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

Diagnosis: Chronic cellulitis
Treatment: Personal Care Aide (PCA): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (Split-Shift) - for a total of 168 hours per week.
The insurer denied the Personal Care Aide (PCA): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (Split-Shift) - for a total of 168 hours per week.
The health plan's determination is overturned.

This is a patient with a past medical history of osteoarthritis, hypothyroidism, urinary incontinence, and hypertension who had been assigned personal care assistant (PCA) services 5 hours/day, 6 days/week, to total 30 hours/week. The patient was hospitalized with sepsis and pneumonia and was discharged to home with peripherally inserted central catheter (PICC) line and intravenous (IV) antibiotics.

There was a request to increase PCA services, the patient underwent a video assessment and notes from the assessment stated the patient had wound care regularly with an ulcer on the right leg. 

The insurer sent an initial adverse determination denial notice denying the request to increase PCA services. The insurer sent a final adverse determination denial notice continuing to deny the request to increase PCA services also stating granting additional hours when tasks are not being performed and for safety monitoring and supervision are not medically necessary.

An overnight care log was provided documenting overnight care needs at least every 2-1/2 hours. The patient's medical provider sent a letter stating the patient's medical diagnoses including chronic cellulitis, hypertension, urinary incontinence, and being prone to pressure injuries.

At issue is the medical necessity of Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total of 168 Hours per Week.

The services are medically necessary. There is documentation from the patient's medical provider and healthcare advocate of the medical necessity of increased PCA services. There is documentation that the patient requires repositioning every 2 hours. There is also documentation from overnight care logs of activities of daily living (ADL) assistance needs at least every 2-1/2 hours which would not allow a PCA 5 hours of uninterrupted sleep. The patient requires assistance with walking, locomotion, transfer toilet, and toilet use all of which are unscheduled and unpredictable care needs that span a continuum of time and the insurer did not document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Missing Teeth

Treatment: Dental/Orthodontic Procedure/
D5214 partial lower denture, lower part of your mouth, D2750 white glass with high gold content crown, Tooth 31, D2750 white glass with high gold content crown, Tooth 30, D5213 partial upper denture.

The health plan denied the requested Dental/Orthodontic Procedure/
D5214 partial lower denture, lower part of your mouth, D2750 white glass with high gold content crown, Tooth 31, D2750 white glass with high gold content crown, Tooth 30, D5213 partial upper denture as not medically necessary. 

The health plan's determination is overturned. 

The patient is a male who presented to the office for evaluation and treatment of teeth #30 and 31, as well as maxillary and mandibular edentulous areas. Provided for review are previous letters of appeal and denial, a narrative by the patient, radiographic images showing missing and fractured/decayed teeth in both arches, explanation of benefits, call log from the insurance representative, a single American Dental Association claim form, and health plan language.
In question is the medical necessity for the requested health service/treatment of D5214 partial lower denture, lower part of your mouth, D2750 white glass with high gold content crown, tooth 31, D2750 white glass with high gold content crown, tooth 30, D5213 partial upper denture.

I overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of D5214 partial lower denture, lower part of your mouth, D2750 white glass with high gold content crown, tooth 31, D2750 white glass with high gold content crown, tooth 30, D5213 partial upper denture is medically necessary for this patient.
From the documentation the crowns on #30 and 31 have been approved, but not the maxillary and mandibular partial denture. Previous denials have been on the basis that the patient must have less than eight back teeth, four upper and four lower teeth in the posterior in order to qualify for a mandibular partial denture. This is not a scientific nor medically based rationale and is not supported as a reason for denial. Currently, the patient has the diagnosis of partial edentulism, and the treatment of partial denture can and will address the diagnosis. The only other option would be to place dental implants to replace the teeth. The number of missing teeth does not determine if replacement is necessary. Hence, the entire treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overjet; skeletal class II malocclusion; crowding
Treatment: D8080 Braces, D8670 Monthly Visits (12), and 
D8680 Retainer
The insurer denied: D8080 Braces, D8670 Monthly Visits (12), and D8680 Retainer
The denial is overturned

The patient is a teenage male requesting orthodontic benefits (including monthly visits and retainer). He has a severe overjet of over nine millimeters. He also has a skeletal class II malocclusion, moderate upper crowding, severe lower crowding and lip incompetence. The prior denial was due to a handicapping index score of 20.

