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

Diagnosis: Coronary artery disease.

Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.

The denial is upheld. 

This is a male patient with a past medical history of hyperlipidemia, hypertension and coronary artery disease who was referred for elective cardiac catheterization with percutaneous coronary intervention (PCI) of the left circumflex artery and first obtuse marginal artery. The patient tolerated the procedure well with no documented post-operative complications during his post-operative observation.  

Based on the review of the medical record and literature, hospital admission was not medically necessary for this patient. This patient presented for elective percutaneous revascularization. The patient underwent an uncomplicated procedure and was discharged the following day. Several investigators have studied the safety and effectiveness surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital.1-4  Current expert consensus from the society of cardiovascular angiography and interventions support this treatment at a lower level of care.4  In conclusion, this patient should have been treated at a lower level of care. Inpatient level of care was not medically necessary.

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

The carrier's denial of coverage for the hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, gastroesophageal reflux disease, hypertension and coronary artery disease. 
Treatment: Increase Home Care/ Personal Care HHC from 42 Hours per Week to 24 Hours per Day (Split Shift). 

The insurer denied the Increase Home Care/ Personal Care HHC from 42 Hours per Week to 24 Hours per Day (Split Shift). 
The denial is upheld. 

The patient is a female with a history of depression, gastroesophageal reflux disease (GERD), hypertension and coronary artery disease. 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 hours/week Personal Assistance Services to offer increased activities of daily living (ADL) support. 

No, the proposed Increase Home Care / Personal Care HHC from 42 Hours per Week to 24 Hours per Day (Split Shift) is not medically necessary. 

An assessment of the patient's functionality and ability to perform activities of daily living was completed and revealed that the currently approved plan of 42 hours per week Personal Assistance Services is sufficient to meet the patient's current needs. 

Specifically, the assessment revealed that the patient is alert and oriented to person and place. Her hearing and vision are adequate. She lives alone in a one bedroom apartment and has not had any recent fall injuries or hospitalizations. 

There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, the proposed treatment 24 hours per day Personal Assistance Services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fallopian tube cancer and four metastatic lesions to the brain.
Treatment: Stereotactic radiation therapy for brain metastasis.
The insurer denied coverage for stereotactic radiation therapy for brain metastasis.
The denial is overturned. 

This is a female patient with fallopian carcinoma status post (s/p) neoadjuvant chemotherapy followed by total abdominal hysterectomy, with bilateral salpingo-oophorectomy (TAH-BSO) and debulking surgery.  She was then treated with chemotherapy and immunotherapy. Magnetic resonance imaging (MRI) of the brain showed four metastatic lesions, and she underwent resection of the right temporal lobe lesion.  Stereotactic radiosurgery (SRS) is planned to treat the resection bed and three other metastatic lesions. She has no evidence of disease on computed tomography (CT) of chest/abdomen/pelvis. She has an excellent performance status of Eastern Cooperative Oncology Group (ECOG) 1. 

The stereotactic radiation therapy is considered medically necessary for this patient.   Clinical outcome evidence on the efficacy of SRS for oligometastasis to brain have been published in evidence based peer-reviewed studies and has been demonstrated by prospective clinical trials.  Based on these high grade clinical outcome evidences, SRS has become a standard of care in the treatment of selected patients with oligometastasis to the brain.  Also, the aggressive management to prevent another recurrence of brain metastasis (including SRS) for patients with good performance status and no (or stable) systemic disease is consistent with National Comprehensive Cancer Network (NCCN) practice guidelines.  

This patient has four metastatic lesions to the brain from fallopian tube cancer and has no evidence of disease outside of brain on systemic therapy and this patient has good performance status of ECOG.  SRS in this case to maximize control of two metastatic lesions is consistent with American Society for Therapeutic Radiology & Oncology (ASTRO) and NCCN practice guidelines.  Therefore, the requested SRS in this case is appropriate and medically necessary.

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

The carrier's denial of coverage for stereotactic radiation therapy for brain metastasis is substantiated.  The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus.
Treatment: Durable medical equipment (A9276 x 180) glucose monitoring system.

The insurer denied coverage for durable medical equipment (A9276 x 180) glucose monitoring system.  The denial is overturned. 

