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

Diagnosis: Knee Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay
The determination is upheld.

The patient had undergone prior right total knee revision surgery and subsequently developed function limiting and painful stiffness in the affected right knee. The records document that this patient underwent a manipulation under anesthesia to restore motion to her right knee. A sterile aspiration was also performed in the operating room. The patient was admitted for inpatient hospital care. The health plan denied these inpatient days as not medically necessary. At issue in this case is the medical necessity of the inpatient hospital stay.

The requested health service/treatment of inpatient hospital stay was not medically necessary for this patient. The medical records document that this patient underwent a knee manipulation under anesthesia and sterile knee aspiration. There were no documented complications of the procedures performed and the patient had an uneventful hospital stay prior to her discharge to a skilled nursing facility. There is no evidence of a peri-prosthetic knee infection documented from the knee aspiration. There is no peer-reviewed literature that supports a five night inpatient hospital stay for pain management or progression of physical therapy after undergoing a manipulation under anesthesia for knee arthrofibrosis following total knee replacement.  Most studies in the current, peer-reviewed literature describe knee manipulation as an outpatient procedure. 

A right knee manipulation under anesthesia and sterile knee aspiration were performed without any complications and these services were consistent with the recommendations of the current, peer-reviewed orthopedic literature as documented by Thompson and colleagues in Orthopedic Clinics of North America and by Newman and associates in the Journal of Arthroplasty. However, the procedures performed for this patient are usually completed at a lower level of care. The provided medical records do not justify the medical necessity of the inpatient hospital stay. This is based upon the provided medical records and the recommendations of the current, peer-reviewed orthopedic literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gynecological. 
Treatment: Infertility 
Treatment: The insurer denied: IVF and PGT. 
The denial is overturned in whole.

The patient is a  female who has a child who is homozygous for a c.710G>A mutation (ALDH3A2) which clinically presents as Sjogren-Larsson syndrome. Both the patient and her partner are carriers for this recessive mutation. In order to prevent having another child with Sjogren-Larsson syndrome, the patient would like to do in vitro fertilization (IVF) with PGT-M in order to identify which embryos would be affected and subsequently only transfer unaffected embryos to yield a pregnancy and baby.
The health plan denied the service of IVF in the absence of infertility.
At issue is the medical necessity of the IVF and pre-implantation genetic testing (PGT).

The denial is overturned in whole.

The requested service is medically necessary for the patient.
A child born with this disease is at significant risk for developmental delay, intellectual disability, speech difficulties, seizures, spastic diplegia/tetraplegia paralysis (diplegia is paralysis of both legs; tetraplegia is paralysis of all four limbs), spasticity in the legs: leg spasms, which can impair motor abilities and walking, glistening white dots in the retina of the eye, and pruritus. There is standard medical technology that exists that can prevent this couple from having another child with this disease. Both the patient and her partner are carriers for this recessive mutation.
As discussed in the letter written by the provider, the medical complications of Sjogren-Larsson syndrome are significant (including intellectual disability, need for physical and occupational therapy, and potentially seizures) and this couple already has a child with this syndrome. It is medically appropriate for this couple to use IVF with PGT-M to be able to select embryos that are not affected by these recessive genes.
There are not specific profession guidelines or peer reviewed literature regarding Sjogren-Larsson syndrome and the use of PGT-M as it is a very rare disease. However, there is a large body of peer reviewed literature, such as the article referenced below[1], that supports the use of PGT-M (otherwise previously known as PGD) for single gene disorders such as Sjogren-Larsson syndrome.
The treatment is covered, including PGT-M, whose only medical application is to prevent diseases such as this, if the patient meets the definition of infertility. However, Sjogren-Larsson syndrome is a very rare disease with medical complications. It is medically appropriate for this couple to use IVF with PGT-M to be able to select embryos that are not affected by these recessive genes. It is not medically appropriate to require this couple to try to conceive without the benefit of PGT-M, as there is a body of peer reviewed literature that supports its use for single gene disorders.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Atrial fibrillation (A-Fib).
Treatment:  Percutaneous transcatheter closure of the left atrial appendage with endocardial implant and related hospital admission. 

The insurer denied the percutaneous transcatheter closure of the left atrial appendage with endocardial implant and related hospital admission.  The health plan's determination is overturned in part. 

