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

Diagnosis: Chronic chest pain and pressure

Treatment: CPT- 71270 Computed Tomography (CT) of the chest without and with contrast (dye)

The insurer denied coverage for CPT- 71270 Computed Tomography (CT) of the chest without and with contrast (dye).

The denial is upheld.

This is a female patient who has been complaining of mid-sternal chest pain and pressure which has been chronic. The patient underwent a left heart catheterization which was unremarkable. The patient still complains of chest pain and pressure. She has a medical history of hyperlipidemia and diabetes mellitus. For further evaluation, a computed tomography (CT) scan of the chest with and without contrast was recommended to evaluate for pathology in the pulmonary and other vascular beds.

A report was written by the patient's cardiologist describing the patient's sestamibi myocardial single-photon emission computed tomography (SPECT) imaging scan. The findings state that the patient's left ventricle (LV) was normal in size, and there is a small in size, moderate in severity predominately fixed apical wall perfusion defect seen. With gated SPECT, the global LV function was normal. The patient's left ventricular ejection fraction (LVEF) was calculated at 87%; regional wall motion/thickening was normal. The impression stated that this was an abnormal myocardial SPECT imaging scan. They could not rule out a small in size, area of apical ischemia. Exercise was excellent. The patient had no symptoms. The patient's stress electrocardiogram (EKG) was equivocal. The hemodynamic response was normal. The patient's resting LV function was normal. 

There is no basis to perform a CT scan with and without contrast for possible pathology in the chest. Compared with conventional angiography, the angiograms produced by multi-detector CT scanners are much lower in quality and are suboptimal for diagnostic purposes. In a patient who has already undergone selective coronary arteriography, CT has no role in the diagnosis of any cardiac disease. In fact, the sequence is in reverse where coronary angiography would be the next step if the CT was inconclusive with regard to the heart. 

As for a search for other causes of chest pain including a pulmonary etiology, Up to Date with regard to the use of imaging notes "Indications for chest radiograph include suspected pulmonary causes of chest pain, heart failure or rib fracture." There is no mention of the use of chest CT with or without contrast. This patient has had a negative electromagnetic radiation (x-ray) imaging of the chest. CT is reserved for situations where a specific disease entity is being considered. The patient's cardiologist does not provide a differential diagnosis that a CT of the chest would help to clarify. In such situations, is not considered clinically useful. 

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 CPT- 71270 Computed Tomography (CT) of the chest without and with contrast (dye) is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who was seen in the emergency department after an episode of seizure activity, which occurred at home that morning and lasted approximately two minutes. The episode included eyes rolling back, fist clenching, and jerky movements of his upper extremities. He had no fever. The patient had prior seizure-like activity. An EEG (electroencephalogram) was negative at that time, and he was not placed on any medication. 

While in the emergency department, the patient had five seizures. The patient was postictal following the first episode in the emergency room. After the second event occurred in the emergency department, the patient was given a loading dose of Keppra. He desaturated to 37% during the last seizure. There were some abnormalities in his lab workup. As his presentation was consistent with seizure, he was admitted for continued monitoring with neurological assessment every two hours. He was given Ativan and Keppra as well as IV (intravenous) fluids. CT (computerized tomography) scan of the brain showed no acute intracranial disease. There was no seizure activity noted during the overnight. It was determined that video EEG would not be necessary and would not alter the care plan. 

The patient was felt stable for discharge. Discharge diagnosis was listed as seizure/status epilepticus. Keppra was prescribed, and neurological follow-up was recommended. 

No, the inpatient admission was not medically necessary. 

The patient had a cluster of epileptic seizures, which was addressed by intravenous antiseizure medications. After the patient was loaded with antiseizure medications, the seizures stopped. The patient's cluster of seizure could have been managed within the scope of a lower level of care stay, without the need of acute inpatient admission. After the seizures were stopped and intravenous antiseizure medications were loaded, there were no more seizures, the patient was hemodynamically and neurologically stable and did not require any inpatient procedures, surgeries, video EEG (electroencephalogram) monitoring or other hospital procedures. Therefore, the hospital admission was not medically necessary. 