The patient is a female with history of Type 2 Diabetes Mellitus (DM) and cirrhosis.  The patient has very labile blood sugars (40-400).  The patient is having issues with hypoglycemic unawareness.  The patient uses insulin for her blood sugar control.  The patient's most recent hemoglobin A1c (HgA1c) showed excellent control, with HgA1c of 5.1%.  The patient is requesting the use of continuous glucose monitor (CGM), the Freestyle Libre 2. 

Per Blum (2018), "The Freestyle Libre Pro is indicated for professional use only. It is intended to be used by health care professionals to detect blood glucose trends and patterns in patients 18 years of age with type 1 or type 2 diabetes. The Freestyle Libre can be used by patients 18 years of age with type 1 or type 2 diabetes."

Per Kudva et al. (2018), "Large randomized controlled trials demonstrated that use of the FreeStyle Libre system resulted in significant reductions in hypoglycemia, increased time in target range, reduced glycemic variability, and greater patient satisfaction compared with fingerstick monitoring [6, 7]. These benefits were seen in well-controlled type 1 diabetes (T1D) [6] as well as suboptimally controlled type 2 diabetes (T2D) treated with intensive insulin therapy [7].  Studies also showed high device utilization, suggesting that the FreeStyle Libre system may enhance patient engagement [6, 7].  Smaller observational and prospective studies have also shown improvements in both A1c and a reduction in hypoglycemic events [8,10]."

Based on the review of the medical record and literature, the CGM is considered medically necessary for this patient.  This patient has hypoglycemic unawareness and needs a CGM to help monitor this patient's glucose level and condition.  Therefore, the durable medical equipment (A9276 x 180) glucose monitoring system is considered medically necessary for this patient.
                                                         
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 durable medical equipment (A9276 x 180) glucose monitoring system should be reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis.
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 56 Hours per Week [8 Hours per Day, 7 Days per Week].

The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 56 Hours per Week [8 Hours per Day, 7 Days per Week].  The health plan's determination is upheld. 

The patient is a female who has a past medical history significant for diabetes mellitus, neuropathy, hypothyroidism, peripheral vascular disease, gastroesophageal reflux disease, osteoarthritis, osteoporosis, hyperlipidemia, anemia, anxiety, incontinence of feces, urinary incontinence, hypertension, and torn right knee meniscus. She did have a surgical procedure with a right knee surgery.

The Consumer Directed Personal Assistance Services (CDPAS): 56 Hours per Week [8 Hours per Day, 7 Days per Week] is not medically necessary for this patient.

The patient has multiple ongoing medical problems with limited mobility and diabetes. The patient was able to ambulate 50 feet with cane or walker. She did recently undergo right knee arthroscopy. It was recommended that the patient seek treatment for urinary incontinence, but the patient declined. At a postop visit, she states she was ambulating with a cane and not taking any medicine for pain. A subsequent postop visit states that she had significant pain relief and is still using a cane. She declined any further intervention or treatment for her knee at that time. According to the reports, the patient needs limited assistance with toiletry. Her neighbor is available to take her shopping. She does have urinary incontinence and is wearing a pad, which she changes herself every one half hours. There is no noted skin breakdown or ulcers.

The patient has multiple medical problems including several orthopedic problems. From the progress notes, it appears that the patient can ambulate adequately indoors with an assistive device. She is not requiring any significant treatment for pain for her leg. She does have incontinence problems but is able to manage these problems on her own with sanitary products.

The provided services are adequate to meet the patient's activities of daily living (ADL) and Instrumental activities of daily living (IADL). There were no other listed services on the appeal that could not be provided during the allotted time. The additional hours will not change the patient's orthopedic status or incontinence status. She appears to be managing these issues appropriately and independently.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status post anterior cruciate ligament (ACL) reconstruction surgery. 
Treatment: Continued Physical Therapy Services. 

The insurer denied coverage for the Continued Physical Therapy Services. 

The denial is overturned. 

This is a female patient who underwent anterior cruciate ligament (ACL) repair.  Physical therapy was initiated and the notes state, "11 weeks out from her anterior cruciate ligament (ACL) reconstruction and is doing beautifully.  Her only problem is that she struggles going down stairs with weakness of her eccentric muscle contraction in the quad.  Otherwise, most of her day to day activities are normal."  Right knee "reveals full range of motion" and "There is no effusion." 

