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

Diagnosis: Arthritis.
Treatment: Home Care / Personal Care home health care (HHC) - Level 2 Personal Care Services, per 15 minutes Increase to 45 Hour(s) per Week.
The insurer denied: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 45 Hour(s) per Week.
The denial is: Upheld.

The patient is a male with a history of pes planus, knee arthritis, bulimia, back pain, fibromyalgia, orthostatic hypotension, irritable bowel syndrome, neurogenic bladder, chronic depression, and insomnia. He was receiving home care services 5.5 hours per day, 5 days per week for a total of 28 hours per week. The patient and his care team requested an increase in hours to 6-7 hours per day, 7 days per week for a total of 45 hours per week. The plan did not approve the full increase but did increase his hours to 35 hours per week (5 hours per day, 7 days per week coverage).

The health plan's determination is upheld.

The requested health service/treatment of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 45 Hours (s) per Week is not medically necessary for this patient.
The patient's primary care physician stated that it was medically necessary to increase his hours to "increase his ability to remain safely at home, to prevent the onset of fall-related injuries, to reduce or ameliorate the physical and mental effects of his disabilities, and to enhance community inclusion." However, this is not a function of personal care services. Hours for safety monitoring and security are not personal care functions.
The plan did increase his hours to accommodate 7 days per week coverage, which seems appropriate given his decreased functioning in Instrumental activities of daily living (IADLs) as demonstrated on the UAS. The task tool recommended 28 hours per week total, and the plan allowed approximately 25% more hours (35 hours per week) to allow for some buffer. There is no evidence that specific medical needs are currently not being met at 35 hours per week and that an additional 10 hours would cover them.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: White glass with gold crown tooth 3; nerve treatment on molar tooth 3.
The insurer denied the white glass with gold crown tooth 3; nerve treatment on molar tooth 3.
The determination is overturned.

The patient presented for the treatment of tooth #3. Provided for review are radiographic images from an unknown date, letters from her providers as well as previous letters of appeal and denial. At issue is the medical necessity of treatment of crown and root canal therapy for tooth number (#) 3.
The requested health service/treatment of white glass with gold crown tooth 3; nerve treatment on molar tooth 3 is medically necessary for this patient. As the radiographs show and as the documentation notes, the patient has extensive decay on tooth #3 involving the pulp of the tooth and resulting in pain. The decay must be removed from the pulp and the roots to stop the infection and to provide relief from pain before the replacement of the missing tooth structure and cusps of the tooth which have been undermined by the decay. Hence the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea/vomiting; cannabis poisoning. 
Treatment: Inpatient admission. 
The insurer denied: Inpatient admission. 
The denial is upheld. 

The patient is an adult female with a past medical history of gastritis, cannabis abuse and cyclic vomiting syndrome. She presented to the ED (emergency department) of the hospital. The patient reported vomiting and abdominal pain. 

The patient's vital signs were unremarkable. Blood tests were unremarkable. There was no concern for a surgical emergency causing her symptoms. The patient was kept in the ED (emergency department) for several hours. She was treated with IV (intravenous) fluids and IV (intravenous) medication for nausea. Despite this, her nausea persisted. Following her ED (emergency department) evaluation, she was admitted to the hospital. The admission note for this patient indicates that would receive IV (intravenous) fluids and medication for nausea. No other diagnostic testing was planned. There was no documented concern for a surgical emergency. Although she was hypertensive during her hospital stay, this did not require treatment with IV (intravenous) medications. 
The following day the patient was improved. The patient was discharged home the next day. 

The inpatient admission was not medically necessary. 

The patient did not have a severity of illness to justify an inpatient admission. Despite having abdominal pain and vomiting, there was no concern for a surgical emergency. The patient's symptoms were attributed to ongoing cannabis abuse. She was never hypotensive due to hypovolemia. There was no evidence of sepsis. 

Likewise, the patient did not have an intensity of required services to justify an inpatient admission. Her admission note indicates that she would be treated with IV (intravenous) fluids and IV (intravenous) medication for nausea. She was written for a liquid diet which would be advanced as tolerated. There is no mention of additional testing or consultations being planned. 

