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

Diagnosis: Major depressive disorder
Treatment: continued inpatient mental health services
The insurer denied coverage for continued inpatient mental health services.
The denial is upheld.

This is a male patient who was admitted for inpatient mental health treatment due to worsened depressive symptoms including feeling very depressed in mood, suicidal thoughts multiple times per day without intent or plan, psychomotor retardation, worthlessness, tearfulness, helplessness, command auditory hallucinations, poor activities of daily living (ADLs), and noncompliance. The patient reported daily cannabis use and alcohol use days prior to admission. The patient's urine toxicology was positive for cannabinoids. The patient had a diagnosis of major depressive disorder with psychotic features, and was treated with sertraline and Zyprexa. The patient reportedly improved and was discharged on day 8 of admission.

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, severe depressive symptoms, or inability to adequately care for basic needs are candidates for hospitalization. Based on the review of the medical record, as of day 5 of admission, there were no reports of suicidal or homicidal ideation, intent, or plan, inability to adequately care for basic needs, manic episodes, and psychotic symptoms, self-injurious, aggressive, threatening, or agitated behavior to warrant and justify for inpatient level of care.  As of day 5 of admission, the chart notes did not provide enough specific evidence that the patient was an imminent danger to self or others or unable to adequately care for his basic needs. Also, as of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24-hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting. Thus, the continued inpatient mental health services from day 5 of admission forward were not medically necessary for this patient. 

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 continued inpatient mental health services from day 5 of admission forward should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Meniscus tear
Treatment: Knee surgery
The insurer denied the knee surgery.
The denial is upheld. 

The patient is a male with left knee pain. He had previously undergone ACL (anterior cruciate ligament) reconstruction and meniscal surgery. He reported his knee was bothersome. He had not received any treatment due to lack of insurance. He reported obtaining insurance and would like his knee to be evaluated. He denied recent injury.

The patient's physical examination was significant for no instability, +McMurray, tender to medical joint line, full motion and normal strength.

MRI report showed small amount of tissue adjacent to tibial insertion 6mm (millimeter), no effusion, meniscus intact. 

No, the Knee surgery was not medically necessary.

The medical record demonstrated the physician's concern for a diagnosis of recurrent meniscal injury. The history provided was consistent based upon additional trauma, complaints of giving way and joint line tenderness. The facts however did not demonstrate evidence of meniscal pathology on imaging. The reported "cyclops lesion" was the six millimeter tissue adjacent to tibial insertion. A cyclops lesion presents with "clunk" and mechanical symptoms when abnormal tissue interferes with normal patella femoral mechanics. Surgery is indicated when there is clinical correlation and lack of response to conservative management. 

The facts were that the patient was evaluated several occasions and declined conservative management. 

Among the findings are that there is no documentation of PT or specific home exercise for a duration of six weeks. Given this, as well as the other findings, the Interqual Clinical Guidelines are not fulfilled. Therefore, the Knee surgery was thus not indicated or medically necessary. 

The patient's physician diagnosed tear to meniscus. He discussed PT (physical therapy) versus surgical intervention. The patient elected to have an operation. Surgery was then scheduled.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Alzheimer's Disease, Meniere's Disease.
Treatment:  Personal care services, level II, seven hours/day, seven days/week, total 49 hours/week.

The insurer denied the Personal care services, level II, seven hours/day, seven days/week, total 49 hours/week.  The denial is upheld. 

The patient is a male with a history of Alzheimer's dementia, Meniere's disease and low back pain.  Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). 

Appeal review requested for potential approval of an increase in personal assistance services to seven hours/day, seven days/week, total 49 hours/week to offer increased ADL support.

No, the proposed treatment of an increase in personal assistance services to seven hours/day, seven days/week, total 49 hours/week is not deemed medically necessary. 

An in-home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 37 hours/week personal assistance services is sufficient to meet the patient's current needs.  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 of an increase in personal assistance services to seven hours/day, seven days/week, total 49 hours/week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Missing teeth
Treatment:  Fixed prosthodontic (crowns and bridges) treatment
D2750 - White glass with high gold content crown, Tooth 3,
D6240 - False tooth for bridge, Tooth 10
D6240 - False tooth for bridge, Tooth 24
D6240 - False tooth for bridge, Tooth 25
D6240 - False tooth for bridge, Tooth 7
D6750 - White glass with high gold content cap for bridge, Tooth 23
D6750 - White glass with high gold content cap for bridge, Tooth 26
D6750 - White glass with high gold content cap for bridge, Tooth 6
D6750 - White glass with high gold content cap for bridge, Tooth 8
D6750 - White Glass with high gold content cap for bridge, Tooth 9

The insurer denied the fixed prosthodontic (crowns and bridges) treatment.
The denial is upheld. 