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, continued physical therapy after undergoing the anterior cruciate ligament (ACL) reconstruction surgery is considered medically necessary for this patient. The patient has good knee active range of motion (0-135 degrees).  Unfortunately, the subsequent physical therapy notes are only short hand-written entries and do not provide quantitative assessments.  However, the protocol for anterior cruciate ligament (ACL) reconstruction provides for well over the approximately 9 weeks of therapy provided.  In addition, the patient's physician documents the patient's quadriceps atrophy, extensor lag on extension and difficulty descending steps, which are deficits that should be addressed in physical therapy. 

The health plan did not act reasonably with sound medical judgment and in the best interest of the patient.  Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical societies boards and associated were taken into consideration.  All decisions are evidenced based. 

The insurer's denial of coverage for the Continued Physical Therapy Services should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara
The insurer denied Stelara. The health plan's determination is overturned.

The patient is a female with severe stricturing Crohn's disease (ileitis) status post loop ileostomy, ileostomy takedown and small bowel resection, subtotal colectomy with end ileostomy, and small bowel resection and region of the ileostomy. Magnetic resonance enterography showed intense enhancement (including transmural circumferential enhancement) of the bowel from the ostomy and small bowel medially below the ostomy. Per a note, she has failed Remicade, weekly Humira, and Entyvio. She has been on azathioprine. Coverage is requested for Stelara for the treatment of Crohn's disease.

Stelara is medically necessary for this patient. Her disease is significantly severe, with stricturing phenotype and multiple surgical resections; she has failed multiple biologic medication classes. A large randomized controlled trial demonstrated safety and efficacy of Stelara for induction and maintenance of remission in patients with moderate-severe Crohn's disease, as this patient has. Another study showed a 73% response in patients with anti-tumor necrosis factor-resistant Crohn's Disease, and 80% of responders maintained remission for 1 year. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-tumor necrosis factor (TNF) medications. A recent study demonstrated that a significant majority of patients who have failed an anti-TNF medication achieve and maintain response with Stelara. In this case, alternatives are limited (Remicade, weekly Humira, and Entyvio have failed), and lack of therapy can result in additional complications of uncontrolled disease, flare, hospitalization, need for surgery, fistula, and stricture.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction. 
Treatment: Substance Abuse: Residential. 
The insurer denied: Residential Rehabilitation. 
The denial is upheld.

The patient is a male who was self-referred and admitted to residential rehabilitation substance use disorder treatment to address substance use disorder with stimulants (methamphetamine) and sedative-hypnotic-anxiolytic gamma hydroxybutyrate (GHB) class substances. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a history of poly-substance use disorder with recreational use of several substances and subsequent use of crystal methamphetamine and GHB as drugs of choice for six to seven years prior to presentation. He was using methamphetamine and GHB on a daily continuous basis with intravenous (IV) use of the crystal methamphetamine. Throughout the residential stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. The patient was social with peers and participating actively in treatment with continued risk for relapse; the patient had no severe withdrawal symptoms or significant post-acute withdrawal symptoms, and he had no complications with respect to biomedical, general medical, emotional or other treatment domains. Progress notes and documentation reflected stable mood with sleep, appetite and energy that were okay with the use of melatonin for insomnia and the availability of psychiatric consultation and as needed (prn) medications for anxiety or agitation. The patient was discharged with clinically appropriate aftercare recommended.
The subject under review is the medical necessity for residential rehabilitation. 

The health plan's determination is upheld.

The patient's treatment could have been safely and effectively provided at a lower level of care. The patient in this case presented with continuous daily use of methamphetamine and GHB; he did not experience complications or present with severe symptoms of a co-occurring psychiatric disorder/depressive disorder, or abnormal findings on examination, or severe withdrawal symptoms or post-acute withdrawal symptoms. He did not pose a safety risk that would have warranted the residential rehabilitation level of care as requested. The clinical features and indicated treatment dimensions of this patient's substance use disorders did not require the structure of a residential setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was overturned. 


