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

Diagnosis: Parkinson's 
Treatment: Personal Care Aide (PCA) Services: Total of 30 Hours per Week 
The insurer denied Personal Care Aide (PCA) Services: Total of 30 Hours per Week 
The health plan's determination is overturned. 

The patient is a female with past medical history of Parkinson's disease, anxiety, depression, dementia, hypertension, urinary incontinence, vitamin B deficiency, vitamin D deficiency, and chronic anticoagulation who had been assigned PCA (personal care aide) services based on a video assessment assessing the patient at total assistance with tasks of ordinary housework, managing finances, and phone use while maximum assistance with tasks of meal preparation, stairs, shopping, and transportation. With tasks of dressing lower body, walking, and locomotion the patient was assessed at extensive assistance while independent with tasks of bathing, personal hygiene, dressing upper body, transfer toilet, toilet use, bed mobility, and eating.

Personal Care Aide (PCA) Services: Total of 30 Hours per Week are medically necessary for this patient.
There is documentation that the patient does not have formal or informal help during the week days 9 AM to 5 PM. The patient requires extensive assistance with toilet use, transfer toilet, walking, and locomotion and therefore has unpredictable and unscheduled care needs that the insurer failed to document a plan for. The patient will require PCA assistance when his family is not available. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The tasking tool estimated 35 hours/week. 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 requested PCA services 30 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: Malocclusion

Treatment: D8080 Braces and D8670 monthly visits

The insurer denied coverage for D8080 Braces and D8670 monthly visits

The denial is upheld. 

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, orthodontist treatment records, appeal letter the patient's orthodontist with references, as well as insurer correspondence, it appears that this patient with muscular dystrophy, presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including mandibular protrusion, open bite, and anterior crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 36 total points to support orthodontic care. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index. attaining 7 points by internal reviewers. The orthodontist is appealing the decision.

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index. Report (HLD, New York State Medicaid program) modeled after Handicapping Labio-Lingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist does not claim an automatic qualifying condition and completes the second portion of the index arriving at 36 points to justify orthodontic care. The reviewer concurs with the index completed by the insurer attaining a total of 7 points on the HLD index (2 overjet, 2 overbite, 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. 

Regarding the validity of the Handicapping Labio-Lingual Deviation Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.

The medical necessity for D8080 Braces and D8670 monthly visits is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Implant tooth number 3
The insurer denied Implant tooth number 3.
The determination is overturned.

The patient is a female who presented for the treatment of tooth number (#) 3. Provided for review are letters of appeal and denial, a letter of explanation/narrative from the treating provider, periodontal indices, radiographic images, computed tomography (CT) scan images, explanation of benefits letters, multiple pages of claim codes, and health plan language. At issue is the medical necessity of the treatment of dental implant (6010) for tooth #3. Previous denials have been on the basis that the treatment is not a covered benefit and that the less expensive alternative would be to provide the patient with a partial denture.

As the patient is missing tooth #3, she has the diagnosis of partial edentulism as well as diminished posterior support. With the diagnosis of partial edentulism as well as diminished posterior support the only therapy capable of addressing both diagnosis is that of implant therapy as it is anchored within the bone offering complete support stability and retention for a tooth prosthesis. Fixed partial dentures do not offer additional support and actually depend on the residual dentition to replace the missing tooth simply putting additional load on the residual teeth without replacing the loss. Removable partial dentures are tissue supported prosthesis and do not offer any support to the dentition as they are designed to become passive upon load. After the implants have integrated they will require restorations in the form of abutments and crowns in order to complete the tooth replacement. This is standard in tooth replacement involving implants. Therefore, the treatment of dental implant (6010) for tooth #3 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The health plan's determination is upheld. 

The patient is a woman with a history of diabetes who presented to the emergency room with abdominal pain and nausea. The vital signs were normal. She was alert and in moderate distress. Physical exam revealed mild left abdominal tenderness. The bowel sounds were normal and there was no rebound or guarding. Labs were remarkable for a white blood cell (WBC) count 13500 and a urinalysis consistent with a urinary tract infection (UTI). 

The requested inpatient admission was not medically necessary for this patient. Upon presentation, there was no objective evidence on physical exam, labs, or imaging of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. There was no hemodynamic instability, mental status changes, persistent hypoxia, or severe metabolic disarray. The services provided - intravenous fluids, antibiotics, insulin, and imaging could have been provided at a lower level of care. Therefore, based on the standard of care, as well as the peer reviewed literature and guidelines cited in the references, the acute inpatient level of care was not medically necessary and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

This is a case of a female admitted for diagnosis of asthma with acute exacerbation. She presented with a chief complaint of cough and shortness of breath. Symptoms had been present for three days prior to admission. It was noted that she had never been intubated but was hospitalized for asthma about every three months. Vital signs demonstrated blood pressure 186/103, pulse 93, temperature 37.1C, respiratory rate 21 and 02 (oxygen) saturation 96%. Physical exam showed no acute distress or altered mental status. White blood cell count was 4.7 with creatinine 0.8 and bicarbonate 25. Blood gas showed potential hydrogen (pH) of 7.34 with carbon dioxide (CO2) 47. Peak flow was 250 with baseline of 400. She was treated initially with bi-level positive airway pressure (BiPAP) in the emergency department, duonebs, solumedrol and Symbicort. Peak flow then improved to 380 and she remained clinically and hemodynamically stable. 