The patient is a male requesting dental benefits for fixed prosthodontic (crowns and bridges) treatment. The patient has existing restorations on teeth 3,6, 8, 9 11, 23 and 26.

No, the proposed dental treatment is not medically necessary.

There are no pre-operative photos presented which might show reasons for the requested need to replace the existing restorations this patient has. Tooth #3 has an existing composite restoration that is intact based on the x-ray, with no recurrent decay seen anywhere, so there is no need for a single crown to be replaced. Teeth 6-11 and 23-26 have existing bridges. There are no areas on any of these teeth on the x-rays showing any decay. If there is decay present that is not visible on the x-rays, photos would be needed to document the need to restore these teeth. Since no photos were provided with the documentation, there is no reason to replace any of the existing bridgework at this time.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: PTSD (post-traumatic stress disorder), major mood disorder
Treatment: Continued partial hospitalization mental health treatment 
The insurer denied the Continued partial hospitalization mental health treatment.
The denial is upheld. 

This female has been attending this partial hospital program (PHP) with diagnoses of post-traumatic stress disorder (PTSD) and major depression. The patient reportedly witnessed domestic violence, had violent outbursts toward her mother, and was sexually promiscuous. She has a highly conflicted relationship with her parents. She had multiple psychiatric hospitalizations following suicidal or para-suicidal behaviors and ideation. 

As per an appeal letter the patient has made great progress in the current program. 

No significant behavioral problems were noted. Specific behaviors noted as supporting continued care at this level were that the patient frequently interrupted group sessions and participated in side conversations instead of being attentive and respectful to a speaker. 

The appeal letter states that if the patient were to return home during this time, she would very likely fall back into old behaviors that ultimately could lead to her experiencing intense suicidal ideation. The utilization review specialist argues in the appeal letter that, "It is generally accepted in the behavioral health community that effective treatment of individuals with mental health or substance use disorders is not limited to alleviation of the current symptoms. Rather, effective treatment requires treatment of the chronic underlying conditions as well."

No, the proposed treatment is not medically necessary. 

The UR specialist is correct in her statement that "effective treatment of individuals with mental health or substance use disorders is not limited to alleviation of the current symptoms" and that "effective treatment requires treatment of the chronic underlying conditions as well."

This does not however mean that ongoing effective treatment requires the current level of care or cannot be effective in an ongoing but less restrictive treatment program. Progress notes available for review show no evidence of active major depression, suicidality, or behavioral dyscontrol. The patient's mood was repeatedly described as bright. The minor instances of defiance cited in the lengthy appeal letter do not constitute a reasonable rationale for indefinite continuation of the current level of care. Based on the documentation reviewed, treatment could have continued safely and effectively in a less restrictive setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post left rotator cuff repair
Issue under review: Continued physical therapy services

Determination:
The Continued physical therapy services were not medically necessary.

The patient is an adult female. She had left shoulder pain.  She was diagnosed with a left shoulder rotator cuff tear.  She underwent left rotator cuff repair.  

The patient started postoperative therapy seven weeks after surgery.  She took anti-inflammatories.  After four months, she had undergone 25 therapy visits that were covered by the health plan.  She had made improvements in range of motion, strength and function.  DASH (Disabilities of the Arm, Shoulder and Hand) scale scores had improved from 79% impaired at onset of therapy to 25% impaired.  She had difficulty with activities such as placing an object over her head, heavy household chores, gardening/yard work, and changing a light bulb overhead.  She continued to have 3/10 pain.  Therapy continued and included services billed under CPT code 97140.

