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

Diagnosis: Shortness of breath
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This is an adult female patient with congenital heart disease status post pulmonary and tricuspid valve repair 8 years ago. She also had a permanent pacemaker (PPM) placement for heart block, cerebral palsy, and developmental delay. The patient presented to the emergency room (ER) with shortness of breath. The patient received intravenous Lasix in the emergency room and was admitted to acute in-hospital level of care. The patient was seen by heart failure consultation team and oral diuretics were adjusted. The acute in-hospital level of care was denied due to lack of medical necessity. This denial is being appealed.

The requested health service was not medically necessary.

The patient was admitted to the hospital for shortness of breath. The patient was seen by the heart failure team within 24 hours of admission and recommended to adjust oral diuretics. The 
patient was discharged home within 24 hours of hospital admission. At the time of admission, the patient's vitals were stable. The patient did not receive high doses of supplemental oxygen. The patient did not have any evidence of severe electrolyte abnormalities. The patient's heart failure was stable at the time of admission and remained stable throughout the hospitalization. The patient was at baseline at the time of discharge. The acute hospitalization was not medically necessary. The patient did not receive any treatment that could not have been provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

orthopedic
inpatient hospital

Diagnosis: status/post fall
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female with history of paranoid psychosis, polysubstance use, hepatitis C virus, and asthma who was admitted with concerns for rhabdomyolysis and acute kidney injury following a fall. Urine drug screen was positive for cocaine and amphetamines at that time. After nearly being hospitalized for a month with completion of extensive unremarkable diagnostic testing, the decision was made to transfer the patient for additional evaluation of right lower extremity weakness and numbness. Upon arrival, initial vital signs found the patient to be afebrile and hemodynamically stable. 

The inpatient admission was not medically necessary. 

The patient initially was hospitalized at an outside facility for rhabdomyolysis and acute kidney injury in the setting of leg weakness. The patient was then transferred for concerns of osteomyelitis and/or a spinal injury. The inflammatory and infectious evaluation was relatively unremarkable. Podiatry was consulted for a malleolar wound, recommended topical care, and did not recommend surgical intervention. Magnetic resonance (MR) imaging of the brain, thoracic spine, lumbar spine, and lumbosacral plexus were relatively unremarkable for a significant acute pathological process. An electromyography (EMG) revealed findings suggestive of a right lumbosacral plexopathy. The neurologist explained to the patient the presentation was best explained by a peripheral nerve injury and the treatment was oral analgesia and therapy services. The hospital course was extensive due to a significant delay in obtaining MR imaging followed by oral analgesia tapering and adjustments thereafter. No other acute issues or complications were documented.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have a fracture, dislocation, or other musculoskeletal injury requiring inpatient care, severe rheumatologic disease, severe vasculitis, severe crystal arthropathy, severe myopathy, or severe pain requiring acute inpatient management. The patient also did not have rhabdomyolysis and an associated acute renal failure, severe or persistent altered mental status, significant electrolyte abnormalities that remains after emergency or observation level care, severe or persistent altered mental status, or neurologic finding requiring inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Missing teeth. 
Treatment: D5214 partial lower denture. 
The insurer denied D5214 partial lower denture. 
The determination is overturned. 

This is a female patient who presented for the treatment of missing teeth in the maxilla and mandible. Provided for review are letters of appeal and denial, health plan language, explanation of benefits, a narrative from the patient, full mouth series of radiographs, clinical notes, a treatment plan, and a single page of American Dental Association (ADA) claim forms. Health plan criteria states that in order to qualify for a partial denture the patient must have less than eight back teeth that touch, either fake or natural. At issue is the medical necessity of partial lower denture. 

The partial lower denture is medically necessary for this patient. As the patient is missing teeth, she has the diagnosis of partial edentulism and requires replacement of the missing teeth to prevent tooth migration and to aid in mastication. The treatment of maxillary and mandibular partial denture is necessary to address the patient's diagnosis and replace the missing teeth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: right lower extremity swelling and redness

Treatment: continued inpatient admission

The insurer denied coverage for continued inpatient admission

The denial is upheld 


The patient is an adult female with past medical history significant for morbid obesity who presented to the emergency department with complaints of right lower extremity swelling and erythema.

