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

Diagnosis: Cognitive impairment
Treatment: Personal Care Assistant services 7 days x 24 hours (continuous services)
The insurer denied the Personal Care Assistant services 7 days x 24 hours (continuous services).
The denial is upheld.

The patient is a female with medical conditions including Alzheimer's disease, HTN (hypertension), depression, MS (multiple sclerosis), CVA (cerebrovascular accident), insomnia, and CTS (carpal tunnel syndrome).  This is a request for approval from live-in to continuous PCA (personal care assistant) services.  Additional care is requested to managed toileting needs at night.

Provider notes that the patient is at high risk for falls due to unsteady gait and cognitive impairment.  She is in rehab and requesting to return home.  Assessment performed shows the patient has severe cognitive impairment; total dependence with meal preparation, shopping, housework, managing finances, bed mobility, and toileting; extensive assistance with managing medications; maximal assistance with phone use, transportation, bathing, dressing, and personal hygiene; uses wheelchair and scooter or locomotion; and frequently incontinence of bowel and bladder.

No, the Personal Care Assistant services 7 days x 24 hours (continuous services) are not medically necessary.

Medically necessary services are typically which are:
- safe 
- effective
- generally accepted national standard of medical practice 
- not provided primarily for convenience of the patient or the practitioner 
- the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested increase in services from live-in to continuous PCA (personal care assistant) is not medically necessary because it was not in accordance with generally accepted national standard of medical practice for this patient's scenario.

Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the provide obtain routine five hours daily of uninterrupted sleep during the aide's eight-hour period of sleep.  The assessment does not support the medical necessity for continuous Personal Assistance Service.  The continuous care was requested to assist with toileting/diapering at nighttime.  This is not a medical condition for which continuous care is indicated.  The approved live-in PCA (personal care assistant) is sufficient to provide assistance with ADLs (activities of daily living) and personal care for this patient's scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems. 
Treatment: Dental/Orthodontic Procedure. 

The insurer denied the dental treatment. 
The denial was upheld in whole. 

The patient is a male who presented for evaluation and treatment of teeth #14 and 18 with extractions, radiographs and a consultation. Provided for review are previous letters of appeal and denial, letters with information regarding which teeth were extracted, letters regarding the medical status of the patient, health plan language, and health plan coding explanations. In question is the medical necessity of the treatment of extraction of teeth #14 and 18 (7210), delivery of intravenous (IV) antibiotics, radiographs, and consultation of the patient. 

Not provided by the treating doctor are any clinical notes from the date of consultation, any radiographs that were claimed to have been taken, any clinical description of the mouth or the teeth in question, any diagnosis for the teeth that were treated, nor any other supporting documentation as rationale for the treatment delivered. Uphold in whole the health plan's determination of medical necessity. The requested health service/treatment of Dental Services with Emergency Provider Out of Area is not medically necessary for this patient. As the documentation does not support the treatment provided, the treatment is not medically necessary. Outside of a description of the patients medical conditions, there is no supporting documentation provided to support the actions of removing the specific teeth #14 and 18. Medical conditions are systemic in nature and affect the entire body, not specific teeth. Although specific teeth can affect the body, there is nothing to support that position, nor was there any dental explanation of the actions taken, any dental diagnosis for the actions taken, nor any notation to support the treatment. With no documentation of any diagnosis, findings, or radiographic support for the treatment provided, this service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion with a severe overbite. 
Treatment: Braces.
The insurer denied coverage for braces.
The denial is overturned. 

The patient is a female child with no documented medical history. She presented to an Orthodontist office for an evaluation.  X-rays and pictures were taken. Handicapping Labio-lingual (HLD) score was 17.  The treating orthodontist recommended D8080 braces in order to correct a Class I malocclusion with a severe overbite.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as letter of support from the treating orthodontist and insurer correspondence, it appears that this patient presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, overbite and impacted canines. The orthodontist has completed the HLD index as required and has chosen the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated.  

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, a HLD Index is utilized. 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 impacted permanent anteriors where extraction is not indicated. This automatically qualifying condition criterion is met and does support comprehensive orthodontic care.  In this case, the clinical circumstance does meet 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. Peer reviewed articles conclude 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 and in the best interest of the patient. 