The proposed treatment (D8080 Braces, D8670 Monthly Visits (12), and D8680 Retainer) is medically necessary.

A severe overjet of more than nine millimeters is an automatic qualifier for orthodontic benefits. This patient has medical necessity due to the severe (greater than nine millimeters) overjet. Orthodontic treatment (with monthly visits and retainer) is needed to correct this problem. Monthly visits are needed to follow the treatment progress and to make treatment alterations as needed. The retainer is needed at the end of the treatment to help keep the teeth in their new positions, and to prevent relapse.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This patient is a previously healthy adolescent female who presented to the emergency department with the complaint of abdominal pain of two-days duration. Examination revealed abdominal tenderness. The patient's vital signs identified a normal temperature and normal vital signs at the time of presentation. The white blood cell (WBC) count was elevated at 14 thousand. Surgical consultation was obtained with tenderness noted in the right lower quadrant. Abdominal ultrasound was completed showing findings consistent with acute appendicitis.

The patient was admitted to the hospital and was started on intravenous antibiotics. On the following day, the patient underwent laparoscopic appendectomy. She was monitored following surgery and remained stable. She was discharged from the hospital following the initial surgical recovery with instructions for surgical follow. The health plan rationale for denial is that there is no documentation of need for an inpatient level of care and the care rendered could have been provided without admission to the hospital. The hospital appeal letter references InterQual criteria regarding urgency of procedure.

The proposed treatment was not medically necessary.

Inpatient care was not medically necessary. The Plan's reason for denial is that the patient had a procedure with no complications that would require inpatient admission. Specifically, the patient did not need inpatient care prior to surgery. There was not a complex surgical approach or situation anticipated. The patient was not at high risk for adverse perioperative event. There was not a drug related risk, abnormal heart condition or breathing status. Vital signs were normal. There were not complications of surgery, and the operation was not extensive or prolonged. This rationale is supported by the submitted medical records. Inpatient care for this patient was not medically necessary based on the standard of care. 

Inpatient care was not medically necessary. This patient presented to the emergency department and was evaluated with physical exam, labs and imaging that supported the diagnosis of acute appendicitis. She was treated initially with nothing by mouth status, intravenous fluid and intravenous antibiotics. The patient underwent laparoscopic appendectomy. Her clinical course was without adverse incident. The patient responded favorably to this treatment and the hospitalization was uncomplicated. The patient had no comorbid health conditions that mandated an inpatient level of care, and the vital signs were consistently normal. The medical records document clinical stability without complication during this period of monitoring. The submitted clinical documentation does not support the need for inpatient admission for this patient. A lower level of care would have satisfactorily provided for the care provided and would have been consistent with the accepted standard of medical care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/Dental Issues
Treatment: Dental/Orthodontic Procedure
The health plan denied the requested custom abutment for teeth 13, 18, 19, 2, 24, 30, 4, 7 and 8, abutment supported porcelain fused to metal crown (noble metal) for teeth 13, 18, 19, 2, 24, 30, 4, 7 and 8, and false tooth bridge for tooth 20 as not medically necessary.

The patient is a male who presented to the office for evaluation and treatment of teeth #2, 4, 7, 8, 13, 18, 19, 24, 30. Provided for review are previous letters of denial, multiple radiographic images from during therapy, one page of American Dental Association (ADA) claim forms, clearance letters from the primary care physician, clinical notes from oral surgery department for implant placement, as well as lab values.
In question is the medical necessity of the requested health service/treatment custom abutment for teeth 13, 18, 19, 2, 24, 30, 4, 7 and 8, abutment supported porcelain fused to metal crown (noble metal) for teeth 13, 18, 19, 2, 24, 30, 4, 7 and 8, and a false tooth bridge for tooth 20.

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

The restorations were not approved because the implants themselves were not approved per the requirements of New York State Medicaid requirements. However, the implants were medically necessary, based on the diagnosis of partial edentulism as well as diminished posterior support which can only be treated with dental implants. As the dental implants were medically necessary, then so too were the restorations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hyperglycemia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult male with hypertension, hyperlipidemia, and history of pre-diabetes who presented for evaluation of hyperglycemia with symptoms of polyuria, weight loss, blurred vision, and dry mouth for a month. His glucose was 723 milligrams per deciliter (mg/dL), sodium was 129, carbon dioxide (CO2) was 25, and glycated hemoglobin (A1C) was 14.3% at an outpatient clinic and the patient was referred to the emergency department. 