Vital signs on presentation included: Temperature 98.6 degrees Fahrenheit, Blood Pressure 112/53, Pulse 104, Respirations 16, Oxygen saturation 94 percent (%) on room air. Laboratory results included the following: white blood cell (WBC) count 22.84, hemoglobin (Hgb) 11.2, hematocrit (Hct) 36.4, creatinine 1.5, glucose 145.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and Zosyn) for right leg infection. Blood cultures grew group A streptococcus. Venous duplex of lower extremity was negative for deep vein thrombosis (DVT). Computerized tomography (CT) scan of lumbar spine showed degenerative changes. Bone scan showed increased uptake in the left side of Lumbar (L) 2. She was treated with intravenous antibiotics for 6 weeks for possible spinal osteomyelitis involving L2. The patient had a peripherally inserted central catheter (PICC) line placed for continuation of intravenous antibiotics at home.

According to documentation, the patient was evaluated by physical/occupational therapy who determined the need for possible subacute rehabilitation. By date of continued admission, medical progress notes indicate decision made to prolong antibiotic course due to "severe back pain and risk for spinal infection...better to err on the side of treatment." Otherwise, the patient remained afebrile, hemodynamically stable with normal laboratory results (compared to admission). Moreover, the patient was medically stabilized and undergoing rehabilitation therapy. Based on the above findings, a treatment plan had been established and the patient was stable to continue treatment in a less acute setting.  

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 the continued admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sarcoidosis, Osteoporosis

Treatment: Personal care aide (PCA) services 12 hours per day, 7 days per week

The insurer denied coverage for personal care aide (PCA) services 12 hours per day, 7 days per week.

The denial is upheld.

This is an elderly patient with chronic medical problems including hypertension, sarcoidosis and osteoporosis.  The patient lives alone in a private residence.  The insurer approved personal care aide (PCA) services 8 hours/day, 7 days/week (total 56 hours/week).  The request is for PCA services; 12 hours per day - 7 days per week, which was denied by the insurer, leading to an external review. 

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognition was described as minimally impaired.  The patient reportedly requires extensive to maximal assistance for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing.  Limited assistance is reportedly needed for personal hygiene,  dressing, locomotion, toilet transfer/use and ambulation.  The patient is at the supervision level for bed mobility and eating.  The patient reports being frequently incontinent of bladder and continent of bowel.  The patient's ability to perform activities of daily living and self-sufficiency has not changed over the prior 90 days.  There have also been no reported falls over the prior 90 days.  The patient's cognitive and functional ability are also much the same when compared to the previous UAS report. 

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested personal care aide (PCA) 12 hours/day - 7 days/week (84 hours/week).  The letter from the patient's treating physician requesting "an increase of homecare hours" was reviewed.  The provider does not include the associated treatment notes to support their claim of the patient's reported functional incapacity. The reviewer would agree the patient may benefit from additional monitoring for safety; particularly due to their reported progressive cognitive decline, weakness and falls risk.  However, safety monitoring under PCA does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  Based on the submitted clinical records, the patient's health and safety are appropriately provided and maintained at home by approved PCA services 56 hours/week.  

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 personal care aide (PCA) services 12 hours per day, 7 days per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Wegovy (semaglutide injection). 
The insurer denied:  Wegovy (semaglutide injection). 
The denial is upheld. 

The patient is an adult male with a diagnosis of obesity. He has a body mass index of 47.1 kilograms per meter squared (kg/m2) with comorbidities of high cholesterol and hypertension. The patient started taking the requested medication 9 months ago with a baseline weight of 310 pounds. His current weight is 271 pounds as of last month. The provider prescribed Wegovy Solution Auto-Inject. 

The requested health service is not medically necessary. 

There is no documentation that the patient is using pharmacotherapy as an adjunct to diet, exercise, behavior modification, and caloric restriction. Although a nutritionally balanced, energy-controlled diet and regular exercise form the cornerstone of weight management, supporting therapies may include anti-obesity medications when a clinician determines that pharmacologic assistance could contribute to treatment success.
Pharmacotherapy alone, without behavior modification, is not effective; patients who respond to medication typically regain weight when the drug is discontinued. (Moyer 2005)
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: ambulatory dysfunction
Treatment: home health care
The insurer denied Personal Care Services 24 Hours per Day, 7 Days per Week (Split-Shift).
The health plan's determination is overturned in part. Personal Care Services 24 hours per day (live-in), 7 days per week are medically necessary for the patient.

This is a case review for a female with medical history notable for incontinence, diabetes, and ambulatory dysfunction. 

