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

Diagnosis: osteoarthritis.
Treatment: PCA (personal care assistant) services increase total of 22 Hours per Week. 
The insurer denied Increase in Personal Care Assistance Services: Total of 22 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of osteoarthritis, bilateral leg pain, back pain, chronic pain syndrome, and constipation who was assigned PCA (personal care assistant) services 14 hours/week. There was a request to increase PCA hours to 22 hours/week. The patient had an assessment tool performed over the phone assessed her at maximal assistance with tasks of meal preparation and ordinary housework while extensive assistance with tasks of stairs and transportation. The patient was assessed at limited assistance with tasks of managing finances, managing medication, equipment management, bath, dressing upper/lower body, and transfer toilet while supervision with tasks of personal hygiene, walking, locomotion, and toilet use. The patient was assessed at set up only for phone use and independent with bed mobility and eating. This assessment noted the patient uses a cane indoors for ambulation and a walker when outdoors. The patient lives alone. The patient has no informal helpers. The assessment noted there was a request for more hours because the patient "needs more hours for assistance with activities of daily living (ADL) / Instrumental activities of daily living (IADL) ".

The Increase in Personal Care Assistance Services: Total of 22 Hours per Week (Additional 2 Hours per Day, 4 Days per Week - Monday through Thursday) is medically necessary for this patient.
The patient indicated she does not have enough time with shopping, transportation, and walking to and from errands. The assessment tool did not allot enough time for walking to and from errands, nor did it allot any time for escort to appointments. The Uniform Assessment System (UAS) indicated the patient walks to some of her errands and has only been allotted 30 minutes per week. There is not specific documentation of the patient's specific weekly errands and appointments by the assessor. The denial notice stated "the hours are enough to help with your activities of daily living such as bathing, dressing, toileting, and housekeeping related services" but does not mention time for shopping, other errands, and appointments. The UAS indicated the patient needs supervision with toilet use but the tasking tool did not allot time for this task. Therefore, the increase in PCA hours is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip and sacroiliac joint (SIJ) pain
Treatment: Additional physical therapy visits

The insurer denied coverage for the additional physical therapy visits.
The denial is overturned.

This is a female patient with left hip and sacroiliac joint (SIJ) pain. The patient underwent left hip arthroscopic surgery with labral and capsulorrhaphy type capsule repairs. The patient participated in physical therapy pre- and post-arthroscopic procedures. Under review is the medical necessity for additional physical therapy (PT) visits that were provided.
Based on the review of the medical record and literature, the additional PT visits that were provided were medically necessary for this patient. The patient's left hip and SIJ pain was initially and appropriately treated conservatively. The treatment included steroid injection, analgesic medication and physical therapy. Failing conservative treatment, surgical intervention was provided. Post-surgical PT was also clinically appropriate. The post-surgical PT notes document gradual improvement particularly with range of motion and gait pattern.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, the additional PT visits were medical necessary.  

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

Based on the above, the medical necessity for the additional physical therapy visits that were provided is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems (skeletal Class I, vertical growth pattern, Class III canines, maxillary and mandibular crowding, posterior crossbite and anterior crossbite).
Treatment: D8080 braces and D8670 monthly visit x 12.
The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.
The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, Class III canines, maxillary and mandibular crowding, posterior crossbite and anterior crossbite.  The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining only 23 points on review by their internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), 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, the HLD Index is utilized. This index provides 6 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion.  In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 23 points (i.e., 2 overjet, 3 overbite, 15 mandibular protrusion, 3 labiolingual spread).

D8080 braces and D8670 monthly visit x 12 are not considered 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 D8080 braces and D8670 monthly visit x 12 should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rupture of quadriceps tendon and ongoing pain.

Treatment: Inpatient stay.

The insurer denied coverage for the inpatient stay.

The denial is overturned. 

This is a male patient with a history of kidney stones, morbid obesity and obstructive sleep apnea (OSA) who fell. Two weeks after falling, the patient underwent repair of tendon quadriceps on the right knee for the diagnosis of rupture of quadriceps tendon, right. The patient tolerated the surgery well without complications. An order was placed to admit the patient to inpatient and the plan of care was pain control. The patient received post-operative pain management. The patient received physical therapy (PT). The patient tolerated PT and achieved all necessary goals for discharge. The patient was medically cleared for discharge on day 3 of admission.

Based on the review of the medical record and literature, the inpatient admission was medically necessary for this patient. The medical record demonstrated a post-surgical problem for this patient. The patient was found to have ongoing pain which was not relieved by standard pain management. The patient reported on several occasions that his "pain was uncontrolled". Multiple practitioners reported need for pain management service and continuation of patient-controlled analgesia (PCA). The patient's pain was not relived with oral medications. The patient required parenteral analgesia. Records document that the patient required multiple dosages of intravenous (IV) narcotic that could not have been safely provided and monitored at a lower level of care than inpatients status.

