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

Diagnosis: Abdominal pain - bowel obstruction.
Treatment: Inpatient admission.
The insurer denied coverage for an inpatient admission. 
The denial is upheld.

The patient was having abdominal pain and irregular bowel movements. He had a recent diagnosis of Hodgkin's lymphoma on a cervical biopsy. He had also been treated with various biologic agents for rheumatoid arthritis. The gastroenterology consultant noted that he was not currently having pain. However, a CT (computed tomography) scan suggested a small bowel obstruction. A PET (positron emission tomography) scan did not reveal an intra-abdominal lymphoma. He was afebrile and the vital signs were stable. The abdomen was soft but showed some distention. There was no leukocytosis. A CT scan showed small bowel distention suggestive of small bowel obstruction. It was felt that his diarrhea was related to the small bowel obstruction. He was put on a clear liquid diet and Miralax and improved. 

Clinical indications for admission for intestinal obstruction are listed in MCG (Milliman Care Guidelines) M-210. The indications include having signs and symptoms of bowel obstruction that are severe or persistent. Vomiting, inability to tolerate PO (oral) substances, pain, and distention are the examples given for signs and symptoms. In this case, there was no vomiting, he was able to tolerate liquids, but there was some distention. The examples given for severe symptoms include feculent vomiting, hypotension, electrolyte abnormalities, bowel ischemia, or perforation. The patient did not have any of these severe symptoms.

This patient had evidence of a partial small bowel obstruction which responded to being on a liquid diet. He was not having abdominal pain and did not have severe symptoms or require continuous nasogastric suction. He responded to a liquid diet and Miralax. No acute interventions were needed. Since he did not have severe or persistent symptoms, he did not meet MCG criteria for admission for intestinal obstruction. The health care plan acted reasonably and with sound medical judgment He could have been managed with observation status. An inpatient admission was not medically necessary. 

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

The insurer's denial of coverage for the full hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, chronic pain, depression, gastroesophageal reflux disease (GERD).
Treatment: consumer directed personal assistance service (CDPAS) at 31 hours per week.
The insurer denied coverage for consumer directed personal assistance service (CDPAS) at 31 hours per week. 
The denial is overturned.


This case involves a female with a history of chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, chronic pain, depression, gastroesophageal reflux disease (GERD), and prediabetes who was being recommended for personal assistant services 31 hours/week.
The healthcare plan did not act reasonably and with some medical judgment and in the best interest of the patient. A rationale was not provided pertaining to why the patient needed a significant reduction in the personal assistance hours previously provided given that her condition had not shown any significant improvements to justify a loss of 13.25 hours.
Literature notes that personal assistance services have proven to be crucial when people with disabilities remain in the community, as opposed to being placed in institutional settings. The patient had cognitive and physical impairments, was a fall risk, and required assistance with several activities of daily living. An assessment was conducted claiming that the patient only needed 17.75 hours a week of personal assistance. However, given that she suffered a fall a month later, resulting in a loss of consciousness and concussion, it was determined that an extension of the previously approved 31 hours would be reasonable until such time as an updated evaluation can take place to determine if the patient has any residual impairments due to the injuries. As such, the procedure code T1019, consumer directed personal assistance service (CDPAS) at 31 hours per week is considered medically necessary for this patient.  The prior determination is overturned.
The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for procedure code T1019, consumer directed personal assistance service (CDPAS) at 31 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic pain. 
Treatment: Personal care services (PCS) level 2, 24 hours per day, 7 days per week (live in). 
The insurer denied coverage for personal care services level 2, 24 hours per day, 7 days per week (live in). 
The denial is upheld. 

This is a female with chronic pain and history of a motor vehicle accident and subsequent surgeries, which included lumbar spine fusion surgery. The plan approved PCS level 2, 10 hours per day, 7 days per week for a total of 70 hours per week. She is requesting PCS level 2, 24 hours/day, 7 days/week (live in); which is currently under review. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is noted as "modified independence-some difficulty in new situations only." She is able to make decisions and can call 911 in case of an emergency. She requires maximal assistance for bathing, lower body dressing and toilet transfers/use. She is frequently incontinent of bladder and continent of bowel. Extensive assistance is needed for personal hygiene, upper body dressing, and walking. She reportedly fell prior to the evaluation with multiple bruises also reported. Bed mobility requires only limited assistance. The patient has significant functional impairments, and her cognitive status is generally intact. However, her condition and functional needs are not at a level or unpredictable as to require the requested PCS continuous care 24 hours (live-in) 7 days/week. The patient's health and safety can be appropriately provided and maintained by the authorized PCS level 2, 10 hours per day, 7 days per week for a total of 70 hours per week. 

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. (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 PCS level 2, 24 hours per day, 7 days per week (live in) is not medically necessary. 

