider note this resulted in chronic pain, joint instability, and difficulty chewing. The patient underwent total joint replacement of the left temporomandibular joint (TMJ). Autologous fat grafting was performed. This was denied by the plan as not being safe and effective, as well as being cosmetic. The subject under review is the medical necessity for the fat grafting.

The fat grafting is medically necessary for this patient to prevent ankylosis. The formation of extensive fibrosis and heterotopic bone has been problematic after total joint reconstruction of the TMJ. The rationale for placing autologous fat grafts is to obliterate the dead space present around the joint prosthesis, thus preventing the formation and subsequent organization of a hematoma. Creating this physical barrier serves to minimize the presence of pluripotent cells and prevents the formation of extensive fibrosis and heterotopic calcifications. Autologous fat grafting is a useful adjunct to prosthetic reconstruction of the TMJ. Graft procurement is quick and easy, with minimal morbidity. The procedure is not cosmetic, and it is safe and effective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (mesenteric panniculitis).
Treatment: Inpatient admission.

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

The patient is a male with a history of atrial fibrillation, antiphospholipid syndrome (APS), COPD (chronic obstructive pulmonary disease), pulmonary embolism with IVC (inferior vena cava) filter, non-ischemic cardiomyopathy with ICD (implantable cardioverter defibrillator) placement and monoclonal gammopathy of undetermined significance who presented to the emergency department (ED) with intermittent abdominal pain and weakness for four days. 

The patient was hemodynamically stable. Vital signs in the ED (emergency department) were as follows: BP (blood pressure) 100/64, Temperature 96.4 F (Fahrenheit), Oxygenation 97% on 4 L (liters) (but later found to be 97% on room air by the examining physician). Pain level was 6/10. CT (computerized tomography) scan of the abdomen revealed scattered mesenteric lymphadenopathy with mesenteric fat stranding, felt to be nonspecific. Outpatient radiographic follow up was recommended by the radiologist. Laboratory evaluations revealed a hemoglobin of 5.8, suspected to be a diluted sample. Stool occult blood was negative. 

The patient was transfused with 0.5 unit packed red blood cells, and repeat hemoglobin mid-transfusion was 9.3. Hemoglobin further increased to 11.2  without any additional blood products. His abdominal pain resolved, and he was treated with oral pain medications (Tylenol, Robaxin and oxycodone), which he takes as an outpatient for chronic musculoskeletal pain. He had no associated gastrointestinal symptoms and was able to tolerate an oral diet. 

The patient was discharged with a diagnosis of mesenteric panniculitis, and outpatient rheumatology follow up was recommended. Appeal is for coverage of inpatient admission.

No, the Inpatient admission was not medically necessary.

This patient was hospitalized for intermittent abdominal pain over four days. He was hemodynamically stable on presentation to the ED. CT scan of his abdomen revealed scattered mesenteric lymphadenopathy with mesenteric fat stranding, felt to be nonspecific. Outpatient radiographic follow up was recommended by the radiologist.  His initial hemoglobin was 5.8, but this was suspected to be a diluted sample. Stool occult blood was negative. He was transfused with 0.5 unit packed red blood cells and repeat hemoglobin mid-transfusion was 9.3, which is much higher than one would expect in the setting of true blood loss. He was able to tolerate an oral diet and oral pain medications, and there were no associated gastrointestinal symptoms. 

In light of the patient's hemodynamic and clinical stability, abdominal CT scan that was unremarkable for an acute issue, and lack of evidence of bleeding, his medical care could have been safely and appropriately managed in a lower level of care setting. Therefore, the Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal/Foot Fracture
Inpatient Hospital

Diagnosis: Foot Fracture
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay. The health plan's determination is upheld. 

The patient is a pleasant healthy male with a history of asthma who initially presented to the emergency department (ED) after an air conditioning unit cover fell onto his left foot and he sustained a left 2nd metatarsal transverse fracture with displacement. He was seen and placed into a bulky Jones dressing and given a surgical boot and told he needed surgery once the swelling subsided. He presented again to the ED with left foot pain. He presented stating his pain was moderate and his swelling had decreased. He denied any lower extremity numbness or tingling. He denied any fever, chills, chest pain, shortness of breath, abdominal pain, nausea, vomiting or diarrhea. His vital signs were within normal limits. The patient was admitted into the hospital for surgery. He underwent surgery (left foot 2nd metatarsal open reduction internal fixation (ORIF)) uneventfully and was discharged home after surgery.
The issue is the medical necessity of the hospitalization of this patient.

