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

Diagnosis: Multiple Right Sided Rib Fractures.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned. 

The patient is a female.  Her medical history included hypertension and psychosis. 

The patient presented to an emergency room as a level-II trauma after being found on subway tracks with altered mental status; she was presumed to have fallen. On work-up, she was found to be stable but combative. Computed tomography demonstrated: 1) multiple, displaced, right-sided rib fractures; 2) "Extensive" contusion/hemorrhage of the pulmonary parenchyma"; 3) right pleural effusion, likely hemothorax; 4) grade-II liver injury; and 5) gluteal hematoma. 

The patient was admitted at an intensive-care-unit level-of-care. The patient reported abdominal and flank pain; however, she remained stable. The patient was transitioned to an acute inpatient level-of-care. Having returned to her baseline function, the patient was discharged to independent living in good and stable condition.

Yes, the proposed treatment -- admission at an acute inpatient level-of-care was medically necessary.
The patient had poly-trauma secondary to a fall -- 1) multiple, displaced, right-sided rib fractures; 2) "Extensive" contusion/hemorrhage of the pulmonary parenchyma; 3) right pleural effusion, likely hemothorax; 4) grade-2 liver injury; and 5) gluteal hematoma. 
Of all of the patient's injuries, the grade-II liver injury was the most severe. According to guidelines from EAST, the Eastern Association for the Surgery of Trauma, there is no consensus on an appropriate length-of-stay for patients with these injuries. Nevertheless, "For lacerations, the median healing time was found to be 29 days for Grade II, 34 days for Grade III, and 78 days for Grade IV." [EAST]. Moreover, according to a report from the Annals of Surgery, the median length-of-stay for patients undergoing non-operative management was 12.7 to 18.3 days [Malhotra et al.]. 
Therefore, it was reasonable to admit this patient at intensive-care-unit and at acute-inpatient levels-of-care (five days) -- this period of clinical monitoring and management was warranted, routine, and consistent with national guidelines and literature. An observational level-of-care would not have been appropriate because to ensure that the patient's liver injury did not progress to hemorrhage acutely, the patient would have required frequent/serial vitals, physical examinations, and laboratories; in fact, for the first days (while she still reported abdominal pain; that is), she would have required continuous monitoring in the intensive-care unit.

Insofar as the patient had grade-II liver injury, admission at intensive-care-unit and at acute-inpatient levels-of-care (five days) was warranted, routine, and consistent with national guidelines and literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder.
Treatment: Braces and Monthly Visits.
The insurer denied the Braces and Monthly Visits.
The determination is upheld.

The patient has a Class I occlusion with 4 millimeter (mm) overbite and 4 mm overjet. She has severe maxillary and mandibular crowing. She is treatment planned for 30-36 months of orthodontics with extraction of all four first premolars to correct her malocclusion.
At issue is the medical necessity of braces and monthly visits. 

The braces and monthly visits are not medically necessary. A Handicapping Labio-Lingual Deviation (HLD) score of 26 or above in the absence of an autoqualifying condition would qualify as medically necessary. This reviewer scored the patient at a 23 (4 overjet, 4 overbite, 10 maxillary and mandibular anterior crowding, and 5 labio-lingual spread), and confirm the absence of an autoqualifying condition as described by the provided HLD index form.
Discounting the HLD score, there is no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no 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.(1) However, this patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) The patient's overjet is more than ideal but her overjet would not affect oral health related quality of life unless it was greater than 6 millimeters (mm).(3) If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. The requested orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease (COPD)
Treatment: Personal Care Worker (PCW) Services
The insurer denied Personal Care Worker (PCW) Services: Requested Increase to 7 Days per Week x 12 Hours per Day; 84 Hours per Week. The health plan's determination is overturned.

