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

Diagnosis: Functional impairments; Multiple medical conditions

Treatment: Personal care assistance services 56 hours per week

The insurer denied for personal care assistance services 56 hours per week.  The denial was reversed.

This is a male patient with multiple medical conditions and functional impairments.  He needs substantial assistance with IADLs including household tasks, use of stairs, and outdoor activities (shopping, transportation).  For ADLs, he needs extensive assistance with bathing and lower body dressing, and limited assistance for most other ADLs (except bed mobility and eating: independent, setup help).

The patient has arthritis which is a frequent cause of functional impairment and often results in a person's loss of independence with daily activities, especially in older people.  In the insurer's denial letter, it is noted that the patient requested additional help due to chronic pain from marked degenerative disc disease, and pain in shoulders and knees.  This is consistent with problems identified in the UAS including: pain, unsteady gait, and history of multiple falls (the UAS noted recent fall; and diagnosis list includes "repeated falls").  The patient takes medication for pain which may help, but it appears that his functional status is adversely affected by chronic pain, as it is noted in the insurer's denial letter that pain was among the reasons the patient was requesting more assistance.  His need for extensive assistance with bathing and lower body dressing is consistent with arthritis associated symptoms (e.g. pain/stiffness with bending and use of upper/lower extremities).  He has difficulty standing up without assistance and needs extensive assistance with stairs, which is also consistent with pain and stiffness in the back and knees.  These symptoms affect ambulation which can result in an unsteady gait and increased risk of falls.  Shoulder pain is also a significant problem, as it limits shoulder range of motion needed for various tasks and can limit the ability to safely lift items.  This can increase risk of other household related accidents (e.g. dropping or spilling).

Personal care assistance services are approved for 56 hours per week. The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

The carrier's denial of coverage for personal care assistance services 56 hours per week  is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nosebleed and hypertension
Treatment: Inpatient admission
The inpatient admission was not medically necessary.

The patient did not have ongoing epistaxis, requirement for surgical intervention, a drop in hemoglobin, need for a blood transfusion, hemodynamic instability, coagulopathy, thrombocytopenia, or need for posterior packing.  The blood pressure improved significantly by the time of admission and the patient did not require intravenous antihypertensive agents.  There was no evidence of hypertensive emergency or malignant hypertension.  There was no evidence of acute heart failure or hypertensive encephalopathy.  The minimally elevated troponin levels were not documented as being due to a type I acute myocardial infarction.  Although the nuclear stress test showed ischemia, cardiac catheterization demonstrated no epicardial disease and no need for percutaneous intervention.  

In summary, acute inpatient admission was not medically necessary.  The health plan acted reasonably, with sound medical judgment, and in the best interest of the member in making its determination.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Edentulous spaces in the areas of the left mandible, areas #19, 20 areas

Treatment: D6010 implant placement, tooth #19; D6010 implant placement, tooth #20; D6056 prefabricated abutment tooth #19; D6056 prefabricated abutment tooth #20; D6064 abutment supported cast metal crown (noble metal) tooth 19; D6064 abutment supported cast metal crown (noble metal) tooth 20

The insurer has denied coverage for D6010 implant placement, tooth #19; D6010 implant placement, tooth #20; D6056 prefabricated abutment tooth #19; D6056 prefabricated abutment tooth #20; D6064 abutment supported cast metal crown (noble metal) tooth 19; D6064 abutment supported cast metal crown (noble metal) tooth 20.The denial was upheld.  

Based on review of the submitted documentation, this patient presented for dental evaluation, treatment, and discussion regarding prosthetic rehabilitation for edentulous spaces in the areas of the left mandible, areas #19, 20 areas.  The treating doctor recommended endosteal implants to be placed at the sites after discussion of treatment plans. 

The insurer has denied the aforementioned services stating that in their estimation endosteal implants are not the only procedure or appropriate treatment and cite that an alternative appropriate therapy, as per the alternate benefits provision of the insurance contract, would be a removable partial denture which would restore form, function and esthetics.  Therefore the endosteal implants are considered not medically necessary, considered elective and therefore no benefit is available.  The patient's sister is appealing the decision.