Based on the above, the medical necessity for braces is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman who presented to the emergency department complaining of headache, minor nosebleed and marked blood pressure elevation. She had recently been discharged after hospitalization for uncontrolled hypertension. Her medical history was remarkable for systemic lupus erythematosus, end stage renal disease, hypertension and asthma. In the emergency department, her blood pressure was 200/107 mmHg (millimeter of mercury) with a heart rate of 77 beats/minute. She had no focal neurologic findings. She was treated with intravenous labetalol, sublingual nitroglycerin and several doses of intravenous hydralazine along with her regular oral medications, including clonidine and losartan. She was admitted to the hospital with a diagnosis of hypertensive urgency. 

The inpatient stay was not medically necessary.
This patient presented with marked hypertension without evidence of acute end-organ damage (hypertensive urgency). Based on the records provided, an inpatient level of care was not medically necessary for blood pressure management. There is no evidence that rapid lowering of blood pressure in patients with hypertensive urgency is of benefit and, in fact, it can be harmful. Outpatient titration of antihypertensive medications with lowering of blood pressure to goal over a period of weeks has been shown to be both safe and effective. Given this patient's headache and nosebleed, it was reasonable to monitor her until she could undergo her regularly scheduled dialysis session. However, this did not require an inpatient level of care. A lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer-Pancreatic cancer.
Treatment: Inpatient stay.
The health plan denied the inpatient stay as not medically necessary. 
The reviewer had upheld in whole the health plan determination.

The patient was admitted to the hospital for fatigue and weight loss. The patient states he was having left sided abdominal pain for approximately 1 year. As an outpatient he underwent a computed tomography (CT) scan of the abdomen which demonstrated a lesion in the tail of the pancreas with hepatic metastasis and was admitted for further work-up. He also was diagnosed with Helicobacter pylori (H pylori). On admission the plan was to order a magnetic resonance imaging (MRI) scan and start treatment of H pylori. The patient underwent an MRI scan which showed similar findings to the outpatient CT scan. The patient underwent an endoscopic ultrasound biopsy of the lesion. During the entire hospital stay the patient's vitals were within normal limits (WNL) and there were no concerning lab abnormalities.

The patient had no needs which required acute inpatient hospitalization.
The patient has metastatic pancreatic cancer. There is no question concerning the diagnosis. The standard of care is to clarify staging and acquire tissue to secure the diagnosis. Unless there is a compelling reason, this is established in the outpatient setting, which is the standard of care. A compelling reason would be that the patient is dehydrated from poor by mouth (PO) intake, has an urgent/emergent complication related to the tumor (e.g. thromboembolism) or has intractable pain requiring intravenous pain medication. A common example in pancreatic cancer would also be if the presentation is obstructive jaundice where an urgent endoscopic retrograde cholangiopancreatography (ERCP) is required. None of these compelling reasons were relevant in this case. The care of the patient, including preventing a complication, was not improved by the inpatient admission. The oncology service deferred management decisions, as they were awaiting pathology from the biopsies. Under normal circumstances the patient's care including work-up would be accomplished at a lower level of care. He could have received pain medication and antiemetics as needed (PRN). The MRI and endoscopic ultrasound (EUS) could have been completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis.
Treatment: Otezla.
The insurer denied Otezla. 
The health plan's determination is upheld. 

The patient is a male with psoriasis. He is being treated with topicals. The patient has 15% body surface area (BSA) involvement. The provider is requesting Otezla. The patient also has a history of diabetes. The health plan denied coverage for Otezla as not medically necessary. This is under review.

Otezla is not medically necessary for this patient. In order for the patient to receive the requested Otezla, the patient must have tried and failed at least 3 months of systemic therapy such as methotrexate or have a contraindication to this, and if contraindication is present then a trial of phototherapy or medium/high potency topical steroids in combination with anthralin, calcipotriene or tazarotene.
In this case, the patient has tried the appropriate topical therapy but has not tried systemic therapy. He does not have any specific contraindications to methotrexate and his alcohol consumption is documented at less than 1 drink per day. The use of methotrexate is still within standard of care for psoriasis and a trial of this medication would be appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This patient is a male who presented with abdominal pain associated with decreased oral (PO) intake and bilious vomiting.  The patient has chronic abdominal distention.  The patient drinks ten shots of vodka per day for 20 years.  