The inpatient hospital admission was medically necessary.

The patient in this case had a peak flow 62% of predicted which would be considered a moderate exacerbation. She had wheezing, tachypnea and required hospital management every three months for asthma exacerbation. Additionally, according to Milliman Care Guidelines (MCG) Health Asthma guidelines she would require admission because she needed ventilatory assistance with bi-level positive airway pressure (Bipap). She also had C02 elevation and wheezing at admission. Given all these findings, she would be at a higher risk level that would not typically be acceptable for a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history (PMH) of schizophrenia, polysubstance abuse, generalized anxiety disorder (GAD), major depressive disorder (MDD), hyperlipidemia (HL), hypertension (HTN), and hypothyroidism who was admitted with complaints of (c/o) a mechanical fall and suicidal ideation, although he denied them in the emergency department (ED). His vital signs were unremarkable. The physical exam was unremarkable. Lab work was notable for a mild elevation in creatinine and troponin. Imaging studies included a computed tomography (CT) scan of the head/cervical (C)-spine which showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without ischemic changes. The patient was diagnosed with suicidal ideation and treated with 1:1 observation and psychiatry evaluation. The troponin elevation was not considered acute ischemia and the creatinine bump improved swiftly with intravenous fluids (IVF). Psychiatry evaluated the patient and determined there was no need for 1:1 observation or inpatient psychiatric admission. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the ED with c/o a mechanical fall and admitted to recent suicidal ideations, but denied them to Emergency Medical Services (EMS) and to the ED physician. The patient did not have any active overdose or alcohol withdrawal and the patient denied active suicidal ideation upon evaluation with psychiatry, as well. The patient had a mild troponin elevation without acute ischemic changes on EKG and there was no need for intervention as it was thought secondary to a concomitant mild acute kidney injury (AKI), which swiftly responded to IVF while there were no marked electrolyte abnormalities or requirement for hemodialysis (HD). The patient was diagnosed with prior suicidal ideation and mild AKI and treated with IVF while receiving observation with a 1:1 sitter for a patient without active suicidal ideation, who was ultimately cleared by psychiatry who determined no active suicidal ideations, and these interventions could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fibromyalgia, chronic pain
Treatment: Consumer Directed Personal Care Assistance Services
The insurer denied Consumer Directed Personal Care Assistance Services. 
The health plan's determination is upheld. 

This is a case review for a female with medical history notable for fibromyalgia, asthma, and chronic pain. The patient and her care team requested consumer directed personal care assistance services (CDPCAS).

The requested CDPCAS are not medically necessary for this patient.

The patient requires a small amount of assistance with instrumental activities of daily living and bathing. She has been receiving informal assistance from her boyfriend. It is unclear which personal care needs, if any, are not being met at this time. There were no letters of medical necessity provided or medical records detailing any currently unmet personal care needs. Therefore, the request for personal care assistance has not been clearly demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Superficial Suprafascial Infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

A review of the medical record was significant for the diagnosis of a superficial suprafascial infection. It was not deep. The treatment provided was irrigation, debridement and closure. The American Society of Anesthesiologists (ASA) score was 2. The duration of surgery was 45 minutes. There was no bleeding. 

The post-surgical course was non complicated with the confirmation of Methicillin Sensitive Staphylococcus Aureus (MSSA). The Infectious Disease (ID) specialist recommended oral antibiotics with follow-up as outpatient. 

The records also showed, "Did not feel comfortable and wanted to stay overnight to have surgical team check the patient's wound. Surgeon did not want the patient to have physical therapy (PT) in hospital and not to remove dressing."

The reported redness to face was noted by chance after initiation of Vancomycin which was ordered to be discontinued. There were no treatments required aside from prophylactic Benadryl. No additional testing nor consultations were required. 

The vital signs were stable. There were no problems taking oral medications. The wound was sealed with no bleeding. There were no problems with ambulation. 