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

The insurer's denial of coverage for personal care services level 2, 24 hours per day, 7 days per week (live in) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebrovascular accident
Treatment: Home health care
The insurer denied Personal Care Assistant (PCA) Hours: 7 Days per Week, 12 Hours per Day. The health plan's determination is overturned. 

The patient is a male with past medical history of cerebrovascular accident (CVA) with right hemiparesis, vascular dementia, hypertension, hypertensive heart disease with heart failure, coronary artery disease, diabetes mellitus type 2, hyperlipidemia, diabetic polyneuropathy, depression, hypothyroidism, chronic kidney disease, kidney cancer, chronic obstructive pulmonary disease (COPD), chronic low back pain, lower extremity edema, bowel incontinence, bladder incontinence, and osteoarthritis who had been assigned PCA (personal care assistant) services.

Personal Care Assistant (PCA) Hours: 7 Days per Week, 12 Hours per Day are medically necessary for this patient. 
There is documentation from the patient's PCP (primary care provider) of worsening cognitive and functional status. The PCP documented medical necessity for increased PCA services. There is documentation that the patient is bedbound and wheelchair-bound. The patient requires assistance with all activities except for bed mobility based on assessment tool. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The insurer failed to document a plan to provide activities of daily living (ADL) and Instrumental activities of daily living (IADL) assistance when the patient does not have informal help. The last assessment underestimated the patient's care needs and because the patient has 24-hour care needs a time-based tasking tool should not of been utilized. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week are medically necessary for this patient. 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 his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral Palsy, spastic quadriplegia
Treatment: K0108 - Wheelchair Component or Accessory, NOS (six)
E2331 - Power Wheelchair Accessory(attendant control)
E2300 - Wheelchair Accessory, Power seat Elevation System
The insurer denied the K0108 - Wheelchair Component or Accessory, NOS (six)
E2331 - Power Wheelchair Accessory(attendant control)
E2300 - Wheelchair Accessory, Power seat Elevation System
The denial is overturned

This is a male child with cerebral palsy, spastic quadriplegia, Gross Motor Function Classification System (GMFCS) V, and periventricular leukomalacia. The child has been evaluated for seating and mobility options by the qualified healthcare providers and has been recommended use of power wheelchair with accessories. The child underwent a six week power mobility trial that has shown to improve independence. Following review by the health plan, the requested wheelchair accessories E2331(attendant control), E2300 (power seat elevation) and K0108 (power control wheelchair accessory) have been denied due to lack of medical necessity. A letter of appeal has been provided by the treating physical therapist

Yes, the proposed treatment, accessories E2331 (attendant control) and K0108 (power control wheelchair accessory) and E2300 (power seat elevation), is medically necessary.
Based on the review of medical records, this child has been approved to receive a power mobility system. The child's condition (i.e. cerebral palsy, Gross Motor Function Classification System [GMFCS V]) limits independent use of power mobility; therefore this child's clinicians have recommended use of both emergency stop and safety precautions permitting the attendant to control wheelchair operation. In addition, the child has difficulties shifting weight in the chair independently and the power set elevation would enable the child to relive pressure and prevent skin breakdown. Based on the review of clinical records and standards of care in the field of pediatric rehabilitation medicine, prescription of the above mentioned items should be considered as medically necessary in this specific case.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The Health plan did act reasonably in permitting the prescription for power mobility wheelchair for this child who has been evaluated by the skilled healthcare providers.  The Health plan initial decision in the denial of the requested wheelchair accessories E2331 (attendant control), E2300 (power seat elevation) and K0108 (power control wheelchair accessory)  are not reasonable taking into consideration safety and complication prevention aspects of power mobility prescription for the child with cerebral palsy Gross Motor Function Classification System (GMFCS) V and well supported statements by the direct clinical providers.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: Codes D8080 (comprehensive orthodontic treatment of the adolescent dentition) and D8670 (periodic orthodontic treatment visit) x 12.
The insurer denied coverage for codes D8080 (comprehensive orthodontic treatment of the adolescent dentition) and D8670 (periodic orthodontic treatment visit) x 12.
The denial is overturned.

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 maxillary and mandibular crowding, open bite, reverse overjet and anterior crossbite with gingival attachment loss (mandibular left canine) in addition to other clinical findings. The orthodontist has completed the Handicapping Labio- Lingual Deviation Index (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio- Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after HLD 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 HLD 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.

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

The insurer's denial of coverage for codes D8080 (comprehensive orthodontic treatment of the adolescent dentition) and D8670 (periodic orthodontic treatment visit) x 12 is overturned. Medical Necessity is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic sinusitis with nasal polyposis. 
Treatment: Dupixent 300 milligrams per 2 milliliters (mg/ml). 

The insurer denied coverage for Dupixent 300 mg/ 2 ml. 

The denial is overturned. 