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

No. The service/treatment of inpatient stay is not considered medically necessary for this particular situation.
This was a healthy male who had sustained a crush injury and needed a surgery to repair his left 2nd metatarsal fracture. He had no indication why he would need an acute level of care. This type of surgery is generally done in an outpatient setting and there was no documentation indicating why this patient needed urgent surgery or an acute level of care. He was previously seen several weeks before which would have given plenty of time to set up surgery on an outpatient basis. There was no documentation of any criteria why the patient would need an acute level of care.
There was no hemodynamic, pulmonary, neurological or metabolic reason for acute level of care. There was no documentation to support the urgent surgical intervention for the metatarsal fracture. It is standard of care to perform a metatarsal ORIF as an outpatient basis. There is no indication or documentation on why this particular patient would have required an acute level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Facet Neurotomy
The insurer denied the Facet Neurotomy.
The denial is overturned. 

The patient is a female with chronic low back pain. She underwent a radiofrequency ablation (RFA) at L3-4 (third lumbar spine vertebra - fourth lumbar spine vertebra), L4-5 (fourth lumbar spine vertebra - fifth lumbar spine vertebra), L5-S1 (fifth lumbar spine vertebra - first sacral vertebra) with 90% improvement in pain, with a subsequent return of symptoms. The request is to repeat the RFA. 

Yes, the Facet Neurotomy (64635 x 2, 64636 x 4) is medically necessary.

The patient has done PT (physical therapy), and she is currently continuing with home exercise. She has tried various medications and chiropractic care. She has no previous lumbar fusion. X-rays show spondylitic changes. She had 90% relief for over six months. The alternative options are considerably more invasive, such as spinal fusion, which has shown to have less than 50% success in axial low back pain without instability and should be avoided given her young age. Chronic opiates are not without risk and are typically not recommended for this condition and age group. 

Given the lack of viable alternatives, the failure of conservative treatment, and the presence of success of over six months to a previous procedure, the requested RFA is medically necessary and is consistent with ASIPP (American Society of Interventional Pain Physicians) procedural guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pseudobullar Affect
Treatment: Nuedexta
The insurer denied the Nuedexta.
The denial is upheld.

The patient is a male with a diagnosis of pseudobulbar affect (PBA), seizures, oligodendroglioma, status post resection. His provider is requesting continuation of Nuedexta.  

No, the treatment with Nuedexta is not medically necessary.

There are no high quality clinical trials demonstrating the efficacy of Nuedexta for persons with brain tumor or focal resection of intracranial mass lesions, as is the case here. The contention by the attending physician (AP) that tumor resection is a traumatic brain injury (TBI) is not consistent with the well-defined pathophysiology of traumatic brain injury (TBI), nor is there any evidence to support that extrapolating data from traumatic brain injury (TBI) to craniotomy and focal tumor resection is valid. Moreover, there is no objective measure of improvement with treatment noted on review of the medical records. The documentation of "Mood is bright and Nuedexta has been very helpful for his pseudobulbar affect" is not an objective measure of efficacy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I normal molar occlusion, severe maxillary crowding, and impacted maxillary canines with anterior crossbite. 

Treatment: Braces and Periodic Orthodontic Treatment Visits. 

The insurer denied the Braces and Periodic Orthodontic Treatment Visits. The denial is overturned. 

The patient is a female.  The request is for dental benefits for orthodontic treatment and monthly visits.  Clinical exam summary reveals a class I normal molar occlusion, severe maxillary crowding, and impacted maxillary canines with anterior crossbite. 

Yes, the proposed treatment with braces and periodic orthodontic treatment visits is medically necessary. 

The patient's x-rays and photos reveal the presence of bilateral impacted maxillary canines. The patient's maxillary arch does not have adequate space for natural eruption of these teeth due to the position of the adjacent teeth. In this clinical situation, surgical exposure and orthodontic treatment is indicated for correction and management. 