The patient had a cluster of seizures, which was addressed by intravenous antiseizure medications. Considering that the patient's needs could have been addressed at a lower level of care, the acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: CVA, Diabetes, Coronary Artery Disease/Hypertension/Hyperlipidemia
Treatment: Home Health Care (Personal Care Assistant)
The health plan denied the request for a personal care assistant. 
The health plan's determination is upheld.

The patient is a male with a past medical history of coronary artery disease, hypertension, hyperlipidemia, diabetes mellitus (DM) type 2 and cerebrovascular accident (CVA) with hemiplegia with a request for PCA (personal care assistant) service hours. The patient underwent an assessment tool and was noted to need maximal assistance with tasks of ordinary housework while extensive assistance with tasks of meal preparation, stairs and transportation. The patient was assessed at limited assistance with tasks of managing finances, managing medication, bathing, personal hygiene, dressing upper/lower body, transfer toilet, and toilet use while set up only for phone use and equipment management. For tasks of bed mobility and eating the patent was assessed as independent. This assessment noted the patient had Mini-Mental State Examination (MMSE) of 26/30, lives with a girlfriend in an apartment without an elevator or disability access, has urinary incontinence and wears pads, and is difficult to move self to a standing position. The insurer sent final adverse determination denial notice stating consumer directed personal assistance services were not medically necessary and the patient was able to perform activities such as toileting, personal hygiene and could walk on his own, and the M11Q (medical request for home care) signed by the patient's doctor reflect chronic or other conditions that do not impact the patient's ability to perform daily activities. The patient appealed the denial decision.

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

No, the requested health service/treatment of Consumer Directed Personal Assistance Services (CDPAP) is not medically necessary for this patient.
The patient is requesting CDPAP services however the patient's CDPAP may not be a spouse, parent or designee that lives with the patient which is the case with this patient.
Per NYCRR 505.28  "consumer directed personal assistant" means an adult who provides consumer directed personal assistance to a consumer under the consumer's instruction, supervision and direction or under the instruction, supervision and direction of the consumer's designated representative. A consumer's spouse, parent or designated representative may not be the consumer directed personal assistant for that consumer; however, a consumer directed personal assistant may include any other adult relative of the consumer who does not reside with the consumer or any other adult relative who resides with the consumer because the amount of care the consumer requires makes such relative's presence necessary.'
The patient has documented PCA care needs with instrumental activities of daily living (IADLs) based on the assessment but was independent or needed limited assistance with activities of daily living (ADLs).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, atrial fibrillation, congestive heart failure (CHF) and hypertension. 
Treatment: 168 hours per week, consumer direct, one client.  
The insurer denied the 168 hours per week, consumer direct, one client. 
The denial is overturned. 

The patient is an female with a history of dementia, atrial fibrillation, congestive heart failure (CHF) and hypertension. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Appeal review requested for potential approval of 168 hours per week consumer direct services to offer increased ADL (activities of daily living) support. 

Yes, the proposed treatment of 168 hours per week consumer direct assistance services is deemed medically necessary. 

This is an female with a history of  dementia atrial fibrillation, congestive heart failure (CHF) and hypertension. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Recent documentation from the patient's Physician indicates that due to worsening cognitive function, gait ataxia and frequent nighttime bathroom trips, the patients requires ADL (activities of daily living) assistance. Hence, the currently approved plan of 36 hours per week consumer direct services is insufficient to meet the patient's current needs. For these reasons, the proposed treatment 168 hours per week consumer direct services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease, Coronary heart disease, Hypertension, Cardiac pacemaker, Urinary incontinence, Benign prostatic hyperplasia, Osteoarthritis, Glaucoma, Visual loss, Hearing loss, Dizziness, B12 deficiency

Treatment: Personal care services (PCS), 24 hours per day, 7 days per week (split-shift)

The insurer denied coverage for personal care services (PCS), 24 hours per day, 7 days per week (split-shift).

The denial is upheld. 

This is a male patient who has the following medical history: Alzheimer's disease, coronary heart disease, hypertension, cardiac pacemaker, urinary incontinence, benign prostatic hyperplasia, osteoarthritis, glaucoma, visual loss, hearing loss, dizziness, and B12 deficiency. The patient lives alone. He has cognitive and physical impairment and needs assistance with instrumental activities of daily living (IADLs) and activities of daily living (ADLs). The patient has been receiving personal care services (PCS) 70 hours per week. The patient (via designee) requested increase of PCS to 24 hours per day, 7 days per week, split shift, which was denied by the insurer. 