Upon review of the objective documentation which primarily consists of the panoramic and periapical radiographs, it is evident that the patient exhibits edentulous spaces in the areas of #19 and #20. As regards endosteal implant placement, although implants are an acceptable treatment to restore edentulous spaces, as in this patient, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include a mandibular removable partial denture as cited by the insurer. Lastly, the dentist states a gag reflex would preclude wearing a partial denture, there is no objective information provided to support this assertion. Therefore as partial dentures remain standards of care in general dental practice, the endosteal implants are not medically necessary.  

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history of multiple myeloma, who had presented to the emergency department  for evaluation of right leg weakness, recurrent falls, and right hip pain. The health plan's determination of medical necessity is overturned in whole . Multiple myeloma has one of the highest cancer-specific incidences of malignant spinal cord compression. The prognosis of patients with malignant spinal cord compression is poor, especially if the presentation includes paralysis or if there is no response to therapy. It was pertinent to begin aggressive therapy and monitoring in the inpatient setting in this patient to avoid persistence or worsening of the neurological deficit. Therefore , there is medical necessity for the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: acute on chronic systolic heart failure

Treatment: IV Lasix

The insurer has denied inpatient admission. That denial was upheld.

This female patient was brought in by ambulance to the Emergency Room (ER) with complaint of worsening shortness of breath and chest discomfort. She has a past medical history of diabetes mellitus, obesity hypoventilation syndrome (OHS) on home oxygen and CPAP, chronic respiratory failure, hypertension, coronary artery disease and ejection fraction 35%. She was admitted and intravenous (IV) Lasix was administered. She discharged.

In the Emergency Department (ED), vital signs were temperature (T) 98, respiratory rate (RR) 24, heart rate (HR) 86, blood pressure (BP) 158/110 mm Hg and oxygen (O2) saturations were 92%. The patient had bilateral crackles on lung exam. Cardiovascular system showed S1 S2 were normal. Her troponin was negative and her EKG showed no acute ST- T changes. The patient was afebrile and hemodynamically (HD) stable throughout. Lungs had cleared after intravenous (IV) Lasix. Oxygen saturations were acceptable. The patient was already on home oxygen. There was no evidence of ischemia. Cardiac enzymes were negative and MI was ruled out. The patient was stable for treatment in observation status with subsequent discharge on oral medications with close follow-up in the outpatient setting.

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

Diagnosis: Hyperbilirubemia
Treatment: Inpatient admission
The inpatient admission for intensive phototherapy was not medically necessary.  
This infant did not have a rapid rise of his total serum bilirubin at a rate greater than 0.25 mg/dL per hour. His total serum bilirubin of 19.9 mg/dL at approximately 176 hours of age did not exceed the risk threshold of 21 mg/dL for his age, gestational age and clinical risk factors. Therefore, acute inpatient hospitalization for intensive phototherapy was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The braces are medically necessary.  The patient has a deep impinging overbite with severe soft tissue damage. This is an "automatic qualifier" on the Handicapping Index report. The patient has an extremely deep bite which needs to be orthodontically corrected to prevent continuing trauma to the palatal gum tissue.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back and knee pain
Treatment: K0825 - Power operated wheelchair 
The power operated wheelchair (K0825) is not medically necessary.

The records do not establish that the patient has impairments that would preclude the use of an appropriately fitted manual wheelchair to address and resolve her mobility deficits.  She is reported to have various chronic medical issues and symptoms but no documented impairments that would preclude her from using a manual wheelchair that is designed for propulsion using both the upper and lower limbs.  There are, for instance, no documented neurological impairments from her stroke or spinal conditions.  There are no documented impairments related to cardiovascular, pulmonary or musculoskeletal systems that would preclude independent manual wheelchair propulsion.  Notably, the patient remains able to ambulate with a walker and propel a manual wheelchair, and she is essentially self-limited by subjective symptoms of dyspnea and various pains.  A power wheelchair is not necessary for accomplishing her mobility-related activities of daily living.  A manual wheelchair would also afford the patient some measure of physical exertion and exercise, which would be health beneficial given her various chronic health conditions.