Based upon the documentation, the level of service could not have been provided at a lower level of care. Thus, the inpatient admission was necessary for this patient. 

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

The medical necessity for the inpatient stay is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental problems (overjet, overbite, and crowding).

Treatment: Dental codes D8080 for braces and D8670 for monthly visits.

The insurer denied coverage for the dental codes D8080 for braces and D8670 for monthly visits.

The denial is upheld. 

This patient is a female child who presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, and crowding and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index twice, on one attaining 27 total points to support orthodontic care, on the other claiming the automatically qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

Upon review of the submitted documentation (study models were not provided for review) 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, an HLD index is utilized. This index provides 6 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 claims both an automatic qualifying condition and in addition also completes the second portion of the index arriving at 27 points to justify orthodontic care.  This reviewer concurs with the index completed by the insurer attaining a total of 20 points on the HLD index (i.e., 6 overjet, 6 overbite, 5 anterior crowding and 3 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. 

The dental codes D8080 for braces and D8670 for monthly visits are not considered medically necessary for this patient.

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

Based on the above, the medical necessity for the dental codes D8080 for braces and D8670 for monthly visits is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dematitis
Treatment: Dupixent
The insurer denied the Dupixent.
The determination is upheld.

This is a patient with severe atopic dermatitis (over 50% body surface area involvement). The patient has tried and failed topical therapies such as triamcinolone and fluocinonide. Eucrisa and Protopic were not seen in the patient's paid claim information, but burning and itching were reported for both topical Eucrisa and Protopic. At issue is the medical necessity of Dupixent.
The Dupixent is not medically necessary.
The patient has no documented treatment failure with, or true medical contraindication to, either topical calcineurin inhibitors, or standard, first-line oral medications such as methotrexate, or azathioprine. The patient is an appropriate candidate for methotrexate, or if gastrointestinal (GI) upset is an issue with methotrexate, she is also an appropriate candidate for cyclosporine.  Oral medications used for moderate to severe atopic dermatitis, and/or phototherapy, are appropriate for this patient at this time. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature [2-5] and standards of care, the requested Dupixent is not medically necessary.
Modern dermatology literature [2-5] supports use of preferred medications as similarly efficacious to the requested Dupixent, particularly for a patient with a limited history of systemic atopic dermatitis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. For severe cases both second-like topical therapies and/or oral/systemic immunomodulators are also needed for concurrent use with Dupixent.
Atopic dermatitis (AD) is a common chronic inflammatory skin disease that predominantly affects children. However, it can persist in adulthood and/or start at older ages. Due to its chronic nature and frequently occurring relapses, AD has a substantial effect on patients' quality of life, often requiring long-term systemic treatment, especially in adult patients, who are more frequently refractory to adequate topical treatment with mid- to high-potent corticosteroids and/or calcineurin inhibitors. Therefore, treatment with systemic therapies is often needed to take control of the disease, prevent exacerbations and improve quality of life. However, data regarding systemic treatment effectiveness and long-term safety in adult patients with AD are insufficient. Standardized international guidelines are lacking, and the treatment approach widely differs among diverse countries. This review focuses on the use of systemic treatments in adult AD patients analyzing published literature. (2)
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: History of stroke, hypertension, dizziness,
gastroesophageal reflux disease (GERD), gait
ataxia and urinary incontinence
Treatment: Increase Personal Care Aide Level II: 7 hours per day - 7 days per day - a total of 49 hours per week
The insurer denied the Increase Personal Care Aide Level II: 7 hours per day - 7 days per day - a total of 49 hours per week.
The denial is upheld. 

The patient is a female with a history of stroke, hypertension, dizziness, gastroesophageal reflux disease (GERD), gait ataxia and urinary incontinence. 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 49 hours per week personal assistance services to offer increased activities of daily living (ADL) support.

No, the proposed treatment of 49 hours per week personal assistance services is not deemed medically necessary. 

This is a female with a history of stroke, hypertension, dizziness, gastroesophageal reflux disease (GERD), gait ataxia and urinary incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). However, a registered nurse (RN) telephonic assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of 31.5 hours per 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 49 hours per week personal assistance services is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient with no past medical history (PMH) who was admitted with complaints of (c/o) left-sided facial swelling without associated difficulty swallowing or breathing. He was seen the day prior to admission and given amoxicillin without significant improvement. Vital signs were notable for a pulse of 100 and temperature (T) of 101.3 degrees Fahrenheit. The physical exam was notable for non-toxic appearing, no apparent distress (NAD), and left cheek swelling. Lab work was unremarkable. A chest x-ray (CXR) showed no active chest disease. The patient was diagnosed with an odontogenic abscess and treated with antibiotics and incision and drainage. He was deemed stable for discharge (DC) per oral maxillofacial surgery (OMS) and discharged in stable condition. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary at an acute inpatient level of care. The patient presented to the emergency department (ED) with c/o left-sided facial swelling without associated difficulty swallowing or breathing. He did not appear toxic, had no hemodynamic instability, unstable comorbidities, did not have a limb-threatening infection, there was no septicemia, life-threatening infection, necrotizing fasciitis, no animal or human bite with extensive damage, pain out of proportion to clinical findings, crepitus, neutropenia, immune-suppression, marked systemic toxicity or worsening symptoms, or inability to take oral medications. While the patient did initially meet systemic inflammatory response syndrome (SIRS) criteria, he received definitive treatment in the ED with incision and drainage (I&D) and appropriate antibiotic coverage with stabilization of vital signs. Overall, this patient was treated with intravenous (IV) antibiotics, expert consultation, and I&D, and this could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Blood Disorder-Anemia
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. 
The reviewer has upheld the health plan determination in whole. 