The requested Personal Care Services: 24 Hours per Day, 7 Days per Week (Split-Shift) are not medically necessary for this patient.

Personal Care Services: 24 hours per day (live-in), 7 days per week are medically necessary for the patient.

The patient requires personal care assistance with all activities of daily living, including toileting, locomotion, transfers, and management of incontinence care. Her personal care needs can be expected to be continuous and unscheduled throughout the day and occasionally at night as well. She has no other informal support in place. Therefore, the patient requires 24-hour personal care assistance. A live-in personal care aide is medically necessary to address the patient's needs.

The documentation has not clearly demonstrated that split shift personal care services are medically necessary for the patient. There were no nighttime logs provided for review. The patient does not have any documentation of pressure ulcers which would require frequent turning and repositioning. A live-in personal care aide is required to receive at least 5 hours of uninterrupted rest at night. There is insufficient documentation to demonstrate that the patient's personal care needs would preclude a live-in aide from receiving adequate rest at night. Therefore, 24-Hour split shift services are not medically necessary for the patient. Personal Care Services: 24 hours per day (live-in), 7 days per week are medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Antibody Deficiency with Near-Normal Immunoglobulin or with Hyperimmunoglobulinemia
Treatment: Gammaked
The insurer denied Gammaked. 
The health plan's determination is upheld. 

This is a female with Antibody Deficiency with Near-Normal Immunoglobulin or with Hyperimmunoglobulinemia. Immunoglobulin G (IgG) was 822 and the IgA (immunoglobulin A) is normal. IgM (immunoglobulin M) was low at 36. A hand written note states that IgG subclasses are not needed. The patient has a cough and frequent antibiotics. She has poor vaccine titers. She has a history of multiple sclerosis (MS). 

Gammaked is not medically necessary for this patient.
Per Bonilla et al, Regarding Specific Antibody deficiency (SAD),
"Summary statement 105. The diagnosis of SAD should be given to patients older than 2 years with recurrent respiratory tract infections, normal immunoglobulin and IgG subclass levels, and impaired response to pneumococcal capsular polysaccharide." Regarding treatment of SAD, the authors note "Summary statement 106. Patients with SAD might benefit from additional immunization with conjugate pneumococcal vaccines, intensified use of antibiotics, and in some cases a period of IgG replacement therapy."
In this case, the patient has a low IgM. Additionally, other first line therapies such as prophylactic antibiotics have not been tried. Therefore, the use of Gammaked is not indicated at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: posterior crossbite on the right involving the first molars
Treatment: Braces, Monthly Visits, and Retainer 
The insurer denied Braces, Monthly Visits, and Retainer 
The health plan's determination is overturned. 

The patient in question is a female. She has 5 millimeter (mm) overjet and 3 mm overbite. She is class I with a posterior crossbite on the right involving the first molars. She has a functional shift to the right. She is treatment planned for Braces, Monthly Visits, and Retainer to correct her crossbite and crowding.

Braces, monthly visits, and retainer are medically necessary. The patient presents with a posterior crossbite and corresponding mandibular midline shift to the right. There is strong medical evidence that early correction of posterior crossbites with a shift reduces the need for future treatment. The evidence shows if such a crossbite is not corrected before the patient reaches skeletal maturity, the ability to achieve orthopedic expansion is greatly reduced. Given that the patient is young and skeletal maturity in females usually occurs around 15-16 years old, she is nearing the end of the time that orthodontics alone can correct her crossbite. Research has shown that early intervention is beneficial for patients that have a crossbite with functional shift; making treatment at a younger age the preferable option. Therefore, the requested treatment is medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: biologic materials to aid in soft and osseous tissue regeneration performed in lower left quadrant
The insurer denied biologic materials to aid in soft and osseous tissue regeneration performed in lower left quadrant.
The determination is overturned.

