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

Diagnosis:  Pneumonia
Treatment:  Inpatient Hospital

The patient is a female with a history of asthma, human immunodeficiency virus (HIV), and schizophrenia.  She presented to the emergency room with a 3-week history of mild cough, shortness of breath, and wheezing.  Documentation is conflicting; on physical exam she was not in any apparent distress by one examiner, but she was in mild distress by another.  She was able to complete full sentences but had a fairly frequent cough.  Vital signs revealed a pulse of 122 but were otherwise non-contributory.  The physical exam was otherwise unremarkable, including the lack of wheezing or other significant findings on pulmonary exam.  Labs were notable for mild hypokalemia.  The electrocardiogram (EKG) revealed sinus tachycardia but was negative for ischemia or other arrhythmias.  The chest x-ray showed "peri-bronchial thickening" but no evidence of pneumonia.  The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with parenteral corticosteroids, parenteral epinephrine, intravenous antibiotics, nebulizers, and inhalers.  The hypokalemia was treated with oral potassium.  A chest computed tomography (CT) scan revealed a small right upper lobe infiltrate, bibasilar atelectasis, and nonspecific mild ground glass opacities.  The hospital course was clinically uneventful, and she was discharged. 

The health plan's determination is upheld.

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient.  Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary.  Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints.  Therefore, there were no objective findings substantiating the need for acute inpatient care.  There is no evidence that she failed appropriate emergency department (ED)/outpatient treatment.  The possible diagnosis of pneumonia did not require acute inpatient care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cervical Radiculopathy due to Degenerative Disease of the Spine
 
Treatment:  Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.

This is a female patient who presented to the emergency room via emergency medical service with complaints in her neck and right cervical area.  Her physical exam was normal with no motor or sensory deficits.  The patient had an x-ray of her shoulder and chest, both were negative.  She had a computerized tomography of her neck that showed no acute skeletal injury with degenerative disc and joint disease.  She had a consultation with neurology and physical therapy.  The patient was treated with Tylenol, intramuscular Toradol, and Robaxin; the patient stated pain relief.  The patient was discharged home with outpatient physical therapy.

The Milliman Care Guidelines indicates that a hospital admission for pain management may be appropriate for patients with severe pain requiring acute inpatient management including the need for intravenous opiate administration as indicated by pain that was unresponsive to non-opioid analgesia and non-pharmacologic treatment, when oral, transdermal, or submucosal route would not be appropriate, or insufficient, and when anticipated titration was not appropriate for a lower level of care, or when pain control regimen for the next level of care was not established as sufficient pain control was not achieved.

The patient's pain was controlled by the time of the admission per the documentation. The patient had not failed observation care.  The physical examination revealed no muscle weakness or strength deficits.  The patient was able to take medications by mouth.  The records failed to support the patient was not appropriate for observation care.