The patient is a female with past medical history of gastroesophageal reflux disease (GERD), hyperlipidemia, anxiety, anoxic brain injury, bilateral lower limb neuropathy, fibromyalgia, hyperlipidemia, schizophrenia, hypertension, chronic obstructive pulmonary disease (COPD), difficulty walking, and anemia who had been assigned Personal Care Worker (PCW) services 5 hours/day, 7 days/week, to total 35 hours/week. The patient saw her primary care physician (or provider) (PCP) for a follow up and to fill out transportation form. The office notes stated the patient needed help with movements and transportation and used a wheelchair and walker for shorter distances. The assessment  stated the patient would be attending rehabilitation to help with ambulation and leg strengthening and would be seeing her neurologist in the near future. There was a request to increase PCW services.

Personal Care Worker (PCW) Services 7 Days per Week x 12 Hours per Day; 84 Hours per Week are medically necessary for this patient. 
The patient has multiple chronic, progressive medical illnesses including fibromyalgia and chronic obstructive pulmonary disease (COPD) with recent amputation of great toe. The assessment noted the patient required at least limited assistance with all activities of daily living (ADL) except managing medication and phone use. The patient required extensive assistance with tasks of walking, locomotion, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient requires the use of a walker/wheelchair for locomotion. The requested increase in PCW services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/ Instrumental activities of daily living (IADL). The patient's care needs cannot be met with current hours and/or adaptive equipment and/or medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCW services 12 hours/day, 7 days/week, to total 84 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left shoulder pain. 
Treatment: Shoulder Scar Removal  (procedure code 29825). 

The insurer denied the Shoulder Scar Removal  (procedure code 29825). 
The denial is upheld. 

The patient is a male with left shoulder pain for two years. He was evaluated. He reported worsening over the past six months and problems with motion. He had taken Ibuprofen. He was very active. His physical examination showed he lacked full motion and but full strength. He received an injection of cortisone on that date. He returned to his physician. He reported continued pain with loss of motion.  An MRI (magnetic resonance image) was recommended. The MRI (magnetic resonance image) report was that of impingement and degenerative changes to the AC (acromioclavicular) joint. Surgery was performed. Services of 29825 and 29826 were performed, and 29825 is the subject of this appeal review. 

No, the Shoulder Scar Removal  (procedure code 29825) is not medically necessary. 
The 29825 code is applicable when prior trauma/surgery is documented. The records show this was not present. The subacromial decompression was applicable (29826) secondary to spur and clinical condition. During this procedure, debridement of scar, bursa and bone is completed.  The 29825 (removal of scar) would be inclusive. There would be no extenuating circumstance to substantiate the service based upon documentation and current practice.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary
Surgical Services

Diagnosis: Macromastia
Treatment: Reduction Mammoplasty 
The insurer denied a Reduction Mammoplasty. The health plan's determination is overturned. 

This female has bilateral macromastia. This has been present for years and has, over the past year and half, resulted in significant shoulder notching and neck and back pain. She has attempted support bras, physiotherapy and other adjunct modalities to no benefit. She does have mild to moderate intertriginous irritation as well which has been of some concern and difficult to manage. She has used panoxyl to control the irritation in her bilateral IMF (intramammary folds) with very little relief. She washes with 10% acne foaming wash with very little efficacy on maintaining the IMF from getting irritated. Of note, she has a family history of breast cancer (grandmother). She is also interested in this surgery as she is aware it reduces the risk of breast cancer. 

The Reduction Mammoplasty is medically necessary and is the only treatment that is likely to cure the patient's symptoms.
Breast reduction surgery is medically necessary for this patient. She has the classic symptoms for macromastia, and medical treatments including support bras and physiotherapy have not improved her symptoms. Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder)
Treatment: Dexmethylphenidate & Methylphenidate ER At A Dose Of 4 Capsules Per Day
The insurer denied the dexmethylphenidate & methylphenidate ER at a dose of 4 capsules per day.
The denial is overturned.

The patient is a adult male diagnosed with attention deficit hyperactivity disorder (ADHD). For at least two years or longer, the patient has demonstrated a response to dexmethylphenidate extended-release (Focalin ER) at a dose of 40 mg (milligrams) four times per day and methylphenidate ER (Ritalin LA [extended release]) at a dose of 40 mg four times per day, with improved symptoms and functioning. The dosage of the extended-release formulations was titrated with noted benefit from this dosing strategy.