The rehabilitation protocols following rotator cuff repair remain suboptimally developed, particularly in light of the progress in surgical techniques in recent years towards less invasive methods.  The optimal times for initiating range of motion and load-bearing exercises, for instance, are unclear.  Notably, there is an emerging body of evidence indicating that an earlier initiation of load-bearing exercise is less likely to result in complications, such as tendon re-tear, than previously believed (Littlewood C, et al., 2015).  With respect to the mode of exercise, the optimal setting and specifics also remain unclear.  Stretching and strengthening exercises after rotator cuff repair surgery are appropriate and necessary, but do not require a formal outpatient setting for a prolonged period of time.  There is a lack of evidence that face-to-face exercise instruction provides a significant benefit on outcomes over, for example, videotaped instruction (Littlewood C, et al., 2015).  There is a lack of high-grade evidence, overall, establishing that formal physical therapy in an outpatient setting, including passive modalities and manual therapy, is routinely necessary on a prolonged basis (Thomson S, et al., 2016).

Based on the available records, while the patient in this case had some ongoing symptoms and decreased function with respect to more challenging activities involving the shoulder, including overhead activities, no marginal benefit in outcomes would have been expected with ongoing formal therapy over a compliantly-followed independent program and the passage of time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis
Treatment: Airway clearance system
The E0483 - Airway clearance device is medically necessary.

The patient is a female with frequent bronchitis episodes. She has received multiple cycles of antibiotics and steroids without much improvement. She was found to have bronchiectasis. Despite multiple cycles of antibiotics and prednisone, the patient continues to have daily productive cough with frequent exacerbations. The chest physiotherapy (CPT) as well as other cough assist devices have been tried and failed. The patient was thus prescribed airway clearance device. 

The clinical documentation provided reports that the patient has bronchiectasis with frequent exacerbations due to inability to effectively clear pulmonary secretions, as well as trial and failure of other modalities, such as CPT, flutter valve. Thus, the use of high frequency chest wall compression device is medically necessary and meets the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Infectious Disease.
Treatment:  Inpatient hospital stay.

The health plan denied the inpatient stay.  The health plan's determination is upheld in whole.  

This is the case of a patient past medical history of diabetes mellitus, methicillin-resistant staphylococcus aureus (MRSA) infections, obesity, and hypothyroidism, who presented to the emergency department with medial thigh abscess developing over the last 5 days in addition to fever to 101 at home.

On presentation to the emergency department, patient was noted to have a temperature of 99.6 with blood pressure 152/98, heart rate 128, respiratory rate 20, and with oxygen saturation of 96% on room air. Exam otherwise noted the patient to be obese with a raised and red lesion that was 4 centimeter (cm) by 6 cm and tender to palpation with redness beyond the raised lesion extending 2 by 3 cm anteriorly.  Labs were notable for white blood cell count 11, Hemoglobin (HGB) 15.6, platelets 193, sodium 136, potassium 4.4, blood urea nitrogen (BUN) 12, creatinine 0.8, glucose 337, lactic acid 1.7, and liver function tests grossly normal.  The patient underwent bedside incision and drainage in the emergency department with 5 cubic centimeter of purulence drained and additional dark blood with clots noted.  Given fever, leukocytosis, and hyperglycemia the patient was subsequently brought into the hospital for ongoing intravenous (IV) Zosyn, IV Vancomycin, glucose control, and further monitoring.  Overnight, the patient's WBC improved, pain was controlled, and  was subsequently discharged with home health and to continue dressing packing changes.

Patient was afebrile on presentation, and the abscess was drained at bedside, after which the patient was reasonably brought into the hospital for ongoing monitoring on IV antibiotics, given hyperglycemia and MRSA history.  Patient remained hemodynamically stable after presentation without fever or hypotension; leukocytosis improved overnight; patient did not require further incision and drainage and  was subsequently able to be discharged within 24 hours.  This patient presenting with small thigh abscess requiring bedside drainage with mild leukocytosis was appropriate for a lower level of care, given  history of MRSA and hyperglycemia, to bring into the hospital for ongoing monitoring, but it is unclear why in the absence of ongoing hemodynamic instability, need for repeat incision and drainage, failure to respond to outpatient therapy, or other complication, this patient with a small abscess could not have been safely cared for at a lower level of care, or why prolonged length of stay would have been expected.  Inpatient care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems 
Treatment: Dental/Orthodontic Procedure 

The insurer denied the tooth colored cap (crown) for tooth 19. The denial is upheld in whole. 

