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

Diagnosis: Breast Cancer
Treatment: Proton Beam Therapy
The insurer denied the Proton Beam Therapy.
The determination is overturned.

The patient has a history of primary tumor (pT) 2 nodes (N)1 metastasis (M) 1 left breast cancer status/post (s/p) surgical resection. She has been recommended to proceed with a course of postoperative chemotherapy and radiotherapy. The request is for proton beam radiation therapy.

The requested proton beam radiation therapy is standard of care and medically necessary in the patient's setting. The treating provider has supplied a proton/photon plan comparison which shows that the well optimized photon-based radiation plan is unable to provide adequate safety/precision with respect to the patient's heart and left lung. The photon plan resulted in excessive and potentially dangerous exposure to the patient's cardiopulmonary tissues. If delivered, photon radiation would result in an unacceptable and unnecessary risk for cardiopulmonary morbidity/mortality. The proton radiation plan was able to significantly reduce the patient's heart/lung exposure to within known safe tolerance limits, thereby minimizing her risk for serious toxicity. Furthermore, proton radiation is expected to minimize her risk for radiation induced secondary malignancy (e.g. new contralateral breast cancer). Proton radiation in the patient's situation is widely utilized and supported by the American Society for Radiation Oncology (ASTRO) Model Policy for situations in which it is shown that photon radiation cannot meet nationally accepted treatment planning objectives. Proton radiation in the patient's situation is supported by numerous high quality prospective clinical outcomes reported in the peer reviewed medical literature.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorder/Cellulitis
Treatment: Inpatient Hospital
The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a man with a history of polysubstance abuse, tobacco abuse, deep vein thrombosis (DVT), gallstones, and cardiac arrhythmias. He presented to the emergency room with a complaint of months-long ulcerations to both lower extremities. He admits to injecting heroin into his legs. The vital signs were normal, and he was well-appearing and in no apparent distress. Physical exam was notable for bilateral pedal edema with extensive erythema and ulcerations with weeping. The urine drug screen was positive for benzodiazepine and cocaine and the hemoglobin was 10. Otherwise, lab studies were non-contributory. The lower extremity venous ultrasound revealed a previously noted possible thrombus in the right femoral vein. The arterial ultrasound did not reveal any significant arterial stenoses. The chest x-ray was negative. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. While in the emergency room the patient returned from the lavatory somnolent. He was treated with Narcan and responded well. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with intravenous antibiotics, Suboxone, and non-opiate analgesia. On the day of admission, the infectious disease consultant evaluated the patient and recommended continuation of antibiotics. The surgeons also evaluated the patient and recommended wound care but did not feel that operative debridement was necessary yet. Later on the day of admission, the intravenous line became non-functional, and the antibiotics were changed to an oral agent. The remainder of the stay was clinically uneventful, but the patient signed out against medical advice.
At issue is the medical necessity for the inpatient admission.

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

No, the requested health service/treatment of an inpatient admission was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The services provided - intravenous antibiotics, wound care, oral medications, and consultations - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, and the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at an alternate level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: hypertension, laceration of the right quadriceps muscle, laceration of the left quadriceps muscle, sleep apnea, sarcoidosis, and unspecified injury of the right quadriceps muscle
Treatment continued stay at the SNF (skilled nursing facility)
The insurer denied coverage for continued stay at the SNF (skilled nursing facility)
The denial is modified.

The patient was initially appropriate for the SNF level of care (1, 2, 3). His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. He participated in physical and occupational therapy with demonstrated gradual improvement.  There was significant improvement particularly for mobility after removal of the lower extremity casts and switching to hinged braces.  According to the physical therapy notes, the patient's ambulation improved from using a rolling walker 15 steps forward/backwards to ambulating 150 feet with the walker. Functional improvement during this time in occupational therapy was without significant change. Allowing additional time for rehabilitation therapy after bilateral lower extremity cast removal was clinically appropriate. However, the patient could have been transitioned to a lower level of care (e.g., long term care, home with therapy services). In addition, there were no acute medical or complicated nursing issues that required continued stay at the SNF after the first 22 days.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty inpatient stay at the SNF for the first 22 days was medically necessity. However, the patient could have been transitioned to a lower level of care (e.g., long term care, home with therapy services) rendering continued stay at the SNF no longer medically necessary.

