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

Diagnosis: Bilateral mandibular fractures 
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

The patient is an adult male who suffered bilateral mandibular fractures. The patient presented to the emergency department and was admitted to Oral and Maxillofacial Surgeons (OMS) service. The patient underwent surgery under general anesthesia. The surgery included an open and closed reduction of bilateral mandibular fractures. The procedure went well and there were no reported complications. The patient remained hemodynamically stable during monitoring without complications and no reasons were provided for an inpatient stay. 

"Mandibular fractures with mucosal, gingival, or tooth socket disruption are considered open fractures, and antibiotics with intraoral anaerobic pathogen coverage should be administered to reduce the risk of infection. Appropriate antibiotic agents include ampicillin/sulbactam, amoxicillin/clavulanate, and clindamycin for penicillin-allergic patients. Tetanus prophylaxis should also be considered in open fractures. Pain control should be achieved with acetaminophen, NSAIDs (nonsteroidal anti-inflammatory drugs), and/or opioids. Steroids and ice packs are useful for reducing edema." (Yuen, H.W., Hohman, M.H., Mazzoni, T.).

"The shorter hospital stay for outpatient care compared to inpatient care "may be clinically significant" because length of stay has been linked to complications including infection, according to the study published in the November issue of the Journal of Oral and Maxillofacial Surgery, the official journal of the American Association of Oral and Maxillofacial Surgeons (AAOMS)." (AAOMS).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased mobility, arthritis, dementia. 
Treatment: Home Care / Personal Care HHC (home health care) - Level 2 Personal Care Services, per 15 Minutes Increase to 80 Hours per Week. 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to80 Hours per Week. 
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for arthritis, dementia, mobility difficulty, and incontinence. A Uniform Assessment System (UAS) was completed  and was available for review. The patient lives with her son in a 1 bedroom apartment. She was alert and oriented and able to direct her own care. For her Instrumental activities of daily living (IADL), she requires total dependence for meal preparation, housework, finances, and shopping. She requires maximal assistance for stairs and medications. For her activities of daily living (ADL), she requires maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for walking, locomotion, dressing upper body, hygiene, bed mobility, and eating. She is frequently incontinent of urine and continent of stool. 

The requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: 80 Hours per Week is medically necessary for this patient. The patient requires maximal to extensive assistance for all activities of daily living (ADL). She is frequently incontinent of urine and is not capable of toileting or changing diapers independently. The patient's care needs are continuous throughout the day and often extend somewhat into the night as well. Care logs that were provided demonstrate the necessity for the increase in care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism
Treatment: Personal Care Aide (PCA), consumer direct, total of 56 hours/week
The health plan denied PCA, consumer direct, total of 56 hours/week.
The health plan's denial is overturned.

The patient is a teen-aged male with severe autism and developmental delay. Per his physician note, he cannot be left alone at any given time, as he is liable to cause harm to himself unintentionally. The note states he is not fully functional and requires assistance in daily tasks, which include supervision of personal hygiene, maintenance of nutrition and hydration, supervision of all activities outdoors and in public areas, transportation to medical visits and his safe return to his home after school. He is non-verbal, and he is non-self-directing, as he is not able to communicate nor assess any potential dangers to his health and well-being.

A child assessment notes: the patient is severely impaired in cognition with never or rarely making decisions, memory problems, and severe difficulty in communication. He cannot read or write.

Task based assessment tool based on the patient's assistance need for bathing, personal hygiene, dressing upper and lower body, toilet use, toilet transfer, eating, walking, locomotion estimated the number of hours needing assistance is 1.5 hours/day, or 10.5 per 7-day week.

The patient has severe autism and cannot self-direct behavior or do any activity without some supervision. His activities of daily living, hygiene, eating, moving from place to place all require supervision. The patient is a significant safety risk for injuring himself or others due to poor decision making. The patient is largely non-verbal, although a full speech evaluation is not in the clinical information. The patient would benefit from closer help throughout the week so that the mother can meet her needs and those of her child. The patient can be left to self-entertain for brief periods with technology, but otherwise requires continuous supervision. Children with autism have many needs and are affected across a wide spectrum. Some are very high functioning and can operate largely independently. The patient's evaluation focused mainly on the abilities of daily living and hygiene, which are only a small part of the day's activities, therefore underestimating the time needed to care for this young patient. Individualized care for all patients with autism must be careful and measured so as to appropriately support their individual needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Full Hospital Admission
The insurer denied the full hospital admission.
The health plan's determination is upheld.

The patient is a female who was admitted to the hospital with posterior hand cellulitis. The patient's symptoms started one month prior, with redness which progressed to drainage from the hand, which prompted the patient to be evaluated in the hospital. She tried treating the symptoms with Neosporin, Zinc Oxide, peppermint, and bleach, with mild improvement. Her vital signs on arrival were stable. The examination showed mild posterior hand swelling with mild erythema epidermal and mild skin breakdown. Her white blood cell count was normal; the electrolytes, renal function, and liver function tests (LFT's) were unremarkable. The x-ray of the hand showed no gas within the soft tissue and the chest x-ray was unremarkable. The medical team started the patient on Unasyn and Doxycycline. Her blood glucose was elevated, with a normal potential hydrogen (pH) and no acidosis; therefore, she was placed on Insulin. The following day, her vital signs remained stable and her glucose remained elevated.