The patient is a female who presented to the office of her dental provider for evaluation and treatment of tooth #19. Included for review are previous letters of appeal and denial, a narrative from the patient explaining desire for porcelain ceramic restoration (2740) for #19, four bitewing radiographic images and one peri-apical image from an unknown date, multiple pages of from internal ledgers of the doctor's office, and clinical codes from the doctor's office. In question is the medical necessity of the planned treatment of porcelain ceramic restoration (2740) for #19. Previous denials have been on the basis that the tooth is not eligible for benefits as there are at least eight other teeth in occlusion beyond tooth #19 and thus not medically necessary. 

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

No, the treatment is not medically necessary as the tooth has a very clear fracture line starting from the base of the pulp chamber extending medially to the level of the mid root. Any attempts to surgically crown lengthen the tooth in order to go beyond the fracture line would result in massive loss of bone. There is already evidence in the bone mesial to the root of #19 that an infection is spreading. The patient has complaints of pain from the tooth in occlusion despite having had a root canal, a symptom that supports the radiographic appearance of the fracture. Tooth #19 is non restorable due to the presence of the fracture and thus the treatment of porcelain ceramic restoration (2740) for #19 is not medically necessary as the tooth has a hopeless prognosis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal 
Treatment: Surgical Services 
Issue: Medical necessity 

The health plan's determination of medical necessity is upheld in whole. The treatment of Knee Surgery: Arthroscopy is not medically necessary for this patient. 

This case describes a patient with a complaint of right knee pain. The patient was initially provided a cortisone injection and referred to supervised physical therapy. Due to persisting pain, a magnetic resonance imaging scan of the right knee was obtained which confirmed severe medial and patellofemoral joint arthritis. There was an associated degenerative medial meniscal tear also present. The patient subsequently underwent right knee arthroscopic surgery. 

The recommendation for arthroscopic knee surgery to perform partial medial meniscectomy in the presence of advanced degenerative changes was not consistent with the recommendations of the current, peer-reviewed literature. The provider in this case proceeded with arthroscopic knee surgery based on the mechanical symptoms reported by the patient for a degenerative type medial meniscal tear. 

A recent article published by Sihvonen and colleagues in the Annals of Rheumatologic Diseases in 2018 concluded that "In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after arthroscopic partial meniscectomy were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or those who have failed initial conservative treatment are more likely to benefit from arthroscopic partial meniscectomy." Thus, the medical necessity of the surgery performed in this case is not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COPD, Hypertension, muscle weakness and
dementia.
Treatment: PCA Level II - 24 hours/day (split shift).
The insurer denied the PCA Level II - 24 hours/day (split shift).
The denial is overturned. 

The patient is a female with a history of severe COPD (chronic obstructive pulmonary disease), hypertension, muscle weakness and dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review requested for potential approval of personal care assistant (PCA) level II - 24 hours/day (split shift) Personal Assistance Services to offer increased ADL support.

Yes, the PCA Level II Personal Assistance services - 24 hours/day (split shift) is deemed to be medically necessary. 

The patient is a female with a history of severe COPD, hypertension, muscle weakness and dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Documentation from the patient's provider indicates that due to the patient's progressively worsening dementia, exertional dyspnea and fatigue related to severe COPD, she now requires assistance with all of her ADLs given her bedbound status. Hence, the currently approved plan of 56 hours/week Personal Assistance Services is not sufficient to meet the patient's current needs. 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 of PCA Level 2 - 24 hours/day (split shift) Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, coronary artery disease and cardiac pacemaker
Treatment: Personal Care Services to 24 hours a day (split-shift), seven days a week, a total of 168 hours a week
The insurer denied the Personal Care Services to 24 hours a day (split-shift), seven days a week, a total of 168 hours a week.
The denial is upheld.

The patient is a female with a history of dementia, coronary artery disease and cardiac pacemaker. 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 24 hours a day (split-shift), seven days a week, a total of 168 hours a week Personal Assistance Services to offer increased ADL support.

No, the proposed treatment of 24 hours a day (split-shift), seven days a week, a total of 168 hours a week Personal Assistance Services is not deemed medically necessary. 

This is a female with a history of dementia, coronary artery disease and cardiac pacemaker. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, an in-home assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved hours are sufficient to meet the patient's current needs. 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 168 hours/week Personal Assistance Services is not deemed medically necessary.