The patient has been hospitalized for one week. No diagnosis or clinical records pertaining to the current hospital admission were sent; and so the patient's current medical condition and functional status are unknown for the purpose of this review. Acute illness can cause changes in a person's physical and mental status; and this frequently occurs in elderly people. The information provided for the external appeal (Uniform Assessment System reports and physician office records) includes the patient's medical history and functional status prior to hospitalization; but the patient's medical condition and functional status at the time of hospital discharge is still to be determined. 

Medical necessity for PCS cannot be determined until the patient is medically stable for discharge. At that time, based on the patient's current medical condition and functional status, it can be determined whether the patient can be safely managed at home with PCS. If discharge home with PCS is an acceptable plan, then the amount of services needed to meet the patient's personal care needs at home can be determined.  
                                                                                                                              Based on the documentation submitted, the medical necessity for PCS, 24 hours per day, 7 days per week (split-shift) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse
Treatment: Inpatient rehabilitation stay
The insurer denied the Inpatient rehabilitation stay.
The determination is overturned.

The patient has a history of multiple substance use disorders including hallucinogens, cannabis, alcohol and nicotine. The patient was admitted with a blood alcohol level of 0.024 and positive for hallucinogens (phencyclidine) (PCP), cannabis, benzodiazepines. Initial vital signs were within normal limits. He had been in an inpatient detoxification level of care immediately prior to the rehabilitation stay. He reported a history of post-traumatic stress disorder (PTSD). He also reported a history of depression and anxiety.
The patient had a history of prior detoxification level of care.
The clinical records are somewhat lacking in evaluative clinical information. The records consist of template informs that have been completed, largely with boxes being checked. There is minimal narrative. It appears that the patient was participatory in groups and motivated for treatment. At issue is the medical necessity of inpatient rehabilitation level of care.
The inpatient rehabilitation stay was medically necessary. The patient had a long history of substance use disorder treatment with poor outcomes. He had engaged in dangerous behaviors prior to admission and demonstrated the inability to manage triggers outside of a controlled setting. He was at significant risk for harm outside of this level of care. He did not have a life-threatening medical condition or severe psychiatric crisis at the time of admission. Alcohol was the substance most likely to cause harm. The patient had clear evidence of substance use disorder diagnoses to multiple substances, as described above. He was not in full remission from a substance use disorder. He did not have a risk of withdrawal as he had already gone through medical detoxification. He did not have serious medical symptoms or psychiatric symptoms that required inpatient care. There was no evidence that he was using and hazardous situations or was imminently dangerous to himself or others. He did have some interpersonal skill deficits. He did not exhibit predatory behavior. There was no evidence that he had continued strong cravings or urges that were unmanageable to use drugs or behavioral or emotional instability. The records indicate that he was unable to maintain sobriety outside of a controlled setting. Based on the responses, the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care is: Rehabilitative Services in a Residential Setting.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with recently diagnosed diabetes. He was started on metformin two days prior to admission. He presented with hyperglycemia and one-month history of polydipsia and polyuria. 

The patient's vital signs showed temperature 97.7, heart rate of 110 and blood pressure 142/67. He was treated with intravenous fluids. His pH was 7.34, bicarbonate 18, and beta-hydroxybutyrate 4.7. Glucose levels improved from 500 mg/dL (milligrams per deciliter) to 350 mg/dL to 289 mg/dL. He was treated with Lantus and lispro. He had a right axillary abscess that was incised and drained by surgery. He was started on ceftriaxone and Zyvox and switched to oral Zyvox. 

No, the Inpatient admission was not medically necessary.

This patient presented with hyperglycemia and dehydration in the setting of recently diagnosed diabetes. He was hemodynamically stable. He had a normal pH with a mildly reduced bicarbonate indicative of mild diabetic ketoacidosis. He did not have altered mental status to support a diagnosis of hyperglycemic hyperosmolar syndrome. He had mild dehydration with tachycardia that responded to intravenous fluids. The documentation does not support that he failed management under a lower level of care. He had an axillary abscess that was drained. He did not have signs of sepsis and did not fail oral antibiotics. He did not have another documented indication for ongoing intravenous antibiotics. Therefore, no, the proposed inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left flank pain.
Treatment: Hospital admission- emergency, 3 days.
The insurer denied coverage for the hospital admission- emergency, 3 days.
The denial is upheld.