No, the proposed inpatient admission was not medically necessary.

This patient was admitted with alcohol withdrawal.  The patient was hemodynamically stable and afebrile.  He had mild tachycardia but no arrhythmia.  He did not have persistent vomiting, delirium, seizures, or gross tremor.  Labs were remarkable for lactic acidosis.  The patient was admitted with plan for IVF and CIWA protocol.  The patient rapidly improved with IVF with resolving lactic acidosis.  CIWA was less than five on day #2.  The patient remained clinically stable through and did not have findings of severe alcohol withdrawal.  CIWA remained less than five.  The patient did not have symptoms that required an acute inpatient level of care.  He had not failed management in a lesser level of care.  The requested inpatient admission  was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Schizoaffective Disorder, Suicidal Ideations
Treatment: Continued inpatient mental health treatment
The insurer is denied coverage for continued inpatient mental health treatment. 
The denial is partial overturned. 
This is a female patient who was admitted to the inpatient mental health treatment due to psychotic symptoms. The patient had disorganized thinking and behavior as she was staggering in the street. The patient reportedly was non-compliant with her medications, and exhibited symptoms of psychomotor retardation, drooling, slow speech, uncooperativeness, poor eye contact, depressed mood, and feelings of hopelessness, inability to care for self (i.e. not bathing or toileting), and not eating with 40 pounds of weight loss in three months. The patient was admitted and was treated with risperidone, Haldol, and gabapentin. The patient improved and was discharged.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Schizophrenia reports that patients with hallucinations, delusional thinking, disorganized thinking or behavior, suicidal or homicidal plan or intent, agitation, or aggressive behavior, or inability to adequately care for basic needs are candidates for hospitalization. The chart notes reported that this patient was unable to care for self until date of service. Notes reported that the patient was still unable to care for self as she was isolative, had minimal interaction, depressed mood, hopelessness, constricted affect, and was struggling with balance issues. Notes reported gradual improvement as the patient required encouragement with caring for her basic needs including showering and changing clothes, and she was still isolative with minimal interactions. After two more days of improvement to the point of feeling better further chart notes no longer supported this patient's need for 24-hour hospital treatment. Notes reported that the patient was feeling much better, had improvement in showering and changing clothes, and she was accepting medications, was better related with staff, selective in interactions with peers, participating in some group activities, and was calm, had fair grooming, normal eye contact, and denied suicidal and homicidal ideation, hallucinations, or delusional thinking. Notes reported that the patient was feeling better and was discharged.  There were no further reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in an inpatient psychiatric treatment setting then or that could not be treated in a less restrictive setting then. Thus, while inpatient mental health treatment was medically necessary continued inpatient mental health treatment was not medically necessary for this patient.

The health plan acted reasonably with sound medical judgment to disapprove coverage for the last five days but did not act in the best interest of the patient for denying coverage for the first seven days.

The carrier's denial of coverage for continued inpatient mental health treatment should be partial overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac /Circulatory Problems/Arrhythmia.
Treatment:  Inpatient hospital stay.

The insurer denied the inpatient stay.  The denial is upheld in whole.

The patient has a history of hypertension, hyperlipidemia and paroxysmal atrial fibrillation.  The patient presented to the emergency department complaining of palpitations, nausea and lightheadedness.  The patient was electrically cardioverted to sinus rhythm and was discharged on Sotalol.  No, an inpatient hospital stay was not medically necessary.

This patient presented with symptomatic atrial fibrillation (AF) with a rapid ventricular rate.  The patient was hemodynamically stable; there was no evidence of ischemia; he was not in decompensated heart failure and was not at high risk for thromboembolism.  For patients presenting to the emergency department with AF, the safety of a lower level care has been well demonstrated.  As stated by Lin et al, "There is growing evidence to suggest that outpatient management is a safe and effective alternative to hospital admission for the management of many patients with acute AF or atrial flutter.  Protocols for early rhythm control, clinical decision rules to guide the decision to initiate antithrombotic therapy, and low molecular weight heparin and direct oral anticoagulants have reduced the need for acute inpatient hospitalization."

