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

Diagnosis: Decreased mobility
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 24 hours/day, live-in, 7 days/week, total of 168 hours/week
The insurer denied CDPAS): 24 hours/day, live-in, 7 days/week, total of 168 hours/week.
The health plan's determination is overturned. 

The patient is a female with past medical history of hypertension, lower extremity edema, osteoarthritis, cervical spondylosis, bladder incontinence, bowel incontinence, moderate mitral regurgitation, and numbness to bilateral fingers who was assigned Consumer Directed Personal Assistance Services (CDPAS). 

CDPAS): 24 hours/day, live-in, 7 days/week, total of 168 hours/week are medically necessary for this patient. 

There is documentation from both the patient's primary care physician (PCP) and her daughter of worsening physical functioning following the recent hospitalization. The video assessment underestimated the patient's care needs for ADLs (activities of daily living), specifically that the patient was independent with locomotion. The patient was not independent with locomotion and required the assistance of a wheelchair. The assessment also underestimated the patient's ability to walk, transfer toilet, use toilet, and bed mobility. The daughter had requested another assessment as she felt the assessment was inaccurate. The tasking sheet also underestimated how many times a day the patient would need to use the toilet and/or transfer from the toilet stating 3 times/day would be typical, when 6-10 times would be more typical for a patient on diuretic therapy.

In addition, the patient had 24-hour care needs and the task-based tool should not have been utilized to calculate CPDAS hours. The patient requires assistance with all ADLs and IADLs (instrumental activities of daily living). The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in CDPAS is not solely for safety and supervision, but to assist the patient with safe completion of ADLs and IADLs. The plan incorrectly assumed the patient had informal help outside of currently approved CDPAS. 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, CDPAS 24 hours/day, live-in, 7 days/week, to total 168 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: Asthma Attack.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.  
The denial is upheld.

The patient is a female with asthma presenting with asthma exacerbation, characterized by cough and shortness of breath. The respiratory rate was 20, and oxygen saturation on room air was 92%. The patient had bilateral wheezing. All of the lab parameters were negative. The COVID anti-viral panel was negative. The patient had some subcostal retractions. The patient was treated with duo nebs, steroids, and epinephrine intramuscularly. The patient was admitted to the floor for further management.  His clinical status improved and the patient was discharged.

No, the proposed inpatient hospital admission was not medically necessary.  The inpatient level care was excessive compared to the clinical picture.

The patient had a moderate asthma exacerbation in the emergency department for which she was treated appropriately. There was no need for magnesium sulfate, no need for continuous nebulization and no need for the continuous positive airway pressure nor bi-level positive airway pressure. As expected, the patient's clinical status improved while in the hospital without escalation of the treatment. Also the oxygen saturation was 92 percent, and there was no need for bi-level positive airway pressure. In addition, the Pediatric Early Warning Score (PEWS) was zero, which shows that the overall clinical picture was reassuring at time of admission. Therefore, the inpatient level care was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Back pain
Treatment: inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is modified. 

This is a patient with chronic medical problems including hypertension, kidney disease, kidney stones, and chronic obstructive pulmonary disease. He presented to the emergency department (ED) with worsening back pain and the inability to walk. The patient was admitted to inpatient services due to the inability to ambulate and for the (empiric) treatment of L (lumbar) 4-5 discitis. Treatment included intravenous antibiotics and pain management. During the hospital stay, the patient was seen by Neurosurgery, Oncology, Infectious Disease, Physical Medicine & Rehab, physical therapy (PT) and occupational therapy (OT). Under review is the medical necessity of inpatient hospital admission.

The enclosed clinical information does not support a level of medical acuity or complexity that supports acute inpatient hospitalization for the total length of stay. After approximately 48 hours of observational care, the patient was appropriately admitted to the acute care hospital; particularly due to severe back pain, increased blood pressure (175/83) and laboratory inflammatory markers.  However, he was seen by orthopedic and neurosurgical teams; both of whom did not recommend surgical intervention. A CT (computed tomography) guided L4-5 biopsy was negative via microbiology and pathology studies. He was placed on IV (intravenous) antibiotics (empirically) via the Infectious Disease physician.  Ongoing clinical workup including physical examination, radiologic studies and laboratory blood studies failed to demonstrate evidence of significant acute or recurrent pathology that supported acute inpatient hospitalization. In addition, there were no specific "red flag" symptoms such as bowel/bladder (cauda equina) symptoms, saddle anesthesia or focal motor weakness. Vital signs were stable and there was no fever. Continuing treatment could have been safely provided at a lower level of care.  According to the case management notes, referrals had been made to lower level of care (i.e. acute and subacute rehabilitation) and the patient could have been safely discharged.