The patient is a female who has a history of chronic sinusitis and nasal polyposis and is status post endoscopic sinus surgery and most recently had revision surgery with placement of mometasone furoate-releasing implant. She reports having had side effect from oral steroids (tachycardia and palpitations) and rash from budesonide rinses. The denial is based on there being "no indication that the patient has taken and had a poor response to medications on the preferred drug list.". The progress notes state that the patient had no improvement with Flonase in the past, which is in the same category of mometasone, budesonide, triamcinolone, and budesonide. Furthermore, the patient has been treated with mometasone intranasally. Thus, the patient in principle has failed nasal corticosteroids and would thus fit the category of nasal polyposis patients who benefit from Dupixent. The patient also has encountered side effects from budesonide irrigations (one of the "preferred drugs"). Dupixent has been shown to be effective in treating patients with chronic sinusitis with nasal polyposis who have symptoms despite intranasal steroids. Thus, Dupixent is expected to be more effective than the formulary drugs listed. 

The insurer's denial of coverage for Formulary Exception for Dupixent 300 mg/ 2 ml is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation

Treatment: Inpatient admission

The insurer denied coverage for an inpatient admission

The denial is upheld 

Asked to review the case of a gentleman that presented to the hospital for elective catheter ablation of atrial fibrillation. Past medical history was significant for sudden cardiac arrest and secondary prevention ICD (implanted cardiac defibrillator) implantation. AF (atrial fibrillation) was noted on ICD telemetry and resulted in inappropriate shocks.  He underwent uncomplicated left atrial catheter ablation and was discharged the following day. This patient presented to the hospital for an elective electrophysiologic study and ablation. According to hospital records, the ablation was successfully performed without complication. Observation following ablation was unremarkable and no post operative issues were noted. The patient was discharged home the following day. In this case, there were no clinical reasons for hospital admission and the patient could safely be managed at a lower level of care. In two multicenter registry studies looking at healthcare utilization after EP (electrophysiology) study catheter ablation, more than 80% of patients undergoing ablation were hospitalized for a single day, regardless of age or co-morbidity (Reference 1) Bartoletti demonstrated that patients undergoing atrial fibrillation ablation procedures could be safely discharged on the same day. (Reference 2) In a report involving over 6000 patients, same day discharge following catheter ablation of AF was found to be safe and comparable to outcomes in patients that were observed overnight. (Reference 3) In conclusion, acute inpatient admission was not medically necessary in this case.  

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community acquired pneumonia (CAP).
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

This is the case of a female who was recently diagnosed with right mammary carcinoma.
Not started on any treatment as yet. The patient presented to the emergency department with complaint of right sided pleuritic chest pain and some shortness of breath (SOB) for about 2 days. She has some mild cough but no hemoptysis.

Vital signs at presentation included temperature 98.2, heart rate 86, blood pressure 134/86, respiratory rate 20, and oxygen saturations 98% (percent) on room air. The patient was in no acute distress and lungs were clear. Cardiac exam was unremarkable.
The patient was alert and oriented times 3 (A x O X 3) and had a non-focal neuro exam.

White blood cell count (WBC) was 8.9, electrolytes and blood urea nitrogen/ creatinine were within normal limits. Troponin was negative. Electrocardiogram was unremarkable with no ischemic changes.

Chest x-rays revealed some patchy right middle lobe (RML) opacity pneumonia (PNA).
The patient underwent a computed tomography chest to rule out pulmonary embolism (PE). No PE was noted but RML PNA with possible extension of breast mass to chest wall and a metastatic right axillary lymph node was seen.

The patient was admitted to the hospital for treatment of CAP. The patient was initially placed on broad spectrum antibiotics Vancomycin and Zosyn. She was subsequently switched to Rocephin and Azithromycin.

The patient remained stable after admission. The patient started feeling better in terms of Chest pain and SOB. V/S (vital signs) showed the patient was afebrile and hemodynamically (HD) stable with O2 (oxygen) saturations 98 % on Room Air. Lungs were clear and the patient was tolerating oral (PO).

This patient did not need acute inpatient hospitalization for her CAP. She was afebrile and HD stable. No hypoxia noted. The patient had not failed outpatient management. She was tolerating PO. WBC was normal. The patient started improving within a day after admission. The patient was eventually switched to PO antibiotics (Abx) and discharged (dced) home. The patient had an episode of diarrhea which was related to campylobacter and the patient had completed 3 days of Azithromycin. In any case, she did not need hospitalization for that.

This patient could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hrs. The patient could have been dced home on PO Abx after a period in observation. The patient's PNA was mild with CURB (confusion, urea, respiratory rate, and blood pressure) 65 score of Zero. The patient's breast Ca (cancer) was being followed up already in the outpatient setting and she had diagnostic studies already planned.

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

The insurer's denial of coverage for inpatient admission is upheld. Medical Necessity is not substantiated.