The patient had tried and failed treatment with Adderall IR (immediate release) and ER, Vyvanse, and Concerta. The patient's prescribing physician is requesting coverage for continued treatment with dexmethylphenidate ER cap and methylphenidate ER tab with the 40 mg dosages and four times a day dosing.

Yes, the proposed treatment is medically necessary for this patient.

The patient has demonstrated a clinical response to the requested treatment with tolerability and improved functioning. Thus, it is in the patient's best interest to remain on the requested medication that provides clear therapeutic benefit, especially with respect to daily functioning.

The requested benefit with dexmethylphenidate ER capsule and methylphenidate ER tab is provided for the purpose of treating ADHD, as clinically appropriate and indicated. It is entirely consistent with nationally recognized scientific evidence as available, and prevailing medical standards and clinical guidelines, referenced below. Dosing for this medication should be based on the individual response, as clinically appropriate and medically necessary. And in this case, the dose was titrated according to clinical response after multiple failed trials with alternative medications indicated for ADHD.

Dexmethylphenidate ER (Focalin ER) and methylphenidate ER (Ritalin LA) at the effective and individualized dosages for the treatment of this patient's ADHD is reasonable, in the patient's best interest, and consistent with prevailing standards of medical practice, as well as the FDA (United States Food and Drug Administration)-indicated use for the treatment of ADHD.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Services
The insurer denied Home Care/Personal Care HHC - Level 2 Personal Care Services: 36 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of glaucoma, urinary incontinence, hypertension, hyperlipidemia, insomnia, osteoarthritis, and rheumatoid arthritis who had been assigned PCS (personal care services) 22 hours/week based on assessment. The patient was assessed at maximum assistance with tasks of meal preparation, ordinary housework, and shopping while extensive assistance with tasks of managing finances, stairs, transportation, and bathing. The patient was assessed at limited assistance with tasks of personal hygiene and dressing upper/lower body while independent with tasks of managing medication, phone use, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. There was a request to increase PCS and the patient underwent a telephonic assessment, assessing the patient at total assistance with tasks of meal preparation and ordinary housework while maximum assistance with task of shopping. The patient was assessed at extensive assistance with task of managing finances, managing medication, stairs, transportation, and bathing while limited assistance with tasks of dressing upper body, walking, locomotion, and transfer toilet. With tasks of personal hygiene, toilet use, bed mobility, and eating the patient was assessed as independent.

Home Care/Personal Care HHC - Level 2 Personal Care Services: 36 Hours per Week are medically necessary for this patient.

The patient has documented decline in physical functioning since her recent hospitalization with specific details in the physical therapy notes. There had been a change in the patient's assistance needs from the recent telephonic assessment noting on the physical therapy note that the patient required significant assistance with walking, locomotion, transfer toilet, toilet use, and bed mobility and subacute rehabilitation was recommended. The family decided to take the patient home and physical therapy (PT) recommended increased aide services. The son further documented the patient's bedbound status and requirement of total care. The requested increase in PCS hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)/ instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the PCS 36 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Arterial Hypertension (PAH).
Treatment: Tadalafil 20mg.
The insurer denied the Tadalafil 20mg.
The denial is upheld.

The patient is a male. He has a history of complex congenital heart disease, including a hypoplastic left syndrome, and mitral valve atresia status post corrective surgeries. The surgeries included a Glenn shunt. His most recent catheterization demonstrated 59% oxygen saturation of the Fontan IVC (inferior vena cava), no stenosis, and a pressure of 17 mm (millimeters). Vascular resistance was 1.6 Wood units. There was moderate to severe tricuspid regurgitation and moderate right ventricular dysfunction. The request for Tadalafil is under review.

