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

Diagnosis:  Acute asthma exacerbation.
Treatment:  Inpatient admission.

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

This is a child with a history of autism and asthma. The patient presented to the emergency room (ER) with complaints of congestion and a cough. In the ER, the patient was given prednisolone, duo-nebulizers, magnesium sulfate, and dexamethasone. The patient was admitted to the Pediatric Intensive Care Unit (PICU) with an acute asthma exacerbation. The patient was given continuous albuterol, Atrovent, methylprednisolone, and intravenous (IV) fluid. Oxygen supplementation was provided. 

The patient had severe status asthmaticus. This was evident from the fact that patient had increased work of breathing (WOB) in spite of multiple bronchodilators and the response to first line therapies was slow. Once the patient is needing frequent DuoNebs, steroids, and Magnesium Sulfate; the patient needs escalation of therapy. That is entirely a clinical decision and needs no lab or imaging work up. Also, there are data that show poor correlation with clinical severity and lab values. Once there is continuous albuterol, that is a prelude to possible mechanical ventilation. The continuous albuterol can contribute to hypotension and severe electrolyte abnormalities and needs to be monitored in intensive care unit (ICU) setting. The patient was at risk for respiratory failure and mechanical ventilation. The patient needed continuous albuterol and also magnesium sulfate. The patient rapidly improved with escalation of therapy, every two-hour nebulizers, second dose steroids, and continued respiratory support with oxygen. As hypoxia is the most common cause for pediatric cardiac arrests this patient was appropriately managed in the PICU with adequate and appropriate respiratory support and intense bronchodilators. Also, autistic children are prone to severe presentation of status asthmaticus and near fatal asthma. The patient also has moderate persistent asthma, and patients with moderate persistent asthma tend to have significantly higher morbidity than patients with mild persistent asthma. Due to the above factors, this patient with severe acute status asthmaticus needed inpatient level care. 

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

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

Diagnosis: Heart failure, obesity, back pain, and diabetes.
Treatment: Increase Personal Care Assistance Service to 32 
Hours per Week
The insurer denied: Increase Personal Care Assistance Service to 32 Hours per Week
The denial is upheld.

This adult male patient has conditions including heart failure, obesity, back pain, and diabetes. He is status post hernia repair seven months ago. The patient complains of pain. He is appealing denial of increase personal care assistance (PCA) service to 32 hours per week. The health plan approved personal care assistance services, a total of 25 hours per week. 
Uniform Assessment System (UAS) evaluation completed 5 months ago shows independent cognition and functional status: maximal assistance with meal preparation, housework, shopping, and transportation; extensive assistance with bathing lower body dressing; limited assistance with managing medications, personal hygiene, upper body dressing, walking, locomotion, toileting; and independent with bed mobility and eating. He is continent of bowel and bladder. The surgical site is healing. An appeal statement from the patient's doctor notes the patient has multiple problems and needs 24 hour per day, spit shift care for assistance with activities of daily living (ADLs).

The proposed treatment is not medically necessary.

Personal assistance services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions and is status post hernia repair seven months ago. He is appealing denial of increase personal care assistance (PCA) service to 32 hours per week. The health plan approved personal care assistance services, a total of 25 hours per week. Uniform Assessment System (UAS) evaluation completed five months ago shows the patient needs assistance with activities of daily living (ADLs), except bed mobility and eating. He is continent of bowel and bladder. The appeal statement recommends 24 hour per day, split shift care due to multiple medical conditions and need for assistance with activities of daily living. The information does not support the medical necessity for the proposed increase in personal care assistance services to 32 hours per week. The information does not support that the patient has continuous needs as noted in the provider letter or that the patient needs assistance with activities of daily living that cannot be met with the approved personal care assistance hours. 
The patient does not need continuous turning, repositioning, or toileting. The patient's needs can be met with the approved 25 hours per week. The approved personal care assistance of 25 hours per week is appropriate to meet this patient's needs for assistance with activities of daily living.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis and depression.

Treatment: Home health care (HHC)/ personal care - level 2 personal care services, per 15 minutes increase to 42 hours per week.

The insurer denied coverage for HHC/ personal care - level 2 personal care services, per 15 minutes increase to 42 hours per week.

The denial is upheld.

This patient is an adult with osteoarthritis and depression. She lives with her daughter and granddaughter. She is approved for personal care services (PCS) 22 hours/week and is requesting 42 hours/week. 

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is "Modified independence." She requires extensive assistance for bathing and lower body dressing. However, only limited assistance is needed for upper body dressing and toilet use. Supervision is needed for ambulation (uses a cane), locomotion and toilet transfer. She is continent of bowel and bladder. The patient is also independent with bed mobility and eating. There has had no significant change in her activities of daily living (ADL) status or self-sufficiency over the prior 90 days. Her condition and functional needs are not at a level or unpredictable as to require the requested 42 PCS hours/week. Based on the enclosed documents reviewed, the patient's health and safety is appropriately provided and maintained by the currently approved PCS, 22 hours/week.  