The patient's temperature was 99.1, heart rate was 96, respiratory rate was 18, blood pressure was 151/112, and oxygen (O2) was 96 percent. He was alert on exam. He was treated with subcutaneous insulin and intravenous fluids. The patient received diabetes education. He was discharged on Lantus, Lispro, and Januvia. Inpatient stay is the topic of this review.

The proposed inpatient stay was not medically necessary.

This patient presented with hyperglycemia and dehydration consistent with a new diagnosis of type II in the setting of known pre-diabetes. The patient had mild tachycardia that resolved with hydration. The patient had modestly elevated blood pressure without cardiac ischemia or other signs of a hypertensive emergency. Overall, the patient was hemodynamically stable. He did not have evidence of sepsis or infection. He was hyperglycemic but without acidosis to support a diagnosis of diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar state. His glucose improved with hydration and insulin therapy. Therefore, no, the requested inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case involves a man with a history of asthma, a history of deep vein thrombosis (DVT), treated with Eliquis and completed therapy, and presented to the emergency department with worsening dyspnea. The patient reported being on a cross-country flight the previous week and, upon arrival, began experiencing exertional dyspnea, epigastric chest tightness, and pressure, similar to prior asthma exacerbation symptoms. The patient also reported a mild cough. He obtained no relief with his home inhaler medications and even took 20 milligrams (mg) of prednisone, which he has chronically at home, with no relief. The patient denies any leg swelling or pain. On arrival in the ED, he was noted to have ambulatory O2 (oxygen) sats (saturation) of 88%. The vital signs included a normal temperature, heart rate, and blood pressure. On exam, the patient had minimal airflow to the bilateral lungs, with a normal cardiac exam.

The inpatient hospital services are not medically necessary. This is a patient with known asthma history, on chronic inhalers at home, who presented to the hospital with shortness of breath and was found to have an exacerbation of underlying asthma. The patient was mildly hypoxemic on arrival; however, 24 hours into the hospital stay, ambulatory oxygen saturation was 96%, as documented in the progress notes. The patient was transitioned from intravenous corticosteroids to oral prednisone with a plan to continue treatment as per the tapering dose. Therefore, the severity of the illness is deemed mild, with clear empirical improvement in the disease process. Inpatient criteria are not satisfied.
From a DVT standpoint, the medical literature is clear that outpatient treatment is indicated for acute DVT without hemodynamic instability or threatened limb syndrome. With the advent of direct oral anticoagulants, there is no need for inpatient medical treatment, bridging therapy, or any significant monitoring. Therefore, there were no barriers to outpatient treatment for this condition.
In conclusion, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: heart failure.
Treatment: home health care.
The insurer denied Personal Care Assistance Services: 35 Hours per Week. 
The health plan's determination is upheld. 

The patient is a female with medical history notable for heart failure, incontinence, gout, chronic pain, and gait difficulty.  A Uniform Assessment System (UAS) was completed and available for review. The patient was alert and self-directing. Forgetfulness was noted, but she knows her medications and when to take them. From a functional standpoint, the patient requires maximal assistance for meal preparation, housework, and shopping. She requires limited assistance for finances and medications. For her activities of daily living (ADL), she requires extensive assistance for bathing and dressing lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility and eating. She is frequently incontinent of urine and uses pull-ups which are changed 4-5 times per day. 

The requested Personal Care Assistance Services: 35 Hours per Week are not medically necessary for this patient.
The patient's personal care needs are mostly centered around Instrumental activities of daily living (IADL). She has PCA hours which should be sufficient to cover these. She also has time allotted for bathing and dressing. Other activities of daily living (ADL) require limited assistance or less. She appears to have informal support from her husband. There was no documentation provided regarding unmet personal care needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I Malocclusion
Treatment: Braces and Adjustments of Braces
The insurer denied: Braces and Adjustments of Braces
The denial is: Overturned.

The patient is a female with moderate crowding. She presents with a skeletal Class I malocclusion. Tooth #6 is in anterior crossbite with #27 and is pushing tooth 27 to the labial. She is treatment planned for orthodontics to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity.