The proposed power wheelchair in question is not medically necessary, as noted in the health plan's adverse determination, as the documented physical examinations and other objective data do not establish the presence of impairments that would preclude walker or manual wheelchair use.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive impairment
Issue under review: Private duty nursing

Determination:
The private duty nursing is medically necessary.

The patient is a male with multiple serious comorbid medical conditions, including severe cognitive impairment secondary cerebral palsy, rendering him nonverbal and a functional paraplegic. He is chronically bed bound and on mechanical ventilatory support. As such, he is max assist with bed mobility, transfers and performance of all ADLs. 

Although the health plan cited lack of adequate reliable informal supports in the home and the lack of documentation demonstrating completed training regarding skilled needs required to maintain the patient in the community, this is not a clinical indication or requirement supported by the current evidence based medical literature.

For these reasons, the requested health service of Private Duty Nursing (PDN)  is deemed medically necessary to better assess with all of the patient's needs.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of hypertension, hyperlipidemia, diabetes, sarcoidosis, and recurrent unexplained syncope. The patient has an implantable cardioverter defibrillator (ICD). Details regarding the indication for the ICD were not provided. The patient presented to the emergency department after an episode of syncope.The patient's ICD interrogation showed no arrhythmias had been detected. The  patient was admitted to the hospital. The health plan's determination of medical necessity is upheld in whole. An inpatient stay was not medically necessary for this patient. The patient was hemodynamically stable, in normal sinus rhythm. There was no evidence of ischemia or decompensated heart failure. The defibrillator interrogation showed normal function and no detected arrhythmias. Thus, the likelihood of an arrhythmic cause for this syncope was quite low. Thus, based on the information provided, an inpatient level of care was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

The patient has a history of solitary kidney who was transferred to the emergency department by Emergency Medical Services (EMS) from an urgent care for vomiting and lethargy. The patient was reportedly well until 9pm on 3/5/2019 when he had 4-5 episodes of non-bloody, non-bilious vomiting and was subsequently taken to an urgent care. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. This patient required Zofran, IV fluids and observation during a period of diet advancement. This treatment does not require inpatient admission and could have occurred at a lower level of care. This patient's physical exam and history are notable only for a report of decreased urine output which is difficult to assess in a diapered child having diarrhea. His vital signs and physical exam in the emergency department otherwise were unremarkable and are not consistent with severe dehydration requiring hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia, Pulmonary Embolus

Treatment: Inpatient Hospital Admission

The insurer denied the Inpatient Hospital Admission. The denial was reversed. 

This is a middle age female patient who presented to the Emergency Department with difficulty breathing for two weeks. It was reported that the patient had been in the emergency room 2 weeks prior to this presentation with the same complaints. At that time the patient's hemoglobin level was 6.8. The patient was discharged home on iron pills.  The physical examination revealed that the patient had no cough or shortness of breath however; the patient reported that shortness of breath was noted on exertion. The patient was admitted to the hospital with dyspnea secondary to anemia rule out pulmonary embolism. The patient had a chest x-ray, revealing no acute disease. A Doppler study of the lower extremities was performed which revealed a popliteal deep vein thrombosis. The Computer Tomogram scan of the patient's chest revealed bilateral pulmonary emboli. The patient was evaluated by gastroenterology where it was determined that the patient had iron deficiency and was given intravenous iron. Additionally, the patient hospital treatment included anticoagulant therapy for the treatment of the patient's deep vein thrombosis and pulmonary emboli, intravenous fluids, and 1 unit of packed red blood cells. The patient was stabilized and discharged. The patient was to be treated as an outpatient for anemia.

This patient was found to have pulmonary emboli in setting of significant anemia. Moreover, both the Tn levels were elevated and the echocardiogram showed evidence of right ventricular strain. These are generally associated with in hospital management. In fact, as noted by the most recent Cochrane review, the data supporting outpatient management of pulmonary embolus remains unclear. 
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The carrier's denial of coverage for the inpatient hospital admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

The patient is a teenaged female diagnosed with idiopathic short stature.  She has been on growth hormone (GH) therapy for three years (Humatrope).  Her GH stimulation test  with arginine and clonidine peaked at 11.80 and 3.62 respectively.  Her pretreatment height velocity is reported to be 3-4 cm/yr.  Her height velocity on therapy is reported to be 7-8 cm/yr.
The health plan has denied Zomacton as not medically necessary.  The health plan's determination is overturned. The Zomacton is medically necessary. 