No, the treatment with Tadalafil is not medically necessary.
Tadalafil is utilized for the treatment of, primarily, WHO (World Health Organization) group 1 pulmonary hypertension. Those with history of a Fontan shunt have clinically significant pulmonary hypertension at lower levels of vascular pressures, as in the setting of this case. Tadalafil has been utilized in the setting of this case of an individual with a Fontan and elevated pulmonary pressures. It has been demonstrated to somewhat improve exertional capacity. However, there is no definitive evidence that it improves either a long-term pulmonary or cardiac outcomes in this setting. It is, therefore, considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer
Treatment: Proton Beam Radiation Therapy 
The insurer denied Proton Beam Radiation Therapy. The health plan's determination is upheld.

This is the case of a patient with pancreatic cancer. He was treated with neoadjuvant chemotherapy followed by SBRT (Stereotactic Body Radiation Therapy) and then resection. The patient then developed metastasis to the liver. The plan is to treat with Proton beam therapy. This is the subject of review.

Proton Beam Radiation Therapy is not medically necessary for this patient. This treatment is not mentioned under National Comprehensive Cancer Network (NCCN) guidelines. There are no published data to support this treatment for this patient.
Medically necessary treatment is defined as treatments which are in accordance with generally accepted standards of medical practice in the United States. The generally accepted standards of medical practice in the United States for this clinical scenario are palliative radiation therapy (RT) using intensity modulated radiation therapy (IMRT), SBRT or radiofrequency ablation.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a woman with a history of gastric bypass complicated by portal vein thrombosis on anticoagulation, who presented to the hospital with a chief complaint of vaginal discharge and right leg pain. She reported vaginal discharge for one month and stated that it was yellow in color and non-bloody. She also reported easy bleeding. She was sexually active with one partner and did not use protection. She had recently finished an outpatient course of antibiotics and fluconazole. In addition, the patient complained of right leg pain and left flank pain. There was no numbness, tingling, or loss of strength in the extremities. Vital signs showed temperature 98.9 Fahrenheit, heart rate 71, respiratory rate 18, and oxygen saturation 100%. On physical exam, heart was regular, breath sounds were normal, there was mild tenderness in the abdomen, and there was right leg swelling in the posterior mid-thigh. Labs showed white blood cell count (WBC) 4.75, hemoglobin 10.8, platelets 182, creatinine kinase 41, and troponin negative. Right lower extremity ultrasound was negative for deep vein thrombosis (DVT) but a fluid collection was present that measured approximately 2.5 centimeter (cm) x 1.3 cm x 2.3 cm. Chest x-ray showed no focal consolidation. The patient was admitted for vaginal discharge likely secondary to bacterial vaginosis or vaginal candidiasis.

The inpatient admission was not medically necessary. The patient was treated for right leg hematoma and vaginal discharge from bacterial vaginosis or vaginal candidiasis. These are outpatient diagnoses and do not require acute inpatient level of care. In addition, the patient had no evidence of sepsis, hemodynamic instability, uncontrolled pain, or other acute symptoms or laboratory findings.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hearing loss
Treatment: Replacement Cochlear Processor 
The insurer denied the Replacement Cochlear Processor. The health plan's determination is upheld.

This is a female who underwent a right cochlear implant and is employed as a nurse. She complains that wearing PPE (personal protective equipment) including a facemask and goggles obstructs her processor's microphone, impairing communications and resulting in poor retention of the device. But she reports that the Kanso processor can be worn successfully off the ear without these problems and is the service under review.

A Replacement Cochlear Processor is not medically necessary for this patient.

Clinically, there is no documentation that the current cochlear implant no longer functions and/or there have been frequent repairs resulting in a device that did not work well. Therefore, replacement of the cochlear implant's speech processor is not medically necessary as it continues to function.

This is a patient with a working cochlear implant sound processor. The patient chose to upgrade to a Cochlear Nucleus Kanso 2 processor. With a working sound processor, this would be considered "for convenience" and not medically necessary, as the device is not frequently in repair, affecting the quality of life, or not working which are often criteria for replacement.