Over the next two days, the patient continued on the antibiotics mentioned above. A computed tomography (CT) scan was completed which failed to demonstrate deep tissue infection, abscess, or osteomyelitis. The patient's hand steadily improved, with decreased edema per the documentation. Lantus Insulin treatment was added for improved glycemic control. The patient was discharged on oral Levaquin for 10 days.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment, and in the best interest of the patient.

The service/treatment of a full hospital admission is not medically necessary. There is no clinical indication for an inpatient level of care. The patient has hand cellulitis without evidence of a deep tissue infection. She has a normal white blood cell count and no signs of systemic illness. The x-ray of the hand shows no damage to the bones, gas-producing organism, or abscess. The CT scan of the hand confirmed similar findings. She has poorly controlled diabetes, which was managed with Insulin, and improved. She did not require surgical intervention on the hand.

There is no evidence of a failure of outpatient treatment. The patient was self-treated with Neosporin, Zinc Oxide, and bleach at home, which is not an appropriate antibiotic therapy for cellulitis. There were no documented barriers to this patient's transition to oral antibiotic therapy or outpatient intravenous (IV) therapy if indicated. There are no clinical indications for the patient to be admitted under an inpatient level of care when she did not fail treatment. The progress notes show gradual and steady improvement in the hand appearance, with decreased drainage and edema. I reviewed the Milliman criteria for cellulitis, and clinical indications for an inpatient admission are not satisfied.

The health plans determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, dementia, osteoarthritis, and urinary incontinence

Treatment: Personal care aide (PCA) Level 2; 12 hours per day, 7 days per week a total of 84 hours per week.

The insurer denied coverage for personal care aide (PCA) Level 2; 12 hours per day, 7 days per week a total of 84 hours per week

The denial is overturned.

 
This is an elderly patient with chronic medical problems including diabetes, osteoarthritis, and dementia.  He lives with his spouse in a private residence. His spouse has significant medical problems and is unable to participate, except minimally, in his care. The insurer approved PCA level 2: 7 hours/day, 7 days/week, a total of 49 hours per week and the request is for 12 hours/day, 7 days/week, for a total of 84 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Severely impaired." He is totally dependent for instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. He also reportedly requires maximal assistance for ADL (activites of daily living) tasks including bathing, personal hygiene, dressing, eating, bed mobility, ambulation and toilet transfer/use. He is frequently bladder and bowel incontinent. He is also reportedly totally dependent for locomotion. However, according to the daughter the patient "will get up from bed in the evening or afternoon and start making the bed because the patient states that he has to go to work." The daughter also reports the patient "needs supervision at all times." The patient's functional ability is much the same when compared to the prior UAS report.

The patient's clinical condition and functional ability are at a level or unpredictable as to require the requested PCA level 2: 12 hours per day, 7 days a week, for a total of 84 hours per week.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA) Level 2; 12 hours per day, 7 days per week a total of 84 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes
Treatment: Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per week 
The health plan denied the requested Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per week as not medically necessary. The health plan's determination is upheld.

This is a case review of a female with a medical history notable for diabetes. The patient is approved for 49 hours per week of level 2 personal care services. The patient and her care team have requested an increase to 70 hours per week.

An office visit note from a visit with gastroenterology was provided for review. The patient was diagnosed with dyspepsia and prescribed antacid medication.

There were no letters of support or medical necessity provided as part of this review. A Uniform Assessment System (UAS) was completed and was available for review. The review was conducted with the patient's son present. The patient lives in a home with her son. The patient was alert and oriented to person only; she was able to make simple needs known but unable to direct her own care. For her instrumental activities of daily living (IADL), she requires total dependence for housework, meal preparation, and shopping. She requires extensive assistance for finances, medications, and transportation. For her activities of daily living (ADL), she requires extensive assistance for bathing, hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility and eating. The patient is frequently incontinent of urine and stool and uses pullups for incontinence care. A task tool associated with the assessment recommended 37 hours per week to address her personal care needs. Compared with a prior assessment, she showed a decline across multiple functional domains.

At issue is the medical necessity for the requested health service/treatment of Home Care/ Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 70 Hour(s) per week.

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

The requested health service/treatment of Home Care/Personal Care home health care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 70 Hour(s) per week has not been demonstrated to be medically necessary for this patient.
The patient has dementia and incontinence, along with functional deficits requiring hands on assistance for multiple ADLs and IADLs. She receives consumer directed personal care and lives with her son. There was no documentation regarding unmet personal care needs. She receives weekly hours which are greater than that recommended by the task tool.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Issues.
Treatment: Braces and Monthly Visits.
The insurer denied the braces and monthly visits.
The health plan's determination is upheld.