This patient presents with an anterior crossbite on tooth 6, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.1,2,3
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and complicated to correct than the patient's existing orthodontic problem. If left untreated tooth 6 will keep pushing tooth 27 to the labial so that tooth 27 will develop periodontal recession. Braces and adjustment of braces is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Narcolepsy.
Treatment: Xywav.

The insurer denied Xywav.  The denial is overturned.

The patient is a male, who suffers from daytime sleepiness. The patient was diagnosed with Narcolepsy. The Multiple Sleep Latency Test (MSLT) showed reduced mean sleep onset latency down to 12 minutes and 2 sleep onset rapid eye movement (REM). The provider is requesting the coverage of Xywav. The patient tried and failed armodafinil, Adderall, Wakix, and Sunosi. The patient was also diagnosed with sleep apnea and has been on continuous positive airway pressure (CPAP). The subject under review is the medical necessity for Xywav.

The requested treatment of Xywav is medically necessary for this patient. Narcolepsy is a chronic neurological disorder caused by the brain's inability to regulate sleep-wake cycles normally. At various times throughout the day, people with narcolepsy experience fleeting urges to sleep. If the urge becomes overwhelming, individuals will fall asleep for periods lasting from a few seconds to several minutes. In addition to excessive daytime sleepiness (EDS), three other major symptoms frequently characterize narcolepsy: cataplexy or the sudden loss of voluntary muscle tone; vivid hallucinations during sleep onset or upon awakening; and brief episodes of total paralysis at the beginning or end of sleep. Without Xywav the patient has severe daytime sleepiness. He will be dysfunctional and unable to perform activities of daily living. Because of the effect of sleepiness, he will be unable to concentrate and execute the requirement of his job adequately. He will be at risk driving with possibility of having a motor vehicle accident because of the overwhelming sleepiness caused by the possible Narcolepsy. The Xywav has proven to be effective in alleviating the daytime hypersomnolence seen in narcolepsy. The Xywav is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara SQ (subcutaneous) 90mg (milligrams) every 4 weeks
The insurer denied Stelara SQ 90mg every 4 weeks.
The health plan's determination is overturned.

The patient is a female with Crohn's disease status post ileocecectomy. She has failed azathioprine, Humira, and Remicade. She started Stelara with improvement. However, she presented with lower abdominal pain and loose bowel movements prior to Stelara injections; the dose was increased to 90 milligrams (mg) every 6 weeks. A Colonoscopy showed active disease. The Stelara dose was then increased to 90 mg every 4 weeks, with improvement. 

The current medical literature supports continued dose escalation of Stelara to 90 mg every 4 weeks as medically necessary for the treatment of Crohn's disease in this patient's case. In this case, the patient has had disease symptoms and colonoscopy showing inflammation with ulcers while taking Stelara every 4 weeks. The American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should...have their medication dose adjusted in order to attempt to optimize therapy" (Battat, et al; Lichtenstein, et al). Decrease of the current Stelara dose or discontinuation of Stelara (even if an alternative is attempted immediately) may result in loss of disease control, with complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, the request for Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is an adult with a history of osteoarthritis, chronic obstructive pulmonary disease (COPD), Obesity, Body Mass Index (BMI) of 36 and schizoaffective disorder. The patient presented to the emergency department (ED) after a fall. The patient complained of some knee pain and had a scalp hematoma. She was afebrile and hemodynamically stable. Oxygen saturations were normal. The physical exam was unremarkable other than right knee pain. The pain was 10/10 and there was difficulty ambulating.

The sodium (Na+) was 132 and the potassium (K+) was 3.1. A computed tomography (CT) of the head revealed scalp hematoma but no fracture. An x-ray of the knee revealed some effusion and she was seen by an Orthopedic Surgery consultant. No acute intervention was recommended. No drainage was needed. She was treated with intravenous (IV) Toradol for pain. The patient was seen by Physical Therapy (PT) and was recommended for short term rehabilitation. She remained stable after admission, was treated with pain meds, and was discharged home after a few days.

This patient did not need acute hospitalization. She could have been placed in Observation status while diagnostic testing and treatment were initiated. The patient remained stable after admission. She could have had fluids and the K+ could have been replaced while in observation for treatment of her mild hyponatremia and hypokalemia. She could have been switched to oral pain medicines after a few doses. She could have received short term rehabilitation as recommended by PT.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for an inpatient hospital admission is not substantiated.