No, the health plan did not act in the best interest of the patient and with sound medical judgement because untreated impacted canines can cause damage to the adjacent teeth and cause their eventual loss. Additionally, proper alignment and position of this tooth in the mouth is essential for chewing, functional guidance, and aesthetics.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Failure.
Treatment: Inpatient admission.

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

The patient is a male with history of decompensated heart failure and general debility. He remained clinically stable with treatment.

Prior to admission, the patient lived alone in an apartment.

The patient required supervision for transfers, upper/lower body dressing/bath, use of motorized wheelchair, modified independence for showers, supervision in use of durable medical equipment (DME), and in simple instrumental activities of daily living (IADLs). The plan was to discharge the patient to his apartment with support from others.

No, the proposed continued acute inpatient rehabilitation was not medically necessary because the patient did not meet all the criteria for acute rehabilitation care INTERQUAL Criteria 2020 for Acute Rehabilitation in a patient with General Debility due to decompensated heart failure but now clinically stable. The patient required supervision for transfers, upper/lower body dressing/bath, use of motorized wheelchair, modified independence for showers, supervision in use of durable medical equipment (DME), and in simple instrumental activities of daily living (IADLs). The plan was to discharge him to his apartment with support from others.  The patient was independent in most activities which should have enabled him to return home and continue with health care at a lower level of care.  The patient did not meet the criteria for more intensive acute inpatient rehabilitation.

Yes, the health plan has acted reasonably in this instance and its decision had sound medical judgment which was in the best interest of the patient based on the above rationale because the patient required supervision for transfers, upper/lower body dressing/bath, use of motorized wheel-chair, modified independence for showers, supervision in use of durable medical equipment (DME), and in simple instrumental activities of daily living (IADLs). The plan was to discharge him to his apartment with support from others. The patient was independent in most activities which should have enabled him to return home and continue with health care at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Treatment (Malocclusion)
Treatment: Braces and Monthly Visits x12
The health plan denied the requested dental treatment. 
The health plan's determination is overturned.

The patient is a male. He has a Class II malocclusion with protrusive maxillary incisors. He has maxillary spacing and minor mandibular crowding. He is in treatment planned for 24 months of orthodontics to correct this malocclusion, but his insurance company rejected the claim on the basis that treatment is not medically necessary. The provider is appealing due to the fact of the patient's severe overjet.
At issue is the medical necessity of the requested dental treatment plan.

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

There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. [1] Teeth #8 and #9 are protruding forward within the dental arch. This makes them more prone to 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 6mm. Overjets of this magnitude are shown to negatively affect the oral health quality of life. [2] For these reasons, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic/Musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: osteoarthritis
Treatment: Personal Care Worker (PCW) Service 
The insurer denied Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day. The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, hypothyroidism, osteoarthritis, urinary incontinence, chronic kidney disease, and chronic constipation who had been assigned 4 hours of PCA (personal care assistant) services per day, 7 days/week. There was a request to increase PCA service hours and the patient had an assessment tool performed telephonically and was assessed at maximal assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while extensive assistance with tasks of managing medication, phone use, stairs, transportation, equipment management, bathing, dressing lower body, transfer toilet and toilet use. The patient was assessed at limited assistance with tasks of personal hygiene, dressing upper body, walking, locomotion, bed mobility, and eating.

The Personal Care Worker (PCW) Service Increase to 7 Days per Week, 8 Hours per Day is medically necessary for this patient. 
The patient's previous informal caregiver moved out of state leaving the patient with no informal caregiver, although the insurer incorrectly assumed the patient continued to have informal caregiver. The patient has activities of daily living (ADL) and Instrumental activities of daily living (IADL) care needs outside of the PCA service hours currently provided, specifically with needed help with meal preparation, eating, dressing, toileting, toilet transfer, walking, and locomotion. The assessment tool performed over the phone also underestimated the patient's ADL and IADL assistance needs for tasks of meal preparation, personal hygiene, dressing upper/lower body, walking, locomotion, toileting, transfer toilet, and eating. The PCA service hours are not solely for safety and supervision but to assist the patient with successful completion of ADL and IADL tasks. 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. The requested PCA services 8 hours/day, 7 days/week are medically necessary for this patient.