This is the case of a patient past medical history of menorrhagia who presented to the emergency department after outpatient labs revealed Hemoglobin (HGB) of 6.
On presentation to the emergency department, she was afebrile with blood pressure 158/84, heart rate  55, respiratory rate  18, and oxygen saturation normal on room air. Exam otherwise noted no obvious abnormalities. Labs resulted with white blood cell count (WBC) 9.3, Hemoglobin (HGB) 6.8, Platelets 330, sodium 140, potassium(K) 4, blood urea nitrogen (BUN) 6, creatinine 0.51, and liver function tests within normal limits. The patient was brought into the hospital with plans for transfusion of 1 unit of packed red blood cells, sending reticulocyte count, and having her establish outpatient follow up for cancer screening and follow up of menorrhagia.
Overnight and the next day, the patient remained hemodynamically stable. Hemoglobin responded well to transfusion. She was given intravenous (IV) iron. Abdominal ultrasound showed no obvious abnormalities. The patient was subsequently discharged.

Inpatient level of care was not medically necessary for this patient. This is a patient who presented with anemia in the setting of menorrhagia. She was hemodynamically stable on presentation and throughout her stay, without signs of rapid ongoing bleeding or other complications of anemia (acute coronary syndrome or arrhythmias), and she responded well to transfusion without need for multiple transfusions without need for uterine artery embolization or hysterectomy. It is unclear why in the setting of hemodynamic stability and no concerns on presentation for rapid bleeding why she could not have been safely cared for at a lower level of care  or why prolonged length of stay would have been anticipated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perirectal abscess.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male child born prematurely at 35 weeks' gestation that was referred to the emergency department (ED) by the pediatrician for evaluation of a perirectal abscess. He presented with two-day history of fever, vomiting, and diarrhea. In the pediatrician's office, a swelling was noted, prompting referral to the emergency department. He continued to have loose watery stool and decreased urine output. 

Vital signs included temperature 37, heart rate 151, and respiratory rate 30. Examination was significant for no distress, moist mucous membranes, benign abdomen, good capillary refill, swelling in the perirectal region at 1200 with erythema extending to the perineum and edge of the scrotal sac, mild fluctuance and induration measuring three by two centimeters, and non-focal neurologic exam. Laboratory evaluation revealed leukocytosis with white blood cell (WBC) count 15.09 thousand (K). Ultrasound was significant for a large complex collection measuring 2.4 by 2.2 by 1.6 centimeters with internal swelling, debris, and peripheral hyperemia, compatible with a perirectal abscess measuring up to 2.4 centimeters. 

The patient was treated with intravenous (IV) fluids and a General Surgery consultation was requested. He started treatment with Zosyn and was taken to the operating room (OR) for incision and drainage, with eight milliliter (mL) purulent fluid recovered. The patient tolerated the procedure well. The following day, half of the packing was removed. Pain was well-controlled, and he remained on Zosyn pending culture results. Cultures returned positive for pan-sensitive E. coli (Escherichia coli). He was deemed stable for discharge after the remainder of the packing was removed to complete a course of therapy with Augmentin

No, the proposed inpatient admission was not medically necessary.

Perianal abscess is a relatively common problem with some controversy associated with management. Conservative management has been favored over surgical management because of less recurrence and lower fistula formation rate. However, in certain circumstances (systemic symptoms, significant discomfort), surgical intervention is necessary. Antibiotics may be prescribed in the office or in the hospital. 

In the case of this young infant with an acute diarrheal illness, he had signs of systemic illness with fever. Ultrasound revealed a complex lesion measuring 2.4 centimeters that the surgeon felt required incision and drainage in conjunction with parenteral antibiotic therapy. While it was reasonable and appropriate to monitor him prior to and immediately after surgical drainage for response to therapy, he was overall hemodynamically stable with no evidence of impending sepsis and no significant underlying chronic illnesses to complicate his recovery. He did not require acute inpatient admission and could have been safely managed at a lower level of care in the hospital such as observation.