From a physical Medicine and rehabilitation/pain Management perspective, as well as within a reasonable degree of medical certainty, inpatient hospital admission for the entire duration of the stay was not medically necessary for this patient.  

From a physical Medicine and rehabilitation/pain Management perspective, as well as within a reasonable degree of medical certainty, the inpatient hospital admission was medically necessary for a partial duration of the total hospital stay for this patient. 

The insurer's denial of coverage for the inpatient hospital admission is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion.
Treatment: Braces and monthly visits.
The insurer denied coverage for braces and monthly visits.
The denial is upheld.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, a montage of extraoral and intraoral clinical images, orthodontist treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, overbite, and ectopic eruption, and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 13 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 11 points by internal reviewers. The orthodontist is appealing the decision. 

Upon review of the submitted, it is evident that the patient exhibits malocclusion. However, to assess the severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. 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 13 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist attaining a total of 13 points on the HLD index (5 overjet, 4 overbites, 3 ectopic eruptions, 1 labiolingual spread) which is below the threshold of 26 points to support orthodontic care. Of note is in this case, the patient's orthodontist does not attain 26 points on the HLD index as required for orthodontic approval and is aware of this limitation.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer-reviewed journals that this methodology for assessing orthodontic needs is a valid approach. Each of these peer-reviewed articles concludes that this index is a valid and reliable determinant of the need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic needs.

Braces and monthly visits are not considered medically necessary for this patient.

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

The insurer's denial of coverage for braces and monthly visits are upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteopenia of multiple sites
Treatment: Teriparatide 20 mcg/dose pen injector subcutaneously daily.
The health plan denied the teriparatide 20 micrograms (mcg)/dose pen injector subcutaneously daily as not medically necessary. 
The health plan's determination is overturned.

This patient is a female with osteopenia. She has been using teriparatide for fracture prevention and bone optimization prior to a large spinal fusion surgery due to degenerative lumbar scoliosis. This will require implantation of pedicle screws and rods for stabilization. The patient is at high risk of hardware failure in the postoperative period. She fell and broke her toe. T-score (standard deviation)-1.9 in the right femoral neck.
A request for teriparatide 20 mcg (micrograms)/dose pen injector subcutaneously daily is under review for medical necessity.

I overturn, in whole, the health plan's determination of medical necessity.

The requested teriparatide is medically necessary. This request is for teriparatide to reduce this patient's risk of hardware failure and optimize healing for a patient with low bone density. Multiple studies have shown efficacy of Forteo (teriparatide)  in patients undergoing spinal surgery. This has not been shown with other osteoporosis agent classes. teriparatide is unique in that it is an anabolic agent, which promotes bone regrowth. In a prospective study of 62 women with osteoporosis undergoing lumbar posterolateral fusion, the incidence of pedicle screw loosening in the teriparatide group was significantly lower than that in the risedronate or the control group (P (statistical significance) < 0.05). A second study showed teriparatide for bone union using local bone grafting after instrumented lumbar posterolateral fusion in women with postmenopausal osteoporosis was more effective than oral administration of bisphosphonate. A third study showed perioperative administration of teriparatide is more effective than that of bisphosphonates in preventing complications and maintaining fusion rates in osteoporotic females with spinal deformities undergoing surgery. Therefore, yes, the requested teriparatide is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal Class I Bite.
Treatment: Braces and Monthly Visit.
The insurer denied: Braces and Monthly Visit.
The determination is overturned.

The patient is an adolescent female.  The request is for orthodontic benefits. The patient has a skeletal Class I bite with slightly excessive overjet, a deep bite and impacted upper permanent canines. The prior denial was due to a handicapping index score of 11. 