In its appeal letter, the hospital argues that an inpatient admission was warranted because the patient had intractable vomiting and required IV (intravenous) fluids and IV (intravenous) medications. Despite having persistent vomiting, the patient remained clinically stable. A limited plan of care was anticipated for her. There would have been no reason to believe she would require a prolonged stay in the hospital. The need for IV (intravenous) fluids or IV (intravenous) medication in a stable patient does not justify an inpatient level of care. 

This patient was clinically stable. A limited plan of care was anticipated for her. An inpatient admission was not medically necessary. The patient could have been safely and effectively managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite, overjet
Treatment: D8080 (Braces) and D8670 (Monthly Visit x4)
The insurer denied the D8080 (Braces) and D8670 (Monthly Visit x4)
The denial is overturned.

The patient is male requesting orthodontic benefits. Has a deep overbite and large overjet. Prior denial was based on a Salzmann score of 16.

Yes, the proposed treatment is medically necessary.
The patient has a deep, impinging overbite with soft tissue damage to his palate. This is an automatic qualifier for orthodontic treatment according to the handicapping index scale. This case has medical necessity and the patient needs orthodontic treatment to correct things.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured ankle
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is overturned.

This is the case of an adult male with a medical history of obesity, myocardial infarction, hypertension, and current smoking status. The patient presented for repair of right comminuted fibular fracture, right distal third tibia comminuted fracture and percutaneous fixation of right posterior malleolus ankle. Per the appeal letter, the patient initially was at an outpatient status; however due to the extended, complex nature of the surgery, slow progress in physical therapy, need for every 2-4 hours compartment checks and significant comorbidities, the patient was converted to an inpatient status.

The facts were the patient was a high risk patient. The Anesthesia department opined ASA (American Society of Anesthesiologists) level 3. He had several underlying comorbidities which would place him at a higher risk for complication and need for monitoring. His fracture was complicated by open wounds which by itself increases the risk of infection. His surgical procedure was over 5 hours. This finding substantiates the complexity of the fracture and likely difficulty in performing the operation. His post-surgical course was complicated by pain to require parenteral analgesia. He required over 9 doses of Dilaudid with supplemental other IV (intravenous) agents. He also required several oral doses of pain reliever.

These findings substantiate necessity of inpatient admission. His treatment could not have been provided at a lower level.

The full hospital admission is considered medically necessary for this patient.

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 full hospital is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Replacement Continuous Positive Airway Pressure (CPAP) Device
The insurer denied the Replacement Continuous Positive Airway Pressure (CPAP) Device
The denial is overturned.

The patient is a male.  The patient had a sleep study with clinically significant apnea with an apnea hypopnea index (AHI) of respiratory disturbance index (RDI) of 34.  The patient has additional morbidity of hypertension. The patient has had a number of months where the continuous positive airway pressure (CPAP) has stopped working during the night.  The patient is reported to be compliant with use sleeping for five hours a night with the device.  There is conflicting information whether the unit has been recalled in the medical record.

Yes, medical necessity has been established for the proposed continuous positive airway pressure device.

The patient had a sleep study with clinically significant apnea with an apnea hypopnea index (AHI) of respiratory disturbance index (RDI) of 34.  He has additional morbidity of hypertension. He has had a number of months where the continuous positive airway pressure (CPAP) has stopped working during the night.  He is reported to be compliant with use sleeping for five hours a night with the device.   

There is report of intermittent failure of the unit.  Based on standard of care, if the unit is not working properly and fails intermittently, it presents a risk to the patient. It therefore should be replaced. Therefore, replacement meets a medical necessity standard.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The plan followed it's medical policy.  With intermittent failure of the device, it is in the best interest of the patient to replace the continuous positive airway pressure (CPAP) machine to insure that it is working for the patient on a nightly basis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough.
treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case involves a woman with seizures and hypothyroidism who was seen in the emergency department (ED) with complaints for several days of a cough. The patient's cough was productive, with congestion in her throat. The patient denied any fevers, chills, nausea, or vomiting. The vital signs showed a temperature of 98.5, blood pressure of 113/71, and a pulse rate of 89. On exam, she appeared comfortable and in no acute distress. Lungs were clear bilaterally.