Therefore, the inpatient level of care was not medically necessary in this particular case, as the patient could have been treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Uterine Fibroids.
Treatment:  CPT code 37243 (vascular embolization or occlusion).

The insurer denied coverage for CPT code 37243 (vascular embolization or
occlusion).  The denial is overturned. 

This is a female patient with a history of fibroids, abnormal uterine bleeding, and menorrhagia with associated anemia requiring iron transfusion.  A magnetic resonance imaging (MRI) of the pelvis was performed and revealed a multi-fibroid uterus, mostly subserosal, with the largest myoma 5.7 cm.  An endometrial biopsy was performed and showed no hyperplasia, atypia, or malignancy.  The patient underwent a uterine artery embolization for treatment of her symptomatic uterine fibroids.  The procedure was performed without complications.

Uterine artery embolization (UAE) is a minimally invasive treatment for uterine leiomyomas (fibroids).  The procedure is a percutaneous angiographic procedure performed with video fluoroscopic imaging with injection of embolic agents into the uterine artery.

Ideal candidates for UAE include women with heavy menstrual bleeding or dysmenorrhea caused by intramural fibroids, who are premenopausal, and who have no desire for future pregnancy.

Many protocols include magnetic resonance imaging before UAE in order to properly determine size and location and ensure that the uterine masses are consistent with uterine fibroids.  This patient had menorrhagia due to uterine fibroids, as demonstrated by MRI.  She is premenopausal and is not interested in having children.  Her Pap smear was normal.  She had an endometrial biopsy that did not show any pathology.  There is no contraindication to perform the uterine artery embolization, and the procedure was indicated and medically necessary.

The health care plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.  CPT code 37243 (vascular embolization or occlusion) performed is considered medically necessary for this patient.

Based on the above, the medical necessity for CPT code 37243 (vascular embolization or
occlusion) performed is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pre-eclampsia postpartum

Treatment: Inpatient hospital admission 

The insurer is denied coverage for inpatient hospital admission.

The denial is upheld. 

The female patient who delivered an infant via spontaneous vaginal delivery. She was readmitted to the hospital approximately one week later with a diagnosis of severe hypertension and pre-eclampsia postpartum. Pre-eclampsia had been diagnosed and treated at the time of delivery. The patient's admission vital signs at readmission included a blood pressure of 170/90. Oral Procardia was given and the patient's blood pressure improved outside of the severe range. The patient's blood pressure improved to normal ranges within six hours. The patient was observed overnight and was discharged the following day.

Pre-eclampsia is a form of hypertension that is unique to human pregnancy. The clinical findings of pre-eclampsia can manifest as either a maternal syndrome or a fetal syndrome. In practice, the maternal syndrome of pre-eclampsia represents a clinical spectrum with major differences between near-term pre-eclampsia without demonstrable fetal effects and pre-eclampsia that is associated with low birthweight and preterm delivery. The clinical course of pre-eclampsia with severe features may be characterized by progressive deterioration in both maternal and fetal conditions. Because these pregnancies have been associated with increased rates of maternal morbidity and mortality and with significant risks for the fetus (growth restriction, hypoxemia, and death), it is generally agreed that all such patients should be delivered if the disease develops after 34 weeks' gestation. Prompt delivery is also indicated when eclampsia is imminent-when persistent, severe symptoms do not respond to treatment-or in the presence of multiorgan dysfunction or severe intrauterine growth retardation (<5th percentile) in association with abnormal umbilical artery Doppler studies, such as reversed end-diastolic flow (REDF) or severe oligohydramnios (largest vertical pocket <2 cm), suspected placental abruption, nonreassuring fetal testing, gestational age less than 24 weeks, or fetal demise. 

In this case, the patient was admitted with severe hypertension which quickly resolved with treatment. The patient's vital signs were normal and she had no acute neurologic abnormalities. The patient could have been treated and monitored at a less acute care setting, such as observation level of care. Therefore, the inpatient admission was not medically necessary for this patient. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial should be upheld.