The proposed braces and monthly visit is medically necessary.

The patient has her left and right permanent maxillary canines impacted, where there is no indication for extraction. These are both automatic qualifiers for treatment and benefits as per the Handicapping Index scale.  Orthodontic treatment is needed to allow these impacted teeth to erupt normally.  Monthly visits will allow for follow up to make sure the treatment is on track.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine Headaches
Treatment: Nurtec 75mg (milligrams) OR (oral) TBDP (tablets disperse) 15 tablets per 30 days
The insurer denied: Nurtec 75mg (milligrams) OR (oral) TBDP (tablets disperse) 15 tablets per 30 days
The denial is overturned

The patient is an adult female with migraines who is currently on Nurtec for abortive treatment. She has four to six migraines a month. The provider wishes to start her on Nurtec for preventative treatment. The request was previously denied as the patient did not meet plan criteria for anti-calcitonin gene-related peptide (CGRP) medication. Appeals documentation notes that patient has tried and failed Topamax and propranolol.

The proposed Nurtec is medically necessary.

Nurtec as a preventative treatment in this patient is medically necessary. The patient has benefited from Nurtec as an abortive treatment and has previously tried Topamax and propanolol, which are two conventional migraine preventative medications of two different classes. According to the American Headache Society, anti-calcitonin gene-related peptide (CGRP) guidelines, it is recommended that those who have tried and failed at least two different conventional preventative medications of two different classes to try anti-calcitonin gene-related peptide medication. Furthermore, Nurtec is Food and Drug Administration (FDA) approved and is effective in the prevention of migraines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal/Neck Problem/Pain.
Treatment: Professional Services.
The health plan denied the requested professional services as not medically necessary. 
The health plan's determination is upheld.

This is a patient with neck pain and weakness. No other clinical information is noted.

The health plan's determination of medical necessity is upheld, on whole.

No, as no there is no clear clinical records provided to identify any clear need for professional services at this time, to include a history, examination, or imaging. Thus, there is no medical necessity at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pheochromocytoma.
Treatment:  MRI of abdomen.

The insurer denied MRI of abdomen.  The denial is overturned.

This is an adult male with hypertension. He underwent evaluation for pheochromocytoma. The request for magnetic resonance imaging (MRI) of the abdomen without and with contrast  is under review. The prior request was denied coverage by the health plan, because of lack of information to support the request. The provider is appealing this determination.  The patient's norepinephrine was 970 pg/mL (picograms per milliliter) (0-874), and normetanephrine was 1042 mcg/24hr (microgams per 24 hours) (156-729).

The magnetic resonance imaging (MRI) of the abdomen without and with contrast was medically necessary.

This request was for an MRI (magnetic resonance imaging) of the abdomen for the evaluation of pheochromocytoma. An abdominal MRI (magnetic resonance imaging) is recommended for further evaluation for patient with two fold elevation above upper limit of normal in urine catecholamines or normetanephrine > (greater than) 900 mcg (micrograms) per 24 hours or metanephrine > (greater than) 400 mcg (micrograms) per 24 hours. This patient had normetanephrines of 1042 mcg (micrograms) per 24 hours, which is above the 900 mcg (micrograms) cut-off and indicates the need for an abdominal MRI (magnetic resonance imaging). Therefore, yes, the MRI (magnetic resonance imaging) of the abdomen was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Uterine fibroids
Treatment: Procedure to Shrink Fibroids 
The insurer denied the procedure to shrink fibroids.
The health plan's determination is overturned. 

The patient is a female with multiple uterine fibroids. She had regular menstrual cycles with moderate bleeding. She also has frequent urination that is getting worse over the last year. She complains of pelvic pressure, sleep disturbances, increased waist line and urinating issues around her menstrual cycle. An magnetic resonance imaging (MRI) showed an 8 centimeter (cm) uterine fibroid with mass effect on the bladder showing compression. She also has a 4.6 cm fibroid and 2.5 cm fibroid. She has opted for a transcervical ablation with ultrasound guidance, radiofrequency Sonata System. 