The reported clinical status did not substantiate necessity for the acute level of service (i.e. superficial infection treated with limited surgery without significant complication).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission to Hospital for Special Surgery is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of chronic pancreatitis status/post (s/p) pancreatectomy, splenectomy and cholecystectomy, chronic abdominal pain with chronic opiate use, insulin dependent diabetes mellitus and multiple hospitalizations for abdominal pain who presented to the emergency department with concerns for worsening abdominal pain. Initial examination documented the patient as alert and oriented without peritoneal signs. Subcutaneous insulin was administered with a decrease in serum glucose to 352. The emergency department physician had an impression of acute on chronic abdominal pain, hyperglycemia, and abnormal electrocardiogram (EKG). The treatment plan included resumption of home medications, oral analgesia, and an echocardiogram. At issue is the medical necessity of an inpatient stay.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not medically necessary for the entire admission.
Savage et al. note that diabetic ketoacidosis is defined by the biochemical triad of ketonemia, hyperglycemia and acidemia. It remains a life-threatening condition despite improvements in diabetes care. The diagnostic criteria for diabetic ketoacidosis are ketonemia 3 millimoles per liter (mmol/l) and/or significant ketonuria (more than 2 plus (+) on standard urine sticks); blood glucose over 11 mmol/l (greater than (>) 180 milligrams per deciliter (mg/dl)) or known diabetes mellitus; venous bicarbonate (HCO3) below 15 mmol/l and/or venous potential hydrogen (pH) less than 7.3.[1]
The patient had a history of chronic abdominal pain and insulin dependent diabetes mellitus who presented with hyperglycemia and abdominal pain in the setting of running out of analgesia prescriptions. The patient was initially treated at the observation care where acute coronary syndrome was ruled out, abdominal pain was adequately controlled with resumption of home oral regimen, and hyperglycemia was improved with adjustments of the home subcutaneous insulin regimen. No significant electrolyte abnormalities were noted. Per documentation, the patient was transitioned to acute inpatient care for concerns of hyperglycemia. On this date, the glucose checks were listed as a fasting 354 and, following administration of the insulin regimen, 215 and 121. The hospital course thereafter included adjustment of the subcutaneous insulin regimen by a few units each day. No other issues or complications related to hyperglycemia or other acute complications were documented.
Clinical indications for admission to inpatient care were not met. The patient did not have diabetic ketoacidosis, hemodynamic instability, hyperglycemic hyperosmolar state, mental status changes, severe or persistent dehydration, significant electrolyte abnormality not responsive to observation care, severe or persistent vomiting, or not sufficiently stable despite observation care.[2]
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hashimoto's thyroiditis with hypothyroidism.
Treatment: Formulary exception for Levothyroxine Sodium (Tirosint) 75mcg Capsule.

The insurer denied: Formulary exception for Levothyroxine Sodium (Tirosint) 75mcg Capsule.  The denial is upheld.

The patient is an adult female. She was diagnosed with Hashimoto's thyroiditis with hypothyroidism. This request is for Tirosint. As per the provided letter, the patient had a pattern of significant hives and a history and a history of Vitiligo. She had been treated with Synthroid and other thyroid preparations, but the hives persisted. She switched her Tirosint and hives resolved. Her current dose of Tirosint is 0.75 mg (milligrams) per day. She is stable for 3 years. Her weight was down to 159 pounds from her diet. Her thyroid size was normal.

The health plan should not cover the Formulary exception for Tirosint.

The formulary drugs are not documented to have been ineffective for the patient. The formulary drugs are reasonably expected to be as effective as the non-formulary drug. The formulary drugs are not documented to have adverse reactions for the patient.

The formulary alternatives would be as effective as the requested medication and should not have adverse effects for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Post tonsillectomy hemorrhage
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient, who underwent a tonsillectomy and subsequently presented to the emergency department with concern for an oropharyngeal hemorrhage. She was admitted to the hospital for hemoptysis and suboptimal oral intake. She had a bilateral post tonsillectomy hemorrhage, which required emergency hemostasis control under anesthesia. She had further observation/monitoring to ensure there was no additional bleeding and for intravenous hydration. At issue is the medical necessity of an inpatient stay.

Based on the available records and available peer-reviewed medical literature, the hospitalization was medically necessary for inpatient level of care and could not have been provided at a lower level of care. Standard of care for hemorrhage following post adenotonsillectomy is a full and complete workup, intravenous hydration, evaluation under anesthesia for cauterization when deemed appropriate followed by an appropriate period of inpatient observation to ensure hemodynamic stability and that there is no additional oropharyngeal hemorrhage. A significant proportion of severe life-threatening bleeding episodes in patients with post tonsillectomy hemorrhage were preceded by minor bleeding episodes. This cannot be safely performed in an alternative setting that meets a safe standard of care.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Home health care

Diagnosis: severe gait disturbance.
Treatment: Home health care.
The insurer denied Personal Care Aide (PCA) Services: Total Amount of 42 Hours per Week (6 Hours per Day, 7 Days per Week).
The health plan's determination is overturned. 

The patient is a male with a medical history notable for severe gait disturbance. The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has multiple medical problems, including acquired immunodeficiency syndrome (AIDS), hypertension, and a history of cerebrovascular accidents resulting in gait disturbance. The provider states that the patient's gait has worsened, and he has become more unsteady. He has not received adequate care for bathing and hygiene. The provider recommends an increase in home care hours.

The requested Personal Care Aide (PCA) Services: Total Amount of 42 Hours per Week (6 Hours per Day, 7 Days per Week) service is medically necessary for this patient.
The patient has functional deficits secondary to a prior stroke which have resulted in weakness. Additionally, he experiences progressively worsening dizziness and unsteadiness. Recently, he fell and was hospitalized when attempting to perform a personal care task unaided, highlighting unmet personal care needs. Furthermore, his provider attested to inadequate bathing and hygiene due to an insufficient amount of time with the personal care aide. Given the patient's evidence of unmet personal care needs, the requested modest increase to 42 hours per week is medically necessary and reasonable. Failure to address the patient's personal care needs could lead to additional falls or injuries.