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

Diagnosis: Headache, dizziness, weakness, parasthesia
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient, a female at the time of admission to the hospital, with a past medical history significant for hypertension, paroxysmal atrial fibrillation on Eliquis, presented to the emergency room (ER) with complaints of left-sided headache, dizziness, left arm and leg weakness and bilateral leg paresthesia. The patient took Excedrin with resolution of her symptoms. 

The patient was evaluated in the ER (emergency room) for suspected transient ischemic attack (TIA). Computed tomography of the head was negative. The patient was seen by neurology in consultation and magnetic resonance image of the head was performed. During the patient's work-up, the patient complained of an episode of chest pain, which was non-exertional, associated with left arm numbness. Electrocardiogram (ECG) revealed no acute ischemic changes. Cardiac enzymes were negative. Lactate was elevated at 3.2, with no signs of shock or hemodynamic instability. Lactate improved with intravenous (IV) fluids. The patient was monitored on telemetry. There was no evidence of infarction or bleeding on the magnetic resonance image (MRI) / magnetic resonance angiogram (MRA) of the head and neck. Echocardiogram revealed normal left ventricular (LV) function. A loop recorder was placed by cardiology and the patient was advised to follow-up as an outpatient. No inpatient ischemic work-up was planned and the patient was discharged home.

No, the proposed treatment, inpatient admission, was not medically necessary.

The patient presented for evaluation of headache and to rule out TIA (transient ischemic attack), as well as for evaluation of atypical chest pain. The diagnosis of an acute myocardial infarct (MI) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, acute coronary syndrome (ACS), decompensated congestive heart failure (CHF), malignant arrhythmia or hemodynamic instability. There was no evidence of cerebral vascular accident (CVA), intracranial hemorrhage, or seizure. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for inpatient admission and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder (recurrent
without psychotic features)
Treatment: Continued Mental Health Residential Care
The insurer denied the Continued Mental Health Residential Care. 
The denial is upheld. 

This female was admitted to this residential facility and discharged home several months later. Her health plan authorized treatment for approximately 3 months.  As per the patient's parents, the reasons for admission included poor self-esteem, emotional dysregulation, aggression, self-injurious behaviors, an overdose, and habitual lying. The patient's history included bulimia, inappropriate relationships with older men, self-injury, and suicide gestures via overdose. She was treated in an emergency room after having taken an overdose the previous day. She then told her father of the overdose. The patient's parents reported that weekly psychotherapy had not helped and that she had become more aggressive in the home. She had been injuring herself for several years.

The patient made gradual progress in the residential center. She presented as euthymic but with flat affect, calm behaviors, soft speech, appropriate concentration, and coherent thought processes. Her diagnosis was rule out borderline personality disorder. She participated in individual, family and group therapies. Her father and her stepmother participated weekly.

Progress notes throughout the first two weeks of the last approved month show that the patient and her family participated in an outdoor physical activities program in order to enhance family communication. The patient had passes home during that time. There was no evidence of significant out of control behavior or danger to self.

No, the proposed treatment, Continued Mental Health Residential Level of Care is not medically necessary. 

During the period in question, the patient did not present evidence of significant behavioral dyscontrol or problems which could not have been dealt with on an outpatient basis. Nothing in the documentation reviewed indicates that treatment could not have continued equally safely in a less restrictive setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness of right arm and slurred speech; possible transient ischemic attack (TIA).
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He presented to the emergency ward with the complaint of transient right arm weakness and slurred speech. At presentation, his neurological examination and CT (computerized tomography) head were normal. He was admitted for possible TIA (transient ischemic attack).

No, the inpatient admission was not medically necessary. 

The patient had no deficit at presentation. Risk stratification based on symptoms of TIA (transient ischemic attack) did not warrant an acute inpatient level of care. The diagnostic studies, monitoring and treatment could have been safely and effectively provided at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (periapical pathology, dental caries, failing restoration)
Treatment: An all-white glass crown on tooth 7
The insurer denied coverage for an all-white glass crown on tooth 7.
The denial is overturned. 

This is a female patient who received dental services. A failing restoration and caries were noted on tooth 7 on examination, and thus, endodontic therapy was recommended due to associated periapical pathology. The insurer has denied the full coverage crown service stating that the service is not medically necessary as the documentation did not demonstrate medical need to support the treatment, or fulfill their criteria for approval.  

Upon review of radiographs, the images support the recommended treatment. The patient's tooth 7 exhibits periapical pathology radiographically and a failing existing restoration. There is ample coronal structure remaining. This tooth would require endodontic therapy to salvage the tooth. This tooth will have adequate residual coronal structure for support of a post and core and crown, and have adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be endodontic therapy for this tooth and subsequent crown which would have an excellent long term prognosis with the recommended treatment.