Based on the above, the medical necessity for the Inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who was admitted  for mood disturbance and psychosis. The patient reported increasing symptoms of depression in the context of symptoms of psychosis (auditory and visual hallucinations) that included morbid thoughts and trauma-related symptoms. The patient was binge drinking alcohol that contributed to his presenting symptoms in order to self-treat his trauma related symptoms. The precipitating event was the brutal death of his uncle. The patient had stopped his medication, and he had a history of medication non-adherence in the context of substance use disorder that included alcohol and cannabis and tobacco class subtances of abuse. 
The patient had a history of psychiatric treatment and several hospitalizations including medication non-adherence and co-occurring substance use disorder with alcohol with a binge pattern of use and cannabis (marijuana) use on a daily basis in large quantity with approximately 20 bags per month.
On Mental Status Examination on admission, the patient was psychotic and cognitively impaired with thought blocking and auditory/visual hallucinations. He had decreased concentration, energy, sleep, and volition. He reported trauma-related symptoms that included flashbacks and nightmares related to childhood abuse. Diagnoses included schizoaffective disorder with major depression, posttraumatic stress disorder (PTSD) and co-occurring substance use disorders with alcohol and cannabis, as well as comorbid medical conditions and compliance problems with medication non-adherence with his usual medications that included Prozac, Depakote and Seroquel.
The health plan's determination is overturned.
The patient's symptoms of psychosis and mood disorder together with continued risk of substance use and medication non-adherence prompted the necessity for the admission and the continued acute inpatient level structure and monitoring through discharge. The case is complicated by active substance use disorder; and non-compliance with treatment and medication adherence problems in the context of an active seizure disorder and substance use with alcohol and cannabis. The residual symptoms of mood disorder and psychosis; risk for suicidal behavior, co-occurring substance use disorder/general medical conditions, and treatment issues related to arranging a safe and appropriate discharge plan together with a history of medication non-adherence warranted the continued services at an acute inpatient level of care to include safety monitoring and maintaining abstinence from substances of abuse. The inpatient continued stay through discharge was therefore clinically appropriate and medical necessary for the proposed inpatient level structure and 24-hour monitoring through the day of discharge.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient has a favorable intermediate risk prostate carcinoma. Many treatment options were discussed with the patient including surgery, radiation, active surveillance and observation with or without hormonal therapy along with radical prostatectomy (open versus robotic approach). The patient's physician felt that the best approach would be radiation and the insertion of perirectal hydrogel spacer to help protect the posterior rectal wall.  The treatment of prostate cancer with radiation, even techniques such as intensity modulated radiation therapy (IMRT), still yields some risk to those organs at risk. The prostate lies between the bladder and rectum which are both organs at risk for radiation damage, more so for the rectal wall. In order to treat the prostate properly with radiation the posterior rectal wall must be in the high-dose radiation field in order to properly dose the posterior portion of the prostate gland itself. The intent of the SpaceOar hydrogel system is to create a space between the posterior rectal wall and the prostate so that higher dose radiation can be given to the entire prostate with a significant reduction of the posterior wall of the rectum since it is no longer in the field. This system is compulsive biodegradable material and maintains a space for the entire course of the prostate radiotherapy and is incompletely absorbed by the patient's body over time.
During the course of radiation therapy treatments for prostate carcinoma organs at risk such as the bowel and bladder are often damaged secondary to the proximity to the target volume that is the prostate itself being irradiated. It is felt that Intensity-modulated radiation therapy (IM RT) treatment and the use of the SpaceOar system would be the most medically appropriate and necessary for the care of this patient. The combination of these techniques allows an increase in the dose to the prostate gland while actually decreasing dose of the organs at risk that is the bladder and bowel but specifically in this case the posterior wall of the rectum. This system is composed of a biodegradable material and maintains space for the entire course of the prostate radiation treatments and that is completely absorbed by the patient's body over time. Perirectal hydrogel spacers were actually Food and Drug Administration (FDA) cleared in April 2015. There have been numerous clinical studies that show that the use of the perirectal spacer decreases rectal toxicity. The procedure has been accepted by the American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) and is actually category 1 current procedural terminology (CPT) code for the use and acceptance of this procedure. There have been numerous published peer review articles that support the use of hydrogel spacers for prostate carcinoma to help protect the posterior rectal wall and reduce the possible morbidity from high-dose radiation. The health plan's determination is overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

This is the case of a patient who presented with a rising prostate-specific antigen (PSA). A magnetic resonance imaging (MRI) of the prostate was abnormal. Biopsy established a diagnosis of intermediate risk prostate cancer. The patient underwent SpaceOAR procedure before Stereotactic body radiation therapy, (SBRT). SpaceOAR was approved by the Food and Drug Administration (FDA) in 2015. This procedure is supported by the American College of Radiology (ACR) and the American Society for radiation oncology (ASTRO). There are several publications supporting the safety and efficacy of this procedure. A prospective multicenter randomized controlled pivotal trial was performed to assess outcomes following absorbable spacer (SpaceOAR system) implantation. This study showed that Spacer application was well tolerated. Increased perirectal space reduced rectal irradiation, reduced rectal toxicity severity, and decreased rates of patients experiencing declines in bowel quality of life. The spacer appears to be an effective tool, potentially enabling advanced prostate radiation therapy (RT) protocols. The health plan's determination is overturned in whole.
Appeal type: Experimental/Investigational
Decision: Overturned

This patient with a rise in his prostate-specific antigen (PSA) to 4.2 ng/ml had prostate biopsies that revealed a Gleason 7 adenocarcinoma. Radiation therapy is recommended as definitive treatment with Stereotactic body radiation therapy (SBRT) and perirectal biodegradable spacer gel is requested prior to the radiation therapy. There are excellent randomized trial data published in peer reviewed medical literature showing the significant benefit of the use of perirectal biodegradable gel injection with significant decreased risk of diarrhea and rectal bleeding as well as improvement in erectile dysfunction risk. This is also supported by National Comprehensive Cancer Network (NCCN) Guidelines as category 2a. The use of this perirectal spacer is considered a standard of care treatment prior to the use of radiation therapy as definitive treatment for localized prostate carcinoma and is approved. The health plan's determination is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Autism Spectrum Disorder, Severe Intellectual Disability
 
Treatment: Increase of personal care aide services

The insurer denied increased personal care aide services. The denial was modified.