The medical necessity for a continued stay at the SNF services is modified. Allow continued stay at the SNF for the first 22 days. Deny continued stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergic Reaction (angioedema)
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission
The denial is upheld. 

The patient is a man. He was admitted for treatment of angioedema of his lip and face secondary to use of lisinopril.
The patient's treatment included IV (intravenous) fluids, IV (intravenous) Benadryl, IV (intravenous) Solumedrol, and IV (intravenous) Pepcid. Prior to presenting to the emergency department, he was treated with Benadryl, Zyrtec, and Medrol as an outpatient without improvement.
The health plan has denied coverage of the hospital admission, as the admission was determined to not meet medical necessity. This denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

Based on practice parameters for angioedema management in the emergency department published by Moellman and colleagues in 2015, decisions regarding the need for hospital admission can be assessed based on involvement of the patient's airway and severity of the angioedema. In this case, there was no airway involvement, and the patient was otherwise hemodynamically stable without signs of distress. In this case, as the patient did not have any signs of hemodynamic instability, the
patient could have been treated at a lower level of care, per the guidelines.
The appeal letter states that admission was needed because of the presence of one or more of the following: angioedema, respiratory status/ compromise, vital signs, aspiration precautions, inpatient IV (intravenous) Solumedrol, and to trend labs. Additionally, the letter states that the patient had failed outpatient treatment and was at risk of readmission if discharged from the emergency department. However, this patient had stable vital signs, including respiratory status and no signs of airway compromise that required aspiration precautions, trending of labs, or vital signs. As he was responding to the acute treatment he received in the emergency department and he was stable, there is no evidence that full inpatient admission was medically necessary.
The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Based on the patient's clinical status including vital signs, severity of his symptoms, labs, and response to treatment, inpatient admission was not medically necessary. Based on MCG (Milliman Care Guidelines) guidelines called Systemic or Infectious Condition, criteria for admission for allergic reaction with severe symptoms that persist despite observation care include one or more the following: airway edema, stridor, respiratory distress, bronchospasm, or hemodynamic instability.
None of these criteria were met in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, hypertension and coronary artery disease.
Treatment: Increase in personal care aide (PCA) services 7 days per week, 12 hours per day for a total of 84 hours per week.
The insurer denied coverage for increase in personal care aide (PCA) services 7 days per week, 12 hours per day for a total of 84 hours per week. 
The denial is upheld.

This is a patient with chronic medical problems including diabetes, hypertension and coronary artery disease. He lives alone in a 1-bedroom apartment. The insurer approved PCA services 12 hours/day, 6 days/week and 11 hours/day for 1 day/week for a total of 83 hours. Currently under review is the request for an increase in personal care aide (PCA) services 7 days per week, 12 hours per day for a total of 84 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "minimally impaired" and is "able to verbalize his needs in Russian or dial 911 in case of emergency." He requires maximal assistance for bathing, dressing and toilet use. He requires extensive assistance for personal hygiene, ambulation and toilet transfers. The patient uses a rollator for ambulation. He is occasionally incontinent of bladder and continent of bowel.  Limited assistance is needed for bed mobility and eating. The patient has minimal cognitive deficits and significant functional impairments, which support the medical necessity of 12 hours/day, 6 days/week and 11 hours/day for 1 day/week for a total of 83 hours. The currently approved PCA services are clinically appropriate and meet his functional needs, allowing the patient the ability to continue living safely at home.   

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

From a physical medicine and rehabilitation perspective, the requested personal care aide (PCA) services 7 days per week, 12 hours per day for a total of 84 hours per week is not medically necessary.  