The patient is a man with a history of paroxysmal atrial fibrillation (AF) and heart failure with preserved ejection fraction.  He was scheduled for catheter ablation for his AF.  However, due to changes resulting from prior esophageal surgery, it was not possible to pass the transesophageal echocardiography probe or a temperature probe.  For this reason, the procedure was aborted.  During that admission, the patient was significantly anemic with a hemoglobin of 8.2 gm/dl.  He was transfused with two units of packed red blood cells.  The anemia was attributed to chronic hemorrhoidal bleeding on oral anticoagulant therapy.

The percutaneous transcatheter closure of the left atrial appendage with endocardial implant is likely to be more beneficial than standard treatment for this patient.  If the procedure is successful and uncomplicated, overnight admission under an observation level of care would be appropriate.  An inpatient admission would not be indicated.  This patient has paroxysmal atrial fibrillation.  Based on his age and history of heart failure his CHA2DS2VASc score is 3, representing a 4.6% yearly risk for stroke or systemic thromboembolism.  On oral anticoagulation, he has chronic hemorrhoidal bleeding resulting in significant anemia and need for red blood cell transfusion.  The alternative option for stroke prevention in this patient is transcatheter left atrial occlusion, such as with the Watchman device.  Surgical occlusion is not recommended in the absence of need for concomitant cardiac surgery.  The 5-year results from the Watchman trials have shown a lower incidence of major bleeding with the device as compared to warfarin, with a similar reduction in stroke.  The 2019 Focused Update of the American Heart Association (AHA) / American College of Cardiology (ACC) / Heart Rhythm Society (HRS) Atrial Fibrillation Guideline states that percutaneous left atrial appendage occlusion may be considered for AF patients with an increased risk of stroke who have contraindications to long-term anticoagulation.

The implantation of the Watchman left atrial appendage occlusion device is indicated in this patient.  If the procedure is successful and uncomplicated, overnight admission under an observation level of care would be appropriate.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Atrial fibrillation (A-Fib).
Treatment:  Percutaneous transcatheter closure of the left atrial appendage with endocardial implant and related hospital admission. 

The insurer denied the percutaneous transcatheter closure of the left atrial appendage with endocardial implant and related hospital admission.  The health plan's determination is upheld.

The patient is a man with history of esophageal cancer, status/post (s/p) esophagectomy and has paroxysmal atrial fibrillation (AF), treated with beta blockers and anticoagulation (Xarelto).  He had an event monitor showing an AF burden of 13%. Some notes report that the patient had fatigue with atrial fibrillation, while other notes report that his AF was asymptomatic.  AF ablation was planned. However, the procedure was aborted as the transesophageal echocardiogram (TEE) probe could not be passed.  He is reported to have had some bleeding with hemorrhoids.

Percutaneous Transcatheter Closure of the Left Atrial Appendage with Endocardial Implant and Related Hospital Admission is under review.

The proposed Percutaneous Transcatheter Closure of the Left Atrial Appendage with Endocardial Implant and Related Hospital Admission are not likely to be more beneficial than standard treatments for this patient's condition. The patient has atrial fibrillation, which is asymptomatic or associated with fatigue (notes are conflicting). His CHADS VASC score is 1 (age > 65) and HAS-BLED score 2.

The device is Food and Drug Administration (FDA) approved.  However, it is a newer technology and is not currently standard of care for patients, who are able to take anticoagulation for cerebrovascular accident (CVA) prevention in AF.  It will not improve AF symptoms.  In addition, in this case, imaging for placement of the device would be difficult, as TEE previously could not be performed due to the patient's previous esophageal surgery.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Atrial fibrillation (A-Fib).
Treatment:  Percutaneous transcatheter closure of the left atrial appendage with endocardial implant and related hospital admission. 

The insurer denied the percutaneous transcatheter closure of the left atrial appendage with endocardial implant and related hospital admission.  The health plan's determination is upheld.

The patient is a male with a past medical history of esophageal cancer status post resection and paroxysmal atrial fibrillation requiring anticoagulation.  He was being treated with a beta-blocker and Xarelto.  There was also history of mild mitral stenosis and a normal left ventricular ejection fraction (LVEF).  A percutaneous transcatheter closure of the left atrial appendage with endocardial implant and related hospital admission is under review.