The inpatient hospital admission was not medically necessary. The patient's presenting symptom was a cough related to influenza A. Chest x-ray, and computed tomography (CT) scan of the chest failed to demonstrate a secondary bacterial infection. Vital signs are stable. There is no evidence of hypoxemia. There was a questionable episode of paroxysmal AVNRT (Atrioventricular nodal reentry tachycardia); however, this could not be substantiated on an electrocardiography (EKG), only on a telemetry strip with many artifacts. The patient was admitted to the hospital for monitoring and had no recurrence. The laboratory studies are unremarkable, and there are no major metabolic processes that would require inpatient hospitalization. There is no evidence of severe sepsis or septic shock. The patient did not require specialized treatments that could only be provided in an inpatient setting. Generally speaking, from a medical necessity standpoint, this patient should have been discharged from the emergency department home without the need for hospitalization. There is no evidence of hypoxemia, severe dehydration, renal dysfunction, pulmonary dysfunction, or mental status change to prompt admission to the hospital. A lower level of care would be appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache.
Treatment: Ubrelvy 100mg.
The insurer denied Ubrelvy 100mg.
The determination was upheld.

The patient is a female with a diagnosis of migraine. However, headaches are reported to have started following significant head trauma.

The patient is listed to have previously tried Fioricet and Oxycodone, which are recommended according to both the American Headache Society (Loder et al.) and the American Academy of Neurology (Langer-Gould et al.), to be avoided in the treatment of migraines given the high risk of rebound. Despite such use, no evaluation for rebound headaches is documented. Rizatriptan is listed as prescribed multiple times, and no significant side effects are documented.

The patient does not have any Food and Drug Administration (FDA) listed contraindications or intolerance to all such agents. Insurance forms mention auras as a contraindication, but that is not an FDA-listed contraindication. There is no documentation of significant cardiovascular disease, basilar or hemiplegic migraine, ophthalmoplegic migraine, or any other FDA-listed contraindication. Pharmacy claims indicate multiple, recurrent prescriptions of Rizatriptan over several years, and no side effects are documented.

There is insufficient evidence from high-quality peer-reviewed literature, large, well-designed, blinded, randomized trials to support the long-term superiority of the requested drug, Ubrelvy, and overall available formulary agents which include several proven and FDA-approved triptans such as Sumatriptan, Eletriptan, Naratriptan, and Zolmitriptan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide services: 7 Days per week, 2 x 12 hours splits shift
The insurer denied the Personal Care Aide services: 7 Days per week, 2 x 12 hours splits shift.
The health plan's determination is overturned. 

The patient is a male with past medical history of dementia, permanent pacemaker, hypertension, hyperlipidemia, urinary incontinence, Foley catheter status, nephrostomy tube status, kidney stones, and anemia who had been assigned PCA (personal care aide) services.

Personal Care Aide Services: 7 Days per Week, 2 x 12 Hours Split Shift are medically necessary for this patient.
There is documentation of medical necessity of increased PCA services by the patient's PCP (primary care provider). The patient's PCP also documents the patient requires turning and repositioning every 2 hours with total assistance to prevent skin breakdown. There is documentation from the plan's own assessment of total assistance with all tasks except for eating. There is documentation that the patient is bedbound and has 2 sacral ulcers. 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 unpredictable and unscheduled care needs. The patient's care needs in the overnight hours are such that the PCA would not be able to obtain at least 5 hours of uninterrupted sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL).
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 7 Days per Week, 2 x 12 Hours Split Shift 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: Upheld

Diagnosis: Congenitally missing teeth.
Treatment: Surgery (bone grafts in upper and lower jaw).
The insurer denied: Surgery (bone grafts in upper and lower jaw).
The denial is upheld.