This male patient had developmental delays in social communication and interaction, ritualistic and perseverative behaviors, and a history of physically aggressive, self- injurious, impulsive, and assaultive behavior, as well as property destruction and past elopement attempts. He had diagnoses of Autism Spectrum Disorder, Severe Intellectual Disability, Intermittent Explosive Disorder, and Disruptive Mood Dysregulation Disorder. He lived with his mother who took care of him. This patient required assistance with ADLs as he was unable to perform most ADLs except with assistance, and was unable to perform household tasks; therefore, he required personal care services. 

The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Autism and Other Pervasive Developmental Disorders reports that some patients with autism and developmental delays have severe deficits in adaptive functioning and require assistance for activities of daily living, as well as supervision for safety and for structure as they often require intense sustained structure due to their delays. It appeared that his mother was not able to provide 24 hours per day supervision and 15 hours per week was not enough supervision for this patient with severe deficits in development, inability to care for his basic needs, and his history of aggression and self- injurious behavior. This placed others in danger; therefore, he required at least 8 hours per day of supervision and consumer directed personal care aide services. If he were to need 24 hour supervision, then he would be a candidate for a therapeutic residential treatment which could provide this treatment. 

Based on the above, the insurer's denial of consumer directed personal care aide services (CDPAS) 168 hours per week (24 hours per day, 7 days per week) is modified. Deny 168 hours per week (24 hours per day, 7 days per week). Approve 56 hours per week (8 hours per day, 7 days per week).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, lumbar fracture, functional impairments
 
Treatment: Personal Care Assistant (PCA) Coverage 

The insurer denied continued PCA coverage of 54 hours per week. The denial was reversed.

This patient has a history of chronic obstructive pulmonary disease (COPD), Hypertension (HTN), lumbar fracture, osteoporosis, osteoarthritis, blindness. Physician noted that patient needs personal assistance to maintain his daily activities at least 8-10 hours a day.  The Uniform Assessment System (UAS) states the patient needs assistance for housework, meal preparation, shopping, transportation, managing finances, stairs,
bathing, dressing upper/lower body, and toilet use.

The patient has multiple medical conditions that have an adverse effect on his ability to move around his home and perform routine daily activities.  The patient is unable to move around his home independently, and so he is restricted to chair or bed when there is no available assistance.  

There are no specific hours identified for when the family is available to help the patient, but it is noted that they are available and willing to help in the evening hours. Per New York State regulations for personal care services, assistance from informal caregivers is voluntary. 

Based on the patient's medical history, symptoms and functional impairments, it is medically necessary for the patient to have caregiver assistance for activities of daily living (ADLs) and instrumental ADLs. In the absence of voluntary informal caregivers it is medically necessary to provide assistance with PCA services.

There does not appear to be medical justification to reduce the patient's PCA hours from 54 to 35 hours per week.  Personal care assistance hours are approved for 6 days per week, 8 hours per day and 1 day per week, 6 hours per day, total of 54 hours per week. The insurer's denial is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overdose
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

Serotonin syndrome occurs when serotonin concentrations increase to a toxic level. The classic presentation is the triad of autonomic dysfunction, neuromuscular excitation, and altered mental status. There are a number of medication categories that can precipitate serotonin syndrome, including drugs that decrease serotonin breakdown, drugs that decrease serotonin reuptake, drugs that increase serotonin precursors or agonists, drugs that increase serotonin release, and drugs that prevent breakdown of drugs in the previous categories. 

Autonomic dysfunction includes diaphoresis, tachycardia, nausea and vomiting, diarrhea, and flushing. Neuromuscular excitation includes myoclonus, hyperreflexia, hyperthermia, and hypertonicity and rigidity. Altered mental status includes confusion and agitation, as well as anxiety, lethargy, and coma. Symptoms typically arise within an hour of the precipitating event. 