The requested Procedure to Shrink Fibroids is medically necessary for this patient.

Radiofrequency ablation (RFA) is medically necessary as an alternative to hysterectomy or myomectomy for the treatment of uterine fibroids when the patient has persistence of one or more symptoms directly attributed to uterine fibroids like abnormal uterine bleeding, pelvic pressure/pain, or urinary symptoms referable to compression of the ureter or bladder, and/or dyspareunia.

Based on the updated guidance by the American College of Obstetricians and Gynecologists (ACOG), the requested procedure is an alternative to hysterectomy for the treatment of uterine fibroids when the patient has symptomatic uterine fibroids. In this case, the patient has a large uterine fibroid compressing the bladder with urinary symptoms and therefore, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vaginal Bleeding
Treatment: Inpatient Emergency Admission
The insurer denied Inpatient Emergency Admission.
The denial is upheld.

The patient is a gravida (G)2 para (P)2 female with reported history of total abdominal hysterectomy, cardiomegaly and coronary artery disease with onset of acute vaginal bleeding per her daughter. The patient was a poor historian. She was noted to have intermittent blood when the patient was using the restroom that became heavier requiring the use of pads. The patient denied any inciting factors. She was not sexually active and had not used any medications or vaginal applicators. The patient denied dizziness, shortness of breath, chest pain or palpitations. She denied any chronic anticoagulation and takes aspirin. On exam, there was no obvious source of bleeding, and the vaginal cuff was intact. There was no pooling of blood. This appeared to be related to a lesion of the left lateral sidewall of the vagina. The cuff at the apex of the vagina was intact. She had no palpable cervix or masses. A hemoglobin was 11.9 grams per deciliter (g/dL) with a hematocrit (HCT) of 39.6%. A place was made for possible intraoperative evaluation and a computed tomography (CT) scan of the pelvis was ordered. She was typed and crossed for 2 units of blood. A plan was made for vaginal packing after the CT was completed. The operating room (OR) was called and there was no available OR for evaluation at presentation. The patient was admitted and consented for the OR for evaluation. She was made nothing by mouth (NPO) in plan for the OR. The CT scan revealed active extravasation at the level of the vaginal cuff (more on the right side). There was no dehiscence. There were no masses or malignancy. The patient was taken to the OR where she underwent repair of vaginal laceration and cystoscopy. The subject under review is the medical necessity for the inpatient emergency hospital admission.

The health plan's determination is upheld.

Based upon a review of the medical records and the procedure of vaginal laceration repair and cystoscopy and course of care there would be no medical necessity for inpatient emergency hospital admission for a postoperative stay after vaginal repair and cystoscopy. In this case, the patient underwent a vaginal repair and cystoscopy. There was no acute bleeding noted on exam and vital signs were stable. The patient had a normal hemoglobin, hematocrit and platelet count at admission. The patient remained with stable and normal vitals. The total blood loss was 50mL and there was no acute hemorrhage or complication of surgery. There was no evidence of cancer or indication for staging. The patient recovered without complications and had a normal course of care. The procedure in this case could be performed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Closed Unstable Plafond Fracture
Treatment: Inpatient Admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient is a male with a history of kidney stones who presented to the emergency room (ER) with complaints of a left ankle injury after falling. Imaging revealed a left tibial plafond fracture. The patient was admitted, and an external fixator was placed. There were no complications. The patient was later discharged. 

Milliman Care Guidelines using the guidelines of Musculoskeletal Surgery or Procedure GRG (General Recovery Care), Musculoskeletal Diseases, and Pain Management GRG. 

The medical records show a diagnosis of a closed unstable plafond fracture. The injury was treated with a closed reduction and external fixator. This type of procedure is of limited duration and morbidity. The physician places pins through small incisions into the leg and ankle. There is minimal to no blood loss and no direct reduction (open) is completed. 

The post-surgical course was non complicated. There were no reported problems with pain management, ambulation nor other treatments required. There was no evidence of neurovascular problems nor other diagnosis. 

There was no reason that the patient could not have been discharged earlier.  There were no acute level services required after application of the fixator. There were no extenuating circumstances to substantiate additional length of stay. 

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

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.