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

Pulmonary Fibrosis
Home Health Care

The patient has a past medical history of oxygen dependent chronic pulmonary sarcoidosis, severe pulmonary fibrosis, pulmonary hypertension, chronic bronchiectasis and chronic renal insufficiency. The patient was hospitalized with respiratory failure. The patient first applied for personal care assistance services, 4 hours per day were approved. The patient continued to follow up with pulmonary medicine with progressive worsening of his underlying pulmonary sarcoidosis. Patient was seeing pulmonary medicine on a monthly basis. The patient continued with clinical decline and was evaluated by lung transplant specialists and remained on oxygen 24 hours a day. Patient  was hospitalized 2 more times with respiratory distress. A letter was written by the pulmonologist and primary care physician requesting 24 hour personal care assistance, 7 days a week. The patient had another comprehensive community assessment. It was noted that the patient required maximum assistance with meal preparation, ordinary housework and shopping and required extensive assistance with stairs, transportation, bathing, dressing lower extremities and toilet use. 
The patient was approved for personal care assistant services for 84 hours a week. The patient continued to worsen with pulmonary capacity with increased shortness of breath with any activity despite using 6 liters of oxygen.  PCP and pulmonologist again requested 24 hour PCAS per day, 7 days a week because of chronic pulmonary sarcoidosis, severe pulmonary fibrosis, pulmonary hypertension, chronic bronchiectasis and chronic hypoxic respiratory failure. They had both reported further deterioration and ongoing evaluation for lung transplantation. The patient and providers specifically requested nighttime hours as the patient had incontinence and with worsening lung function has not been able to get to the bathroom in time and then needs help with incontinence cares. The patient has severe shortness of breath with transferring and it was felt condition worsened further since the last comprehensive community assessment report. The health plan determination is overturned in whole. 
The patient's primary care provider and pulmonologist both reported progressive worsening shortness of breath with less and less activity and they felt 24 hour per day, 7 days per week of personal care assistance services were medically necessary. The patient has had progression of disease from the last comprehensive community assessment report. The patient requires the maximum amount of oxygen therapy and despite this is very short of breath with any activity including activities of daily living (ADL's). Patient requires assistance with these ADL's overnight. Even if the patient had a bedside commode, the patient would still require assistance with transferring, toileting, and incontinence cares.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke.
Treatment: Air ambulance transport.
The insurer denied Air ambulance transport.
The denial is upheld.

The patient is an adult female who presented to the Emergency Department due to confusion, word-finding difficulty, and right-sided facial numbness and droop. Upon arrival at the emergency department, the patient appeared confused, but she was able to answer questions, albeit in a slow manner. After arriving, her expressive aphasia had slightly approved. The patient complained of headache for one week, which had been treated by her family doctor with an injection and Imitrex. 

The patient's exam was notable for right facial numbness and mild distress. Differential diagnoses were listed as stroke/TIA (transient ischemic attack) and acephalic migraine. The patient was given Compazine for possible migraine equivalent. As the patient was experiencing a rapidly developing stroke and she required intensive stroke services, including diagnostics and treatment, including possible tPA (tissue plasminogen activator), which were not available at the Hospital, the patient was flown by Medevac helicopter to another Hospital due to the fact that delay associated with ground transport could be detrimental. 

According to records from the receiving Hospital, the patient was admitted, and MRI imaging showed left parietal occipital stroke. Workup did not show the source of her ischemic stroke. She was monitored on telemetry without any significant events. Platelet agents and statins were administered. Diagnoses were listed as headaches, acute cerebrovascular accident (left acute arterial ischemic stroke, parieto-occipital region), and expressive aphasia. Discharge exam was notable for word-finding difficulties but no other focal deficits. It was determined that she did not require occupational or physical therapy, however, speech therapy was recommended due to significant expressive aphasia. She was discharged in good condition.

The patient sustained stroke and required advanced stroke services at a nearby hospital 36 miles away. The hospital was accessible by a standard ground ambulance. The estimated drive time would be around 40 minutes. There was no advantage, in terms of transport time, in using air ambulance versus ground ambulance in the patient's case. In other words, the patient's treatment and stroke services were not expected to be conducted any faster with air transportation. 

The patient was clinically and hemodynamically stable and did not require a crew of more than one medical professional to accompany her during the interhospital transfer. There was no expectation of any need in medications administration during the transfer. There is no documentation of any local conditions such as highway closures that would make ground transport unsafe or would significantly delay the transfer. Therefore, medically, ground ambulance transport was expected to be as safe as air transport.

Therefore, given the above, air transportation was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis of the right fifth digit 
Treatment: Inpatient admission 

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

The patient is a male whose inpatient admission is under review. The patient had an injury to his right hand, which led to an infection. He was seen by his PMD (primary medical doctor) four days prior to the ER visit, and he was placed on Bactrim. His symptoms worsened until he sought care. His presentation was significant for pain, redness, and swelling in the right fifth digit. 