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. All decisions are evidence-based.  

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

The insurer's denial of coverage for the home care/personal care HHC(home health care) - level 2 personal care services, per 15 minutes increase to 42 hours per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Foot cellulitis 
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient is an adult with a past medical history significant for diabetes mellitus, hypertension, gastroesophageal reflux disease, hyperlipidemia, chronic obstructive pulmonary disease, and alcohol use who presented to the emergency room with complaints of redness and swelling of the left foot. 

Vitals on presentation included: Temperature 97.2 degrees Fahrenheit (F), Blood Pressure 147/69, Pulse 87, Respiratory Rate 16, oxygen (O2) saturation 96% on Room Air. Laboratory results included the following: White Blood Cell (WBC) count 9.2, Hemoglobin (Hgb)-10.1, Hematocrit (Hct)-29.0, creatinine-0.60, lactic acid-1.5.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and ceftriaxone) for left foot cellulitis. Ultrasound of the left lower extremity was negative for deep vein thrombosis (DVT). Blood cultures were negative. The patient remained afebrile and hemodynamically stable. He was discharged to continue oral antibiotics (Bactrim) as an outpatient.    

According to documentation, the patient presented to the emergency department with left foot infection. Otherwise, the patient was afebrile, hemodynamically stable with a normal WBC and lactic acid. Ultrasound was negative for DVT. Patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management.  

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Short stature
treatment: Genotropin
The insurer denied Genotropin.
The health plan's determination is overturned. 

This is a male diagnosed with SGA (small for gestational age) and idiopathic short stature (ISS). Genotropin is under review. 

Genotropin is medically necessary for this patient. Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines. FDA (Food and Drug Administration approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

This patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity and bone age would not allow the patient to reach a normal adult height. The request therefore meets idiopathic short stature criteria. The use of Genotropin for this patient is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Other/decrease production of thyroid hormones
Treatment: Levothyroxine 175 micrograms (mcg) capsule.
The health plan denied the requested medication, Levothyroxine 175 mcg capsule as not medically necessary. 
The health plan's determination is upheld.

This is a male diagnosed with hypothyroidism. This request is for Levothyroxine. As reported, he has been on Levothyroxine. He was taking Tirosint in the past and was symptomatically and biochemically euthyroid. Switching to Levothyroxine generic formulation made him feel tired with low energy level. His thyroid stimulating hormone (TSH) was 14.49; Free Thyroxine (FT4) was 0.95.
At issue is whether the formulary drug (Levothyroxine tablet, Levoxyl, Synthroid, Unithyroid, Euthyrox) will be or has been ineffective, would not be as effective as the non-formulary drug (Levothyroxine capsule), or would have adverse effects.

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

The patient is reported to have failed the generic Levothyroxine. There is no documentation of trial and failure of any of the other formulary alternatives. The other formulary alternatives are expected to be as effective as the requested nonformulary drug. The other formulary alternatives are not expected to have adverse effects.
Tirosint is a brand name of Levothyroxine. Levothyroxine capsules are a generic formulation for Tirosint. The patient is reported to have hypothyroidism. Tirosint is Food and Drug Administration (FDA) approved for the treatment of hypothyroidism.[1] As with other forms of Levothyroxine it is effective in the treatment of hypothyroidism. [2, 3] There are no studies showing superiority of Tirosint over Levothyroxine tablets. The patient as reported to have failed generic Levothyroxine tablets. There is no documentation of failure of other formulations such as Synthroid Levoxyl. The request is not consistent with generally accepted standards of medical practice. My recommendation is to uphold the plan's determination.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Mental Health/Other/Confusion and an inability to concentrate on simple tasks
Treatment: Inpatient Stay
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is overturned, in part.

At the time of her admission, the patient was a female with a past history of sexual abuse and post-traumatic stress disorder, brought to the emergency department (ED) by her mother for a psychiatric evaluation. The ED note documents the mother saying her daughter has been acting differently, confused, and slow," and that she has a therapist and has been prescribed Sertraline, but mom is not sure if she has been taking it. The patient denied drug use and stated she wanted to 'live her life." The vital signs and physical exam were normal; the mental status exam documented that she answered questions inappropriately after significant pause and appeared confused. A complete blood count (CBC), metabolic panel, liver panel, urinalysis (UA), pregnancy test, viral respiratory swabs, electrocardiogram (EKG), and toxicology screen were all negative or normal. The ED documents she was "medically cleared for psychiatric treatment." She was admitted to the pediatric floor for further workup of organic causes of her altered mental status. The assessment on the admission history and physical was that the presenting problem was "likely due to extensive psychiatric history as patient now is acting more like herself at bedside according to her mother. Physical exam (PE) and labs unremarkable. Will proceed with electroencephalogram (EEG) though as recommended by neurology and follow up on psychiatric recommendations to determine disposition." Psychiatry saw her on the day of admission and determined that "delirium or other abnormal brain activity (e.g., seizures)" that could cause fluctuating attention and mentation could not be ruled out. She was not on a psychiatric hold for danger to self or others. She had a normal magnetic resonance imaging (MRI) and a normal EEG and was discharged.
At issue is the medical necessity for the inpatient stay.