The percutaneous transcatheter closure of the left atrial appendage with endocardial implant and related hospital admission is not likely to be more beneficial for this patient. 
Left atrial appendage closure devices, such as the Watchman, have been considered a mechanical method to prevent stroke in those with atrial fibrillation (A-fib) requiring anticoagulation, both as a substitute for anticoagulation and for individuals with a contraindication to anticoagulation.  It has not, in general, improved A-fib stroke prevention outcomes compared to oral anticoagulation.  This individual had paroxysmal atrial fibrillation requiring anticoagulation.  He was tolerating the direct oral anticoagulant Xarelto.  In this setting of an individual tolerating anticoagulation left atrial appendage closure has not been established as standard of care towards improved atrial fibrillation stroke prevention outcomes.  Therefore, proposed health service is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Ilumya 100MG/SC SOSY
The insurer denied the Ilumya 100MG/SC SOSY.
The denial is overturned. 

The patient is a female with severe psoriasis affecting her scalp, trunk and extremities for whom Ilumya is requested. She has tried and failed multiple topical steroids and calcineurin inhibitors.

Yes, the proposed treatment with Ilumya is medically necessary.

The current treatment guidelines that are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis recommend typical first line treatments such as topical corticosteroids and calcipotriene followed by typical second line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, acitretin, cyclosporine) or  biologics. The patient has tried and failed topical treatments. 


The next appropriate treatment would be phototherapy, oral systemic medications or biologics. The patient has lesions on the scalp, which are not suited for treatment with phototherapy.  Since the patient is adult female, use of methotrexate and acitretin are not medically appropriate. Additionally, they carry a much higher risk of adverse events, while not offering an advantage in efficacy. Cyclosporine is not an appropriate long-term solution due to the side effect profile and is used as a bridge or rescue treatment while another treatment's effect is waited upon to "kick in".

Therefore, Ilumya is medically appropriate and necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase Personal Care Assistant (PCA) services to 7 days x 12 hours (84 hours) per week 
The insurer denied the Increase Personal Care Assistant (PCA) services to 7 days x 12 hours (84 hours) per week.
The denial is overturned. 

The patient is a male with a history of dementia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). An appeal review has been requested for potential approval of 84 hours per week of personal assistance services to offer increased support for activities of daily living (ADLs).

A letter from the treating neurologist indicates that the patient's dementia has progressed to the point that he requires full care and assistance with all activities of daily living (ADLs). It is noted that the patient has worsening balance, incontinence and insomnia over the last two weeks.

Yes, the proposed treatment of 84 hours per week of Personal Care Assistant (PCA) services is deemed medically necessary. 

The patient is a male with a history of dementia. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Additional medical records including recent documentation from the patient's provider indicates that due to progressive functional decline and worsening insomnia, the patient requires increased assistance for activities of daily living (ADLs). Hence, the currently approved plan of 70 hours per week of Personal Care Assistant (PCA) services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of 84 hours per week of Personal Care Assistant (PCA) services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental carries and Failing Restoration on tooth number 30

Treatment: Root canal on tooth number 30

The insurer denied coverage for a root canal on tooth number 30.

The denial is overturned. 

This is a male patient who presented to the dentist with pain in the right mandible. A failing restoration and caries was noted on tooth number 30 on examination and endodontic therapy was recommended. The insurer has denied these services.

Upon review of radiographs, these clinical findings support the recommended treatment. The patient's tooth number 30 has a large carious lesion on the distal aspect encroaching on the pulp radiographically. This tooth would require endodontic therapy to salvage the tooth. This tooth will have adequate residual coronal structure for support of a post and core and crown and adequate residual periodontal alveolar bone height.  The standard of care in general dental practice would be endodontic therapy for this tooth, and subsequent post and core and crown which would have an excellent long term prognosis with the recommended treatment.

Thus, the requested root canal on tooth number 30 is considered medically necessary as the clinical and radiographic documentation support these services, and these services would be a standard of care in general dental practice.

Based on the above, the medical necessity for the requested root canal on tooth number 30 is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Gynecological
Inpatient hospital

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

This patient is a female who is under evaluation for medical necessity for admission to acute inpatient level of care. This patient was taken to the operating room for a plan of supracervical hysterectomy, myomectomy, and bilateral salpingectomy for the indication of fibroids for surgical management. The estimated blood loss was 100 mL with 1200 mL of intravenous (IV) fluids. Urine output was normal at 100 mL. The patient was taken to the operating room and underwent an uncomplicated procedure. The anesthesia start time was at 9:27 AM and end time was 11:03 AM. The patient's procedure start time was 9:57 AM with a procedure in time at 10:50 AM. Following the procedure, patient had stable vital signs with a blood pressure of 99/63 and a Pulse oxygenation of 100%. The patient's respirations were 16. She was noted to have a pain scale of zero. Pain was well-controlled. The patient had a normal postoperative evaluation on the day of surgery. There were no complications noted. Pain was well-controlled.