This is a male patient who presented for treatment of implant number (#) 19. Provided for review are letters of appeal and denial, a narrative from the treating doctor, full mouth radiographic images, periodontal and peri-implant indices, current dental terminology (CDT) code definitions, explanation of benefits, and health plan language. At issue is the medical necessity of biologic materials to aid in soft and osseous tissue regeneration performed in lower left quadrant. 
The requested health service/treatment of biologic materials to aid in soft and osseous tissue regeneration performed in lower left quadrant medically necessary for this patient. As the patient has the diagnosis of peri implantitis there is a need not only to clean the implant in an attempt at reducing the bacterial load of the foreign body but also the need to fill the defect and promote bone healing in an attempt at regeneration. Without this the tissue will re granulate resulting in another deep pocket and continued disease as deeper pockets support more destructive anaerobic bacteria. Hence, the treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal bloating and pain
Treatment: Abdomen and pelvis computed tomography (CT) scan
The insurer denied coverage for: Abdomen and pelvis computed tomography (CT) scan
The denial is: Overturned
The patient was seen by their gynecologist and was complaining of abdominal bloating and pain. The patient had a history of ovarian cysts. Both left lower quadrant (LLQ) and right lower quadrant (RLQ) moderate abdominal tenderness was present without rebound or guarding. An abdominal radiographic image (x-ray) was normal. The patient had cervical motion tenderness and was given Doxycycline. However, the physician did not think that this explained the moderate tenderness and advised a computed tomography (CT) scan to evaluate the etiology of the pain. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) A-0013 for Abdominal/Pelvic CT (computed tomography) scan. Pain localized to the abdomen or pelvis is an indication for the exam if the diagnosis is unexplained after the initial history, physical examination, and plain x-ray or ultrasound imaging. The patient had moderate tenderness, that is documented in the medical records. The history and the abdominal x-ray did not determine the etiology of the pain. This met MCG criteria for doing the abdominal and pelvic CT scan. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for abdomen and pelvis computed tomography (CT) scan is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient hospital

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

This is the case of an unvaccinated FT (full term) female with eczema who presented to the emergency department (ED) with a seizure. The Mother reported that the patient was in her usual state of health when she was noted to have 5 minutes of generalized stiffness with staring followed by sleepiness. Emergency Medical Services (EMS) was called to transport the patient to the ED. There was a reported family history of seizure at 6 months old in the father with no recurrence. The review of symptoms (ROS) was otherwise negative.

The inpatient hospital care was not medically necessary. This patient could have been managed safely and appropriately a lower level of care. This infant presented to the ED after a Brief Resolved Unexplained Event (BRUE). Risk factors included estimated time of event >1 minute and family history of infant seizure in the father. Other criteria were reassuring -- no intervention needed, self-resolved, baby born full term, no underlying disorders, age >60 days old. Therefore, observation was an appropriate decision. Given the resolution, normal vital signs and stable status, observation would have been appropriate for this patient with discharge to the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is overturned.

This patient is an adult female with acute chronic back and left leg pain. Magnetic resonance imaging (MRI) showed disc herniation at (lumbar) L4-L5. The patient was provided intravenous pain medications in the emergency room. The patient underwent microdiscectomy while in the hospital and was discharged on day (number) #4.

The requested health service was medically necessary.

The patient had intractable pain and required intravenous pain medications and an emergency room visit. The patient would not have been able to be treated at a lower level of acuity. In this setting, the patient required intravenous pain medications and surgery to treat her intractable pain and because of this, the entire hospitalization is warranted and medically necessary for acute inpatient hospitalization length of stay.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male and was admitted for elevated blood sugar and newly diagnosed diabetes. He was started on intravenous (IV) fluid for dehydration with elevated creatinine and was evaluated by endocrinology. He was started on Lantus and Lispro and underwent diabetic education. His blood sugar improved, and creatinine normalized, and he was discharged in stable condition.

The inpatient hospital admission was not medically necessary. The patient was noted to have hyperglycemia but without significant metabolic acidosis and did not require intravenous (IV) insulin infusion. He also had abnormal creatinine which responded to IV fluid in 48 hours. He was hemodynamically stable, with normal oxygenation, did not have significant electrolytes disturbance, he did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration.
When taking into account the patient's exam, imaging, and lab findings, a lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion.
Treatment:  D8090 Braces, D8670 Monthly Visit x 3.

The insurer denied: D8090 Braces, D8670 Monthly Visit x 3.  The denial is overturned.

The patient is a school aged female. The requested is for orthodontic benefits and monthly visits (X3). She has a Class I malocclusion. The health plan denied coverage of the request due to patient still having some primary teeth. The denial is being appealed.

The D8090 Braces, D8670 Monthly Visit x 3 are medically necessary.

The patient has an impacted permanent anterior tooth (# [number] 6, upper right canine) that is not to be extracted. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment, with monthly follow up visits is needed to correct this problem. This case has medical necessity.