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9).  FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient has a pretreatment height less than or equal to -2.25 SD.  The height velocity and the bone age predict a height that is far below the normal range.  The patient therefore met idiopathic short stature criteria.  The patient benefited from growth hormone with improvement in height velocity.  The request is consistent with generally accepted standards of medical practice and is, therefore, medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol abuse
Treatment: Inpatient admission

The inpatient admission was not medically necessary for this patient.

The proposed inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The treatment of this patient's substance use disorder did not require the structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and co-occurring anxiety and mood disorders. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk for self-harm, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment. There were no severe/objective symptoms of withdrawal or biomedical issues in this case, and the patient was acutely intoxicated at the time of his presentation and admission, as noted in the clinical summary. Admission for detoxification treatment and withdrawal management and 24-hour monitoring was not medically necessary in this case scenario. The patient could have been treated and stabilized at a lower level of care with an appropriate discharge plan and disposition for community treatment.

This answer is consistent with New York State OASAS LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.

In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The patient displayed no serious disturbance of mental status despite having a history of ongoing substance use disorder with alcohol and history of a mood and anxiety disorder. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted an inpatient level admission and treatment, as noted above. The admission for detoxification treatment and 24-hour monitoring, and the requested inpatient level services were not medically necessary in this case scenario, as the health plan asserts. And, NY State OASAS LOCADTR 3.0 Criteria/Guidelines are not met for the inpatient level of care, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain,  
 
Treatment: Back surgery 

The insurer denied the coverage for back surgery. The denial was upheld.

This case involves a female patient with a past medical history of low back pain, prolapsed lumbar intervertebral disc, lumbar post laminectomy syndrome, nonunion of spinal fusion and lumbosacral radiculopathy.  The patient underwent a laminectomy and fusion from L3-S1.  Previous x-ray indicated that the patient had no interval change.  There was a posterior fusion from L3-S1 that was again noted and the fractured right side pending nuclear fixation screw at S1 was stable.  There was a stable anterior spondylolisthesis of L5 over S1 measuring approximately 3 mm. 
An office visit in this current year indicated that was dated indicated that the patient was in the office for follow-up.  The patient was complaining of severe pain in the back radiating to the right lower extremity.  The patient had a history of nonunion of the lumbar spine fusion with loosening of the screws at the lower end of the construct.  The patient was also complaining of severe, right buttock pain.  The pain has been getting worse.  The physical examination revealed there was a healed, midline incision longitudinal in nature.  The patient had lumbar spine tenderness in the paravertebral region bilaterally with decreased range of motion.  The patient had pain with range of motion.  The motor strength was intact.  Reflexes were absent bilaterally.  Straight leg raise was positive on the right at 30 degrees.  The provider stated that the patient had not responded to conservative care.  Because of the patient's severe, unremitting pain, the provider was to try and schedule surgery for the lumbar spine for the repair of nonunion with extension of the fusion to L2.  

There was a lack of documentation of identification of findings specifically starting at L2-3 and no specific dermatomal or myotomal findings were noted to support surgical intervention at all of the requested levels.  Therefore, the healthcare plan acted reasonably and with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with short stature, who is followed by a pediatric endocrinologist Pre-treatment height was less than (<) the 3rd percentile, weight was tracked at the 50-75th percentile. and growth velocity was < 3 centimeters (cm)/year. Mid-parental target height was 65.4 +/- 2 inches. Bone age in 4/2018 was 13 at a chronological age of 12 6/12 years, indicating open epiphyses. The health plan's determination is overturned.
The patient's pre-treatment height was more than 2.25 standard deviations (SDs) below the mean for age and gender and his growth velocity was poor. He responded to GH therapy with acceleration in his growth velocity and has not experienced any adverse effects of therapy. Withdrawal of therapy at this time would hamper his achieving his full growth potential. GH therapy is medically necessary for this patient.