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

Yes. One hospital day to complete the workup for an organic cause of her altered mental status was medically necessary, given the presenting history of deterioration from her baseline psychiatric problems. That included the metabolic and toxicologic workup that had been completed in the emergency department, the MRI, the EEG, and neurologic and psychiatric consultations. Given that she was already improved and "acting more like herself" upon admission from the emergency department and did not have any worsening in the first hospital day, one hospital day should have been sufficient to complete the workup.
The extended medical stay beyond one hospital day was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ventral hernia.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is overturned.

According to the documentation submitted, this was a child with a history of giant omphalocele treated with non operative dressing changes who subsequently developed a small bowel obstruction (SBO) requiring two exploratory laparotomies for lysis of adhesions and ultimate Strattice mesh placement over 6 years ago. The patient presented with a large ventral hernia for repair recently.

The patient was taken to the operating room and operative note indicated a ventral hernia from history of giant omphalocele with procedure being done exploratory laparotomy with lysis of adhesions (LOA), component separation, ventral hernia repair and ultrasound guided transversus abdominis plane (TAP) anesthetic blocks with placement of bilateral subcutaneous drains. Postop the patient was kept on patient-controlled analgesia (PCA). The operative note indicated the large ventral hernia contained liver which was adherent to the hernia.

Post operative check indicated the pain was well controlled on multimodal analgesia. The patient was on a clear liquid diet and denied nausea or vomiting. The patient had not passed gas yet. The abdomen was soft and non-distended. The right and left Jackson - Pratt (JP) drained 15 and 10 cubic centimeters (cc) serosanguinous, respectively.

Progress notes indicated the pain was well controlled. He used Morphine PCA 39 times and attempted 46 times since a few days prior in the evening. Overnight he used it twice. He was tolerating a regular diet and ambulating. Vital signs were stable. The plan was for discharge today with drains in place.

Based upon the records provided the patient did require inpatient admission as the patient could not have been cared for based upon an observation/ambulatory admission as his surgery was extensive given the prior two surgeries with adhesions noted and the need for repair of a large ventral hernia with component separation. He also had a significant amount of pain postoperatively requiring PCA numerous times and thus an extended stay.

Given the above, the patient did warrant inpatient status as he could not have been managed in an ambulatory setting/observation setting given the complex surgery with LOA in a patient who had two prior exploratory laparotomies and LOA. He required at this time to have component separation as well to allow for primary repair of the large ventral hernia. He required a considerable amount of PCA post op for pain control. In this case he met criteria for ambulatory surgery exception criteria and for the need to be placed in an inpatient status.

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion 
Treatment: D8080 braces and D8670 monthly visit
The insurer denied coverage for D8080 braces and D8670 monthly visit
The denial is upheld

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to impacted permanent anterior teeth among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated. 

Upon review of the submitted documentation, 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, New York State requires the use of an orthodontic index, the HLD index. This index provides six specific condition 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 impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is not met and does not support comprehensive orthodontic care using this criterion. This reviewer concurs with the findings of the insurer of attaining 12 points on the HLD index (4 points overjet, 6 points overbite, 2 points labiolingual spread). 

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. 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 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 D8080 braces and D8670 monthly visit is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, osteoarthritis, dementia and visual impairment
Treatment: Increase in consumer directed personal assistance services (CDPAS) from 35 hours per week to 45 hours per week.
The insurer denied coverage for increase in CDPAS from 35 hours per week to 45 hours per week.

The denial is overturned.

This is an elderly patient with hypertension, osteoarthritis, dementia and who is visually impaired. She lives alone. She is currently approved by the insurer for CDPAS 35 hours/week and is requesting an increase of CDPAS to 45 hours/week, 7 days/week.

According to the most recent Uniform Assessment System (UAS) report, the patient's cognition is described as "minimally impaired." She is also "confused and forgetful." The patient requires maximal assistance for bathing and lower body dressing. Extensive assistance is needed for personal hygiene and upper body dressing. Limited assistance is needed for eating, locomotion, ambulation (with a cane) and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. The patient is independent with bed mobility. The combination of the patient cognitive deficits and functional impairments support the medical necessity of increasing CDPAS to 45 hours/week.  Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing CDPAS to 45 hours/week. 

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, the requested increase in CDPAS to 45 hours/week is medically necessary.  

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

The insurer's denial of coverage for the increase in consumer directed personal assistance services from 35 hours per week to 45 hours per week is overturned. Medical necessity is substantiated.