The patient is an adult male with a history of congenitally missing maxillary and mandibular lateral incisors. He had earlier undergone bone grafting and implant placement in an attempt to replace and restore these areas. These were subsequently unsuccessful. Maryland bridges were then used to restore these missing teeth. The patient did not like the functional and cosmetic results of these restorative procedures. The patient is now electing to have autogenous bone grafts and osseointegrated implants placed in these areas. The procedures were denied coverage by the health plan as being not medically necessary. The denial is being appealed.

The requested surgery is not medically necessary.

The replacement of congenitally missing teeth is not a medically necessary procedure. The standard of care does not indicate that the replacement of congenitally missing teeth by grafting teeth must be done.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sepsis

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

The patient is an adult male who presented to the emergency department (ED) on with history of nausea, vomiting, abdominal pain and myalgias of 2 days duration. The patient also reported tea colored dark urine. The patient reported use of cannabis prior to this presentation.

At presentation Temperature of 98 degrees F (Fahrenheit), Heart Rate 110, Respiratory Rate 20, Blood Pressure 117/68 mm Hg (millimeters of mercury), oxygen (O2) saturations 97 % at room air. The patient was in some distress. Lungs were clear. The patient's white blood cell count (WBC) was 22.5K (thousand), hemoglobin (Hb) 17.9 BUN (blood urea nitrogen)/Creatinine (cr) 26/2.75 (Baseline Cr was normal).

Liver function tests (LFTs) were within normal limits (WNL), Lipase was elevated suggesting pancreatitis. Creatine phosphokinase (CPK) was elevated and peaked at 3537. Chest x-rays revealed (CXR) left infra hilar infiltrate. Urinalysis (UA) showed red blood cells (RBC) 50-100.

The patient was admitted for Sepsis rule out (R/O) pneumonia (PNA), Dehydration, Rhabdomyolysis and acute kidney disease (AKI). The patient was aggressively hydrated and treated with Rocephin and Azithromycin for PNA. He received PPI (proton pump inhibitors) and Zofran for nausea/Vomiting. A sonogram of the Kidney was done to R/O Obstruction.

The patient's CPK's continued to rise after admission.  Creatinine slowly started decreasing.

This patient had multiple medical issues as described. He needed very close monitoring for his AKI and Rhabdomyolysis. Renal function was closely monitored with aggressive hydration. Once the patient improved, he was discharged home. 

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 the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: tachycardia

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

The patient is an adult female who presented to the Emergency Department (ED) with fever, chills and headache. She was pregnant. The patient was noted to be tachycardic. Her oxygen saturation on room air was 100%. She tested positive for the Flu (A) she was hydrated with 3 1/2 liters of fluid and started on Tamiflu. However, she remained tachycardic. Because of tachycardia, it was decided to admit the patient.

Chest X-ray showed left lower quadrant (LLQ) pneumonia. Her oxygen saturation dropped to 92% and she was placed on supplemental oxygen. There was concern about sepsis and the patient was started on Rocephin.

She was evaluated by infectious and pulmonary who both recommended continuation of Tamiflu and Rocephin.

The next day she was doing well and was discharged home on Tamiflu and Cefpodoxime.

Pregnant patients with seasonal influenza are more likely to be hospitalized and admitted to an intensive care unit and have a higher mortality compared with the general population. Maternal influenza also increases the risk of adverse fetal outcomes (eg, congenital anomalies, preterm birth, fetal death).

As per standard of care, hospitalization is warranted for patients with significant dehydration and for severely ill patients, especially those with respiratory distress, hypoxemia, impaired cardiopulmonary function, or altered mental status. For patients at risk for complications but without these findings, admission for observation may be warranted.

This patient had influenza with concern about impaired cardiopulmonary function. In addition, there was evidence of deterioration in her respiratory status as her oxygen saturation dropped from 100% to 92%.

In addition, there was concern about possible concomitant infection based on the findings on chest x-ray necessitating IV (intravenous) antibiotics.
  
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 the inpatient admission is overturned. Medical Necessity is substantiated.