In the ER, the patient's vitals were as follows: T (temperature) - 36.8, P (pulse) - 105, RR (respiration rate) - 16, BP (blood pressure) - 144/91. On general examination, the patient was NAD (no acute distress). Examination of his chest, CVS (cardiovascular system), and abdomen were normal. Examination of his skin revealed right fifth finger with tenderness, swelling with pus coming from multiple open areas, as well as erythema. 

The patient's wound culture revealed MRSA (methicillin-resistant Staphylococcus aureus). The patient was thought to have a cellulitis that failed to outpatient therapy. He was admitted and started on IV Zosyn. He improved after several days and was sent home on PO (oral) clindamycin. 

Yes, the inpatient admission was medically necessary.

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

This patient should have had inpatient admission and treatment for the following: 1) Failure of outpatient treatment 2) Evidence of systemic signs of infection (tachycardia). 

Each of the above are independent reasons to admit a patient such as in this case, as supported by guidelines of the Infectious Diseases Society of America (IDSA) (1). Thus, this admission was warranted, supported by IDSA guidelines. Failure to admit such as a patient can lead to loss of function, deep abscess, septic shock, or death.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation 
Treatment: Inpatient Admission 

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

This is a female patient with a history of gastroesophageal reflux disease gastroesophageal reflux disease, (GERD) sleep apnea, and obesity. She presented to the Emergency Department (ED) with complaints of possible atrial fibrillation. Cardiology consulted on the patient. An electrocardiogram was performed (EKG) that revealed atrial fibrillation with a heart rate ranging from 90-115 beats per minute. A chest x-ray was done that was negative. The patient was admitted to telemetry for further monitoring. The patient received oral Cardizem and aspirin. A repeat EKG was done that showed a normal sinus rhythm. The patient was medically stabilized and discharged home with outpatient follow up instructions. 

Based on the review of the medical records, the patient presented with atrial fibrillation but otherwise, the patient's vitals were stable. The patient's cardiac workup with electrocardiogram, chest x-ray and cardiac troponin were not concerning for cardiac ischemia, and the patient remained clinically and hemodynamically stable throughout the hospitalization. Based on the literature guidelines on the medical indication for inpatient admission for the management of atrial fibrillation, this patient's inpatient admission was not medically necessary. In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, this patient's care could have been provided in the observational setting, allowing for additional cardiac testing. 

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

The carrier denial of coverage for the inpatient hospital services is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Basal Ganglia Infarct

Treatment: Inpatient Admission

The insurer denied the inpatient admission.  The denial was reversed.   

This is a male patient with a history of hypertension, congestive heart failure, hyperlipidemia and a ventricular thrombus. He presented to the Emergency Department with complaints of right facial droop and right hand weakness. His presenting vital signs were; BP 180/80 with a heart rate of 90. It was reported that the patient was able to ambulate with a steady gait and right hand muscle strength rated 4/5 in strength. A neurological work up was performed that included laboratory studies and a magnetic resonance imaging (MRI). The MRI revealed a small left acute basal ganglia infarct. It was reported that the patient was outside of the window for tissue plasminogen activator (TPA) treatment.   The patient was medically stabilized and discharged home with outpatient follow up instructions. 

An MRI of the brain showed a small acute left basal ganglia stroke.  According to referring physician, the patient may be admitted to inpatient services when there is imaging evidence of an acute stroke The patient has multiple vascular risk factors including hypertension, elevated cholesterol level and diabetes.  He presented with an acute stroke with right upper extremity weakness with MRI correlation showing a stroke in the left basal ganglia.  The care provided was warranted and the inpatient admission was justified given the finding of an acute stroke. Therefore, the review outcome is reversed. 

The insurer did not act reasonably, or with sound clinical judgment, or in the patient's best interest. 

Based on the above, the medical necessity for the inpatient hospital services is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I Malocclusion, Maxillary Crowding and Mandibular Crowding, Incisor Protrusion and Anterior Crossbite with Gingival attachment loss.  

Treatment: Orthodontic Braces

The insurer denied orthodontic braces. The denial was reversed.   

This is a female patient who consulted an orthodontist for orthodontic treatment. Diagnostic studies were performed that included HLD index, lateral cephalometric radiograph, panoramic radiograph, and montage of extraoral and intraoral clinical images. Orthodontic treatment was recommended due to her diagnosis of Class I malocclusion, maxillary crowding and mandibular crowding, incisor protrusion and anterior crossbite with gingival attachment loss. 

Upon review of the submitted documentation, it is evident that the patient exhibits a significant malocclusion.  However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index.  This index provides six 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 crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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.  This is confirmed by several studies. 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.  