The inpatient hospital admission was not medically necessary. In this case, the patient was noted to undergo a supracervical hysterectomy, myomectomy and bilateral salpingectomy for the indication of fibroids for surgical management. The patient was admitted and underwent surgery that was uncomplicated with very little blood loss (described as 100 cc). There were no complications and post-operative pain was 0/10. Vital signs were normal and incision sites were well healing and stable. Hemoglobin was also stable. The patient was advanced on diet and ambulation without complication. Based upon the procedure and lack of complications noted, the patient could have been managed at a lower level of care rather than acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoglycemia
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial was overturned.  

This is a female patient with a past medical history significant for type 1 diabetes mellitus. It was reported that the patient was several days postpartum. She was brought to the Emergency Room (ER) for a witnessed hypoglycemic seizure.  The patient was admitted to the hospital for further evaluation and management of hypoglycemia. In the ER, the patient received fluids and diabetes management. The patient was discharged home with instructions to follow up with her primary care doctor and endocrinologist.

Based on the review of the medical record, this patient with type 1 diabetes with recent post-partum history presented with hypoglycemic-induced seizure. As per Dude et al. (2018), "postpartum insulin requirements decrease dramatically as a result of the rapid decrease in diabetogenic placental hormone levels and resulting dissipation of pregnancy-induced insulin resistance", and  some patient's insulin requirement decreases following delivery. Dude et al. (2018) states that patients are "typically advised to decrease basal and prandial insulin doses to 50 to 80% of their preconception doses, but recommendations are individualized". In this case, this patient could have had an iatrogenic hypoglycemia due to her post-partum decrease in insulin requirement. This likely had caused her seizure which was supported by her significant bandemia (band of 12%) and normal white blood cell count (WBC of 8.8). As per Mckechnie et al. (2019), "Hypoglycemia triggers activation of counter regulatory hormonal systems and is associated with multiple negative effects, including cardiovascular events and death."

Given this patient's major hypoglycemia event, such as seizure, it was medically appropriate for the patient to be admitted for glucose stabilization, management and monitoring. With type 1 diabetes, the patient's blood sugars can vary and not be stable, particularly after mental alteration with hypoglycemia.  In addition, the patient was not on any medications for seizures for the past two years due to being seizure-free.


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

The carrier's denial of coverage for the inpatient hospital admission should be overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease COPD.
Treatment: Personal Care Worker (PCW) Services.
The insurer denied the Personal Care Worker (PCW) Services. 
The health plan's determination is upheld. 

The patient is a female with a past medical history significant for chronic obstructive pulmonary disease (COPD), hypertension, hyperlipidemia, osteoporosis and compression fracture. The patient also has history of dementia of Alzheimer's type. The patient is requesting an increase in personal care aide hours, 12 hours a day 7 days a week for a total of 84 hours a week. She was previously receiving 56 hours a week which was increased to 66 hours a week, 10 hours per day 5 days a week and 8 hours per day 2 days a week.

The Additional Personal Care Worker (PCW) Services: 12 Hours per Day, 7 Days per Week is not medically necessary for this patient. According to documentation provided, the patient's medical needs can be met with the hours approved by her health plan. The additional services are not medically necessary.
There was no change in her needs in regards to bathing, personal hygiene, or dressing upper body. There was improvement in dressing lower body, walking, locomotion, and toilet transfer. The patient had a decline in eating since last evaluation. The patient was able to take medicines with a reminder of a PCW (personal care worker).
The most recent UAS (uniform assessment system) - state of New York noted a total of 3360 minutes a week or 56 hours a week. The provided appeal letter along with the physician statement request additional hours, however, there were no additional activities of daily living (ADL) or Instrumental activities of daily living (IADL) indicated that could not be met within hours allocated by the health plan.
Regarding the appeal letter provided, the patient was evaluated in person along with a telephonic interview. Unfortunately, due to the coronavirus, there are limitations in medical care and evaluations for both the health of the patient and also the caregiver. However, the determination of legitimacy of services has not been a concern. It appears that the evaluation was done in good faith and with proper concerns for the patient. Specifically, in the appeal there were no services that were noted that could not be done in the appropriate time that was allotted for this patient by her health plan. There is no noted additional ADLs or IADLs that were not covered in these hours. Additional service hours are not medically necessary for monitoring and fall prevention without underlying performance of ADLs or IADLs.