Thus, coverage for an all-white glass crown on tooth 7 is considered medically necessary for this patient. The patient's clinical and radiographic documentation support these services, and these services would be a standard of care in general dental practice.

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

The carrier's denial of coverage for an all-white glass crown on tooth 7 should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Rheumatoid Arthritis.
Treatment:  Consumer and Self-Directed Personal Assistance Services: 168 Hours per Week.

The insurer denied Consumer and Self-Directed Personal Assistance Services: 168 Hours per Week.  The health plan's determination is overturned. 

The patient is a female with past medical history of rheumatoid arthritis, Felty's syndrome, contractures of both hands, abnormality of gait and mobility, anemia, asthma, gastroesophageal reflux disease (GERD), hypertension, osteoporosis, chronic pain, MGUS (Monoclonal gammopathy of undetermined significance), hyperlipidemia, and edema, who had been assigned CDPAS (Consumer and Self Directed Personal Assistance Services).  The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, personal hygiene, and eating.  The patient was assessed at limited assistance with walking, locomotion, and transfer toilet while independent with bed mobility.  The daughter reported a progressive decline in the patient's physical functioning and requires assistance with all ADLs (Activities of Daily Living). 

The Consumer and Self-Directed Personal Assistance Services: 168 Hours per Week is medically necessary for this patient.

The patient has the diagnosis of rheumatoid arthritis with documented severe deformities and progression of her disease with the inability to perform personal hygiene and use the toilet without assistance.  The patient has unscheduled and unpredictable care needs that span a continuum of time.  The patient's current informal helpers are no longer available to provide care outside of the assigned CDPAS hours.  The patient is not able to use incontinence supplies due to previous history of skin breakdown.  The patient's PCP (Primary Care Physician) documented medical necessity of 24-hour PCA (Personal Care Assistance) services given the patient's severe hand deformity and the need for assistance with all ADLs.  The plan incorrectly used the universal assessment tool in a patient, who has unscheduled and unpredictable care needs over a particular span of time with the need for 24 hour/day services.  PCA/CDPAS services are not solely for supervision and safety but to assist the patient with safe completion of ADLs and IADLs.  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.  In this patient's case, the requested hours are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Cardiac / Circulatory Problems. 
Treatment:  Home Health Care (2 skilled nursing visits). 

The insurer denied 2 skilled nursing visits.  The denial is upheld in whole.

This is the case of a male with heterotaxy, anatomical difference of the larynx and epiglottis, developmental delay, and atrial septal defect (ASD) with 1st degree atrioventricular (AV) block.  The primary care physician has provided a letter indicating the patient's underlying diagnoses, as well as documenting that the patient intermittently chokes while eating due to his anatomical differences.

There is also a form requesting the two skilled nursing (SN) visits.  At issue is whether two skilled nursing visits denied by the plan were considered medically necessary.  The health plan previously approved one skilled nursing visit.

Records provided include speech therapy (ST) tele-visits, and skilled nursing (SN) recertification tele-visit.

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

According to the documentation provided, the request for two skilled nursing visits is not medically justified.  According to the documents provided, the primary diagnosis for justification of skilled nursing services is 'heart failure, unspecified.'  However, this patient is not on any medications that are cardiac in nature.  In addition, the skilled nursing recertification indicates that there is no evidence of altered cardiac function under the Cardiac Overview Assessment section.  It is also indicated that there has been no change in health status, no interim emergency department (ED) visits or hospitalizations.  This patient has no indication of need for IV/catheter care, wound care, feeding tube, new or changing medications, or recent changes in health status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems (overjet, class I malocclusion, vertical growth pattern, open bite, maxillary crowding and mandibular crowding and maxillary and mandibular incisor protrusion). 
Treatment: Braces and monthly visits. 

The insurer denied coverage for braces and monthly visits. 
The denial is upheld. 

This is a female patient who presented for evaluation for orthodontic care. The orthodontist identified several clinical findings including overjet, class I malocclusion, vertical growth pattern, open bite, maxillary crowding and mandibular crowding and maxillary and mandibular incisor protrusion and has recommended orthodontics. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 31 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 having attained a score of 8 points on the HLD index. 

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 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 31 points to justify orthodontic care. However, this reviewer concurs with the index completed by the insurer attaining a total of 8 points on the HLD index (i.e., 4 for overjet, 2 for overbite, and 2 for labiolingual spread) which is below the threshold of 26 points to support orthodontic care. 

Thus, based on the review of the medical record and literature, the coverage for braces and monthly visit is 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 braces and monthly visits is not substantiated. The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Generalized weakness and lightheadedness.
Treatment:  Inpatient admission.

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a male.  He presented to the emergency room for generalized weakness and lightheadedness.  The emergency room workup included blood work, CT (computerized tomography)-head and CT-chest, which were unremarkable. 

The patient was hemodynamically stable.  The physical exam was