The insurer's denial of coverage for the personal care aide (PCA) services 7 days per week, 12 hours per day for a total of 84 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Knee Pain
Treatment: Surgical Services/Knee Surgery
The health plan denied the requested knee surgery as not medically necessary.
The health plan's determination is overturned.

This case describes a female patient who sustained an initial medial meniscal tear in her right knee. She underwent arthroscopic medial meniscal repair. Her right knee was aggravated acutely in physical therapy while doing some side shuffles as part of her therapeutic exercise. The patient unfortunately had persistent right knee pain after the operation and failed to improve despite extensive post-operative physical therapy, use of oral medications and a cortisone injection. A magnetic resonance (MR) arthrogram of the right knee was obtained and it revealed post-operative changes in the medial meniscus of the affected right knee. The patient continued to have function limiting right knee pain despite the conservative treatments that were attempted. The provider therefore recommended repeat right knee arthroscopy which was completed. A new medial meniscus tear was, in fact, identified anterior to the previous medial meniscus repair site.
At issue in this case is the medical necessity of the second right knee operation which involved a partial medial meniscectomy.

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

The requested health service/treatment of knee surgery was medically necessary for this patient. This determination is based upon the provided medical records and the recommendations of the current, peer-reviewed literature. First, the provided records document that this patient underwent an index right knee arthroscopic medial meniscal repair. She progressed well through her recovery until an acute onset of pain occurred while she was doing side shuffling exercises in supervised physical therapy. Her pain persisted and her flexion of the knee was limited after this incident despite further attempts at therapy, use of oral medications, and a cortisone injection. A follow up MR arthrogram was not specifically diagnostic of a re-tear of the meniscus, but based upon the history and physical examination and her failed attempts at conservative treatments, the decision to proceed with a repeat knee arthroscopy was reasonable and medically necessary. The provided operative note documented that a new tear was identified in the medial meniscus adjacent to the previous repair site. The provider performed a partial medial meniscectomy. Based upon the patient's acute onset of pain, her persistent symptoms despite reasonable conservative treatment, and physical exam findings, the partial medial meniscectomy (CPT 29881) performed was medically necessary for this patient. The care rendered was consistent with the recommendations of the current, peer-reviewed literature as documented by Dai and colleagues in Orthopedic Journal of Sports Medicine in 2021. Therefore, the surgery was medically necessary and the determination should be overturned in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned.

This is a patient with a history of type 1 diabetes. She presented to the emergency department with hyperglycemia, weakness, vomiting. Glucose levels at home were in the 300s. She woke up feeling weak and had 2 episodes of non-bloody nonbilious vomiting. The glucose meter read High. Her mom took off the insulin pump and administered 22 units of Lantus and 5 units of rapid acting insulin at 6 AM. Serum glucose was 341. Ketones were greater than 160. Anion gap was 17. pH (potential hydrogen) was 7.25 with a bicarbonate of 11. Repeat anion gap was 24. She was treated with a normal saline bolus. The patient developed hypoglycemia with a glucose of 67. She was started on dextrose. Her repeat blood gas demonstrated resolution of diabetic ketoacidosis (DKA). The patient received blood glucose monitoring every hour. The patient was discharged.

Hospitalization for DKA is universally medically necessary. [1-9] Patients with diabetes and DKA initially generally require intensive care unit (ICU) level care [1],[3],[4],[5] until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care. [10],[11] Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with every 1 hour blood draws and nursing rules. The patient was admitted for treatment of DKA. 

The patient's DKA resolved with insulin treatment and the patient developed hypoglycemia which was also treated. Discharge from the emergency department was not appropriate. A lower level of service such as observation is not appropriate given the complexity of treatment required for DKA. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: posterior crossbite.

Treatment is D8080 braces and D8670 monthly visit x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.
 