In mild toxicity, patients may present with anxiety, tremor, diaphoresis, and tachycardia. In moderate toxicity, patients are in significant distress, and may be profoundly hyperthermic. Severe toxicity is a life-threatening situation because it may lead to multi-organ failure. Muscle rigidity is a classic finding, and may result in profound hyperthermia. 

Serotonin syndrome is a clinical diagnosis for which several criteria exist to facilitate the process: Hunter criteria, Sternbach criteria. In addition to discontinuation of the offending agent, treatment includes IV fluids and benzodiazepine administration. With more serious toxicity, life support is of primary importance. Serotonin antagonists may be helpful, and include cyproheptadine and chlorpromazine. Adderall falls under the category of medications that increase serotonin release. 

In the case of this patient, she ingested 150-200 mg of Adderall and subsequently experienced a number of the signs and symptoms of serotonin syndrome. Her symptoms were refractory to Ativan and Valium, but improved somewhat with cyproheptadine. While the care of this patient was seemingly labor intensive, she was overall hemodynamically stable and responded in a timely fashion to the cyproheptadine combined with benzodiazepines. She needed to be in the hospital for monitoring, she needed to transfer to a psychiatric facility. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psychiatric disorders
 
Treatment: Brand name Wellbutrin SR and Lamictal

The insurer denied coverage for the brand name drugs Wellbutrin SR and Lamictal. The denial was reversed.

The patient is a woman in psychiatric treatment for eating disorder, anxiety, panic disorder, major depressive disorder, and post-traumatic stress disorder (PTSD).  According to records, the patient has had trials on many different medications over the years. She has been stabilized in her symptoms on brand name Wellbutrin SR 100 mg twice a day and brand name Lamictal 100 mg three times a day. Attempts to use generic formulations of these medications have resulted in worsening of symptoms, including self-harming behaviors, mood lability, inability to function at work, and allergic reactions/side effects (hives, rash). 

Based upon the information available, the patient medically requires the brand name Wellbutrin SR and Lamictal. The medical record establishes the need for the brand name medication due to allergic reactions, side effects and ineffectiveness of the generic medications.   

Based on the above, the medical necessity for coverage of the ancillary charges for brand name Lamictal and Wellbutrin SR is substantiated. The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Seizures
Treatment:  Inpatient admission

The Inpatient admission was not medically necessary.

The patient was reported to have seizures in the past (indicative of the diagnosis of epilepsy).  The patient was brought to the emergency room in a setting of two brief seizures triggered by gastrointestinal illness.  The patient's vital signs were stable, and her level of consciousness promptly recovered.  The patient was loaded with antiepileptic medications, and she remained stable neurologically without recurrent seizures and without status epilepticus. 

Seizure triggering by intercurrent illness is a common occurrence in epilepsy patients.  Most typically, it is managed by oral or intravenous antiepileptic medications loading in the emergency room.  This treatment usually contains seizures and prevents reoccurrence.  

Therefore, given the above, acute inpatient care was not within standards of care and was not medically necessary.  The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Overjet, Class I Malocclusion, Flared Anteriors and Traumatic Occlusion
 
Treatment: D8060 - Interceptive Orthodontic Treatment of the Transitional Dentition

The insurer denied the D8060 - Interceptive Orthodontic Treatment of the Transitional Dentition. The denial was upheld.   

This is a young female patient who presented to an orthodontist for an orthodontic consult. It was determined based on her clinical findings; overjet, Class I malocclusion, flared anteriors and traumatic occlusion and a Handicapping Labio-Lingual Deviation (HLD) index attaining 6 total points that orthodontics was an appropriate course of treatment for this patient.

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.  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. 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. 

The treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 6 points to justify orthodontic care.  This reviewer concurs with the index completed by the orthodontist attaining a total of 6 points on the HLD index (2 overjet, 2 overbite, 2 labiolingual spread) which is below the threshold of 26 points to support orthodontic care.  

Based on the above, the medical necessity of D8060 - Interceptive orthodontic treatment of transitional dentition is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

This patient with a skeletal Class II malocclusion with an overjet of 5(mm)millimeters, 90% overbite. Moderate maxillary and mandibular crowding. The proposed treatment is braces for 24 months.The health plans determination is upheld in whole. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 15 with no auto qualifiers which is less than the required score of 26 for medical necessity. Auto qualifiers include 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. Thus, the braces in this case are not medically necessary.