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

The carrier's denial of coverage for the orthodontic braces and monthly periodic dental visits is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Overbite
Treatment:  Dental/Orthodontic treatment

The patient has a Class II malocclusion.  There is mild maxillary crowding and moderate mandibular crowding.  There is severe overjet and moderate overbite with bimaxillary incisor protrusion.  The proposed treatment is braces.  The health plan's determination of medical necessity is upheld, in whole.  Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 24 with no auto qualifiers.  Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9mm or greater and underbite 3.5mm or greater. The patient requires a score of 26 or more for treatment to be considered medically necessary.  The malocclusion of the patient in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a skeletal Class I occlusion, Class II cuspids, mild maxillary crowding and mild mandibular crowding, moderate overjet and moderate open bite. The proposed treatment is braces for 24-30 months with extraction of the first premolars. The health plan's determination is upheld.
Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 21 with no auto qualifiers. Auto qualifiers include cleft palate deformity or cranio-facial anomaly, severe traumatic deviation, impacted permanent anteriors where extraction is not indicated, deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeters (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, the braces are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous system/Neuromuscular Disorder - Ataxia/Inability to coordinate voluntary muscular movements, Epilepsy

Home Health Care

The patient is a female with past medical history of spinocerebellar ataxia type 2 and epilepsy. She lives with her grandmother. The patient had an assessment for personal care assistant services. Per this assessment, the patient required limited assistance with walking and locomotion. The patient required extensive assistance with personal hygiene, dressing of the upper and lower extremity and toileting. The patient required maximum assistance for meal preparation, shopping and bathing. The patient had total dependence with housework. The patient's physician wrote a letter requesting an increase in personal care assistant services due to the patient's medical condition. The patient has a progressively worsening condition with worsening weakness and ataxia as the day goes on. The patient had been approved for personal care assistant services from 9 am to 2 pm daily. The patient's grandmother provided further assistance before 9 am and after 2 pm. The patient's grandmother has worsening health and is not able to care for the patient as previous. The patient has had multiple falls. Increased personal care assistant services have been requested up to 5 times prior to the provider's letter. The health plan has denied  an increase in personal care assistant service hours as not medically necessary. The health plan's determination is overturned.

Yes, personal care assistance services 8 hours per day, 7 days per week, to total 56 hours per week are medically necessary for this patient for reasons noted as above. The patient has a progressive neurological illness with an increase need of personal care assistant services since her last assessment. The patient required more assistance with walking and locomotion due to the progressive nature of her illness. The patient also needed more help with toileting transfers and personal hygiene due to the progression of her neurologic illness. At the same time, the patient's caregiver is elderly with worsening medical condition and is not able to care for the patient as she has in the past.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, DM, HTN 

Issue under review: Increase in personal care worker services

Determination: The increase in personal care worker services is medically necessary.

The patient is an elderly female with a history of Alzheimer's dementia, diabetes mellitus, hypertension and hypothyroidism. Due to impairments related to the combination of her various comorbid conditions, she requires assistance with the majority of her activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in Personal Care Worker Services from seven days/week, five hours/day to seven days/week, 12 hours/day to offer increased assistance with completion of the patient's ADLs.

Documentation from the patient's primary care physician indicates that the patient requires 24 hours of health services as she is unsafe to be left home alone due to her worsening dementia and cognitive impairment. For these reasons, the currently approved plan of personal care worker services seven days/week, five hours/day is not sufficient to meet the patient's current needs. Hence, the proposed treatment of an increase in personal care worker services from seven days/week, five hours/day to seven days/week, 12 hours/day (health plan approved day seven days/week, seven hours/day) to offer increased assistance with completion of the patient's ADLs is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

This is a patient who was noted incidentally to have a right upper lobe (RUL) mass when he sought care following a motor vehicle accident. A positron emission tomography/computed tomography (PET CT) scan confirmed a RUL mass, and he underwent a bronchoscopy with transbronchial biopsies which were read as negative. He declined a video-assisted thoracoscopic surgery (VATS) procedure at that time. A follow up CT scan was read as showing an increase in size of the RUL mass with adjacent ground glass opacities possibly related to lymphangitic tumor spread, probable mediastinal invasion, hilar and mediastinal adenopathy, scattered bilateral pulmonary nodules, and questionable nodularity of the left adrenal. He then underwent a VATS procedure with biopsy of RUL mass and pathology was interpreted as poorly differentiated squamous cell carcinoma with abundant necrosis. Programmed death-ligand (PD-L) 1 was high. An oncology clinical note mentions the patient was feeling well overall aside from night sweats and dry cough, and that "next gen sequencing will be requested." There was no mention that a tumor specimen from recent VATS procedure was insufficient for tissue-based molecular profiling.
The health plan's determination is upheld. The Guardant 360 test was not medically necessary. The National Comprehensive Cancer Network (NCCN) Guidelines indicate that liquid biopsies (such as Guardant360) may be considered in specific circumstances, including when the patient is medically unfit to undergo an invasive biopsy procedure, or (in the initial diagnostic setting) when there was insufficient tissue for molecular profiling, provided follow up tissue-based analysis is planned for all patients in whom an oncogenic driver is not identified. This is because liquid biopsies have been shown to have up to a 30% false negative rate.
Medical records for this patient do not indicate that he was medically unfit to undergo an invasive biopsy; he recently underwent a VATS procedure and oncology clinical note mentioned he was feeling well overall. The medical records also do not indicate there was an insufficient sample from the recent biopsy. Therefore, the Guardant360 liquid biopsy was not medically necessary according to NCCN guidelines.