The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite and posterior crossbite. The orthodontist has completed the HLD (Handicapping Labia-Lingual Deviation) index attaining 2 total points. 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 attaining only 22 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant 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 Labia-Lingual Deviation Index Report (HLD New York State Medicaid program) modeled after Handicapping Labiolingual 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 completes the second portion of the index arriving at 27 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support orthodontic care.

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 need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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

The insurer's denial of coverage for D8080 braces and D8670 monthly visit x 12 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Disorder.
Treatment:  Nerve treatment on tooth #29 and #30.
The insurer denied nerve treatment on tooth #29 and #30. The determination is overturned.

The patient presented for the treatment of teeth number (#) 29 and 30 with endodontic therapy due to the presence of decay. The health plan denied nerve treatment on teeth #29 and 30 with the rationale that for treatment to be necessary the patient must have less than 8 other posterior teeth in contact. Provided for review are multiple pages of denials and explanation of benefits, a narrative by the patient, a full mouth set of radiographs and dental payer case notes. At issue is the medical necessity of the treatment of endodontic therapy for teeth #29 and for #30.

The requested health service/treatment of nerve treatment on tooth #29 and #30 is medically necessary for this patient based on the provided documentation which shows the presence of extensive decay reaching the pulpal chamber of #29 and 30. The indication for root canal therapy is that of infected pulp as a result of decay or exposure to the oral cavity. Endodontic therapy is not determined by the number of poster teeth in contact. The teeth in question are not terminal teeth and have a good prognosis with endodontic treatment and restorations. Hence the treatment of endodontic therapy for #29 and for #30 is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal - Abdominal pain.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Hospital Stay.
The denial is overturned.

This patient is a male with a past medical history (PMHx) significant for bipolar illness, who presented with acute gastrointestinal (GI) symptoms (left lower quadrant [LLQ] abdominal pain, decreased oral intake) in the setting of abnormal infective indices (tachycardia, leukocytosis, elevated inflammatory markers) consistent with acute sigmoid diverticulitis on diagnostic computed tomography (CT) scan. The patient was admitted to the inpatient floor and received intravenous (IV) fluids, pain control, IV antibiotics, Infectious disease, and Gastroenterology consultation. The patient's clinical symptoms improved slowly with the exacerbation of abdominal pain during hospitalization. The patient symptoms improved with resolution of inflammatory markers and was discharged home.
At issue is the medical necessity of the Inpatient Hospital Stay.

The health plan's determination of medical necessity is overturned in whole.

Yes, the requested health service/treatment of Inpatient Hospital Stay was medically necessary for this patient.
This is a patient with significant comorbidities (bipolar illness, seizures, HTN) admitted for acute diverticulitis. His clinical presentation of acute diverticulitis was characterized by abdominal pain, tachycardia, and dehydration and required immediate inpatient care (IV fluid, serial monitoring labs, IV spectrum antibiotics, and GI/ID consultation). This patient was at high risk for sigmoid diverticulitis complications, including intra-abdominal abscesses, peritonitis, sepsis, and death. This detailed inpatient care cannot be prudently provided under a lower level of care without increasing mortality or morbidity.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Loss
Treatment: Cochlear implant
The insurer denied the Cochlear implant.
The determination is overturned.

The patient has hearing loss. She has severe to profound right sided hearing loss. Her left sided hearing is basically normal. The patient's history is significant for a right sided meningioma. She has not received benefit from a contralateral routing of signals (CROS) aid or hearing aid. A right sided cochlear implant has been proposed and is under review for medical necessity.

The cochlear implant is medically necessary for this patient.
The patient has unilateral, severe sensorineural hearing loss that has not been successfully rehabilitated with a hearing aid. Cochlear implantation for unilateral hearing loss has been shown to be a successful treatment for unilateral hearing loss. Cochlear implantation for unilateral hearing loss is Food and Drug Administration (FDA) approved and is considered standard of care in the United States. This patient has severe to profound hearing loss and has not had benefit from a hearing aid or CROS hearing aid.