This patient is a female with a history of diabetes and hypertension who presented to the hospital with abdominal pain and chest pain for 4 days with nausea, vomiting and diarrhea. 
Labs were significant for hyperglycemia, normal electrolytes, and renal function. The computed tomography (CT) scan of the abdomen and pelvis showed a right renal cyst.
The patient was admitted to the hospital for acute gastroenteritis with  leukocytosis. 
An infectious disease specialist assessed the patient and concluded the patient had abdominal pain due to gastritis, doubtful there was a bacterial infection. 
Cardiology was consulted for the chest pain. The cardiac troponin was negative.
The endocrinologist noted, the glycated hemoglobin (hemoglobin A1c) was greater than 10. 
The patient was vomiting, had dark stools, and was seen by gastrointestinal(GI) for an endoscopy. The procedure showed Los Angeles (LA) grade C esophagitis, which was biopsied, erosive gastropathy, and bilious gastric fluid, with gastritis. There was erythematous to adenopathy, which was biopsied. 
A CT scan of the chest angiogram was done to rule out thromboembolic disease, which was negative. There was evidence of diffuse ground-glass opacities throughout the lungs raising the possibility of edema versus superimposed atypical pneumonia.
The esophagogastroduodenoscopy (EGD) pathology report showed negative H. pylori stain, essentially reflux changes noted in the stomach, and otherwise benign histopathology.
On the day of discharge, the patient was seen by all consultants, with no sign of acute distress.
At issue is the medical necessity of the inpatient level of care.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient stay is medically necessary for this patient.
This is a complex presentation in a patient experiencing upper GI symptoms and bleed with concurrent diarrhea. The endoscopic evaluation showed a grade C esophagitis and erosive gastropathy with gastritis. There was evidence of leukocytosis, worrisome for an infectious process. There were fluctuations in the renal function, and fluctuations in the blood pressure causing further deterioration of the renal function. There was persistent leukocytosis, which was being assessed daily, and treated with antibiotic therapy.
The patient had persistent nausea and vomiting, with coffee-ground emesis and possible melena, with multiple bouts of diarrhea. The symptoms were severe, as it led to dehydration, with tachycardia, leukocytosis, and trending down hemoglobin. Based on multiple bouts of vomiting, and 7-8 bouts of diarrhea per day during the hospitalization, the patient required Intravenous(IV) fluid support.
Therefore, the inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Congenital malformation of optic disc, seizure
disorder, and expressive language disorder
Treatment: Consumer Direct 1 Client 105 Hours/Week
The insurer denied the Consumer Direct 1 Client 105 Hours/Week
The denial is partially overturned. 

The patient is a female child with medical history significant for blindness secondary to congenital malformation of optic disc, seizure disorder, and expressive language disorder. She is able to creep/crawl and play with toys. She remains incontinent of bowel and bladder. She is non-verbal and receives speech and language therapy three times a week. She is legally blind, receiving services for the blind. She takes two anti-convulsant medications.

According to an assessment, the patient has occasional breakthrough seizures, most recently associated with vomiting. She tolerates a mechanical soft diet. She does not sleep through the night, waking up several times screaming and taking one to two hours to fall back asleep.

The patient lives with her parents and two siblings. Her mother does not work outside of the home. Her father works full time outside of the home. Both parents are capable caregivers.

The patient's home health needs include assistance with all activities of daily living (meals, toileting, bathing, laundry), monitoring for seizure activity, and maintenance of safety due to age and blindness. Some of her needs such as toileting and bathing are consistent with typical same age children and not associated exclusively with her condition.

Yes, in part. The Consumer Directed Personal Assistance Sercvices Client 105 Hours/Week are medically necessary, in part. Specifically, Consumer Directed Personal Assistance Services are medically necessary 56 hours per week (8 hours/night 7 nights per week).

This child has a number of needs as a result of and in addition to her seizure disorder and blindness. She is non-verbal and ambulatory by creeping/crawling. She is blind and must be monitored for safety at all times. She awakens frequently at night and stays awake for extended periods of time. She has occasional breakthrough seizures, but it is unclear if she requires rescue medication or if they resolve on their own. A number of her needs are consistent with same age typical children, including bathing, toileting, meal preparation. Needs unique to her condition include breakthrough seizures, altered fine and gross motor skills, and poor sleep hygiene.

Based on the documentation provided, home health nursing services are not medically necessary during the day. The mother is at home full time and the father, who works outside of the home full time, is available to participate in care before and after work. However, this child requires constant supervision at nighttime to maintain safety, prevent injury, and address issues such as eating and toileting. Based on this child's clinical condition, the current standard of care, and the documentation provided, the requested services are medically necessary and appropriate 8 hours nightly 7 nights/week, for a total of 56 hours per week.