This is a male patient with a history of an immunocompromising illness, Hepatitis B, hypertension, hyperlipidemia, and gastroesophageal reflux disease (GERD) who presented to the Emergency Department (ED) with complaints of left flank pain. He was admitted for worsening left flank pain. His vital signs in the ED were: blood pressure 118/78, pulse 98, temperature 99.2, respiration 18, and oxygen saturation 97%. The patient's laboratory results were remarkable for elevated creatinine levels. The patient's computed tomography (CT) scan of the abdomen was negative for acute process. The patient's ultrasound of the kidney was unremarkable. The patient was started on intravenous fluid and pain medication, his condition responded appropriately. His creatinine level improved on day 2 of admission. He was discharged on day 3 of admission in a stable condition.

Based on the review of the medical record, the patient was hemodynamically stable, with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or sign of intrinsic kidney failure, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration, no documentation of refractory pain. The patient was able to tolerate oral diet and did not require total parenteral nutrition. His condition responded appropriately to intravenous fluid within 48 hours. There is no evidence-based literature [to support that] inpatient level of care was medical necessary. His condition could have been treated safely under a lower level of care.

The hospital admission- emergency, 3 days is not considered 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 hospital admission- emergency, 3 days is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Covid-19 infection, Pneumonia, Sepsis

Treatment: Continued inpatient rehabilitation stay

The insurer denied coverage for the continued inpatient rehabilitation stay.

The denial is overturned.

This is a male patient whose medical history includes morbid obesity, diabetes mellitus, hypertension and sleep apnea. The patient was also diagnosed with bilateral acute cerebrovascular accident (CVA). He was admitted to inpatient rehabilitation for comprehensive rehabilitation after Covid-19 infection, pneumonia and sepsis. The patient was discharged home approximately one month after admission. The insurer has denied coverage for the continued inpatient rehabilitation stay for the last 8 days of admission.

The clinical records submitted for review support that the patient required a level of medical acuity and rehabilitation intensity that necessitated the continued inpatient rehabilitation stay. From the time of admission, the patient's treatment notes document gradual and consistent functional progress with an eventual excellent clinical outcome after Covid-19 infection, pneumonia and sepsis as well as bilateral CVA. According to the occupational therapy notes during the week before discharge, the patient continued to require contact guard assistance for activities of daily living including dressing and grooming. During this time in physical therapy, the patient also required contact guard assistance for transfer activities, ambulating with a rolling walker and ascending/descending 6 stairs. Over the subsequent week, the patient continued to make excellent functional progress. By the time of discharge home, the patient was independent to modified independent with activities of daily living. The patient was also modified independent with ambulating in and out doors. The patient's ascending/descending steps was also (modified) independent. Concurrent wound care was excellent and also supported the patient's need for additional week of inpatient rehabilitation. The medical, nursing and rehabilitation care was overall excellent with optimal outcomes and patient discharge home to family. 

The clinical records support the medical necessity for the continued inpatient rehabilitation stay.   

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 the continued inpatient rehabilitation stay is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems- Overbite
Treatment: Dental/Orthodontic Procedure-Braces
The health plan denied the treatment of braces as not medically necessary. 
The reviewer has upheld the health plans determination of medical necessity.

The patient has mild maxillary and mandibular crowding. #6 is erupting lingually within the arch and baby teeth C and R remain. The patient has a Class I occlusion with overjet and 60% overbite. The patient is treatment planned for 24-30 months of orthodontics to align the teeth and correct the bite. 
The requested health treatment of Braces is not medically necessary for this patient. #6 is lingual but it is not impacted since it is visible in the maxillary photograph. There are no indications of gingival recession or pathology from the tooth position of #6. It is not as if the tooth were so crowded it was prevented from erupting, which left untreated it could damage the roots of other permanent teeth leading to more invasive and expensive procedures than orthodontic treatment.
While the patient has crowded teeth, there is not anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. If the teeth were aligned it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health. For these reasons, treatment is not medically necessary.