The patient is a female with maxillary and mandibular crowding and many unerupted permanent teeth. The orthodontist mentioned in the diagnosis that tooth number (#)11 is impacted. The patient was treatment planned for 36 to 42 months of comprehensive orthodontics with surgical canine exposure but the plan was denied due to lack of medical necessity.

The health plan, in its determination of medical necessity, did act reasonably, with sound medical judgment and in the best interest of the patient. 

Braces and monthly visits are not medically necessary for the patient. She is in the process of losing her remaining primary teeth as they are replaced with permanent teeth. The patient is in the mixed dentition phase of development. Neither tooth #6 nor tooth #11 appear to be erupting at a poor angle on the radiograph, and it is too early to determine if it will require an exposure. There is still much time to see if the tooth will erupt successfully on its own without orthodontic intervention.

Research indicates the following risk factors for impacted canines:

1- If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph.)
2- The canines cannot be palpated and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption.)
3- The lateral incisor is proclined and tipped distally (Neither lateral incisor looks proclined or tipped distally.)
4- On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided.).
The patient does have maxillary crowding and treatment may be indicated in the future. However, the patient does enough of the criteria to suspect tooth #11 is, in fact, impacted. For this reason, orthodontic treatment is not medically necessary.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Leg pain
Treatment: Injection to treat pain and/or tingling in leg (procedure code 64483)
The insurer denied coverage for injection to treat pain and/or tingling in leg (procedure code 64483).
The denial is overturned.

This patient has bilateral leg pain and numbness. He is taking Methocarbamol, Lyrica and Tylenol for pain. The patient had a trial of physical therapy. His magnetic resonance imaging (MRI) shows moderate to severe spinal stenosis at lumbar (L)3-L4. The request is for bilateral transforaminal epidural steroid injections.

The use of Epidural steroids in this case is supported by:

A recent Cochrane review of epidural steroid injections was published and found in "25 clinical trials (from 29 publications) providing data for a total of 2470 participants with sciatica, an increase of six trials when compared to the previous review. Epidural corticosteroid injections were probably more effective than placebo in reducing short-term leg pain (MD -4.93, 95% CI -8.77 to -1.09 on a 0-100 scale), short-term disability (MD (mean difference)-4.18, 95% CI (confidence interval): -6.04 to -2.17 on a 0-100 scale) and may be slightly more effective in reducing short-term overall pain (MD -9.35, 95% CI -14.05 to -4.65 on a 0-100 scale). There were mostly minor adverse events (without hospitalization) after epidural corticosteroid injections and placebo injections without difference between groups (RR (risk ratio) 1.14, 95% CI: 0.91-1.42). The quality of evidence was at best moderate mostly due to problems with trial design and inconsistency. 

They concluded: A review of 25 placebo-controlled trials provides moderate-quality evidence that epidural corticosteroid injections are effective, although the effects are small and short-term. There is uncertainty on safety due to very low-quality evidence."

Evidence based clinical practice guidelines also support the performance of an epidural injection.

There is insufficient evidence to make a recommendation for or against the use of physical therapy or exercise as stand-alone treatments for degenerative lumbar spinal stenosis.

Interlaminar epidural steroid injections are suggested to provide short-term (2 weeks to 6 months) symptom relief in patients with neurogenic claudication or radiculopathy. There is, however, conflicting evidence concerning long-term (21.5-24 months) efficacy.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for injection to treat pain and/or tingling in your leg (procedure code 64483) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

This is an adult patient that presented to the hospital complaining of both left and right sided chest pain. Past medical history was significant for hypertension, end stage renal disease and an indwelling dialysis catheter. The patient noted that she had not had dialysis for two weeks. Upon arrival to the hospital the patient was hypertensive with blood pressure (BP) of 165/106 and pulse was 83. On exam she noted tenderness at the site of her indwelling right sided dialysis catheter, but no erythema or swelling was noted. 12 lead electrocardiogram (EKG) revealed normal sinus rhythm without evidence of ischemic ST or T wave changes. Serum blood testing revealed an elevated troponin (0.13) and elevated B type natriuretic peptide (BNP) (2451). She was hyperkalemic (potassium 8.2) and blood urea nitrogen (BUN) was 71. The patient was admitted to the hospital for monitoring and treatment. She underwent dialysis and signed out against medical advice.

This patient presented with chest pain, untreated hypertension, uremia and hyperkalemia. She had not been dialyzed for two weeks and troponin as well as BNP were elevated.  Her pretest probability of coronary artery disease is intermediate. (Reference 1) Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score she was considered intermediate risk (5 points). (Reference 2) Risk assessment of patients presenting with chest pain and no significant ST changes on EKG was reviewed by Hedayati et al. (Reference 3) Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. These findings are concerning and warrant management and evaluation at a higher level of care. Serial troponin measurement, echocardiography and ischemia work up were warranted prior to discharge. In conclusion, given the patient's presentation, multiple cardiac risk factors, hyperkalemia and uremia, inpatient hospital admission was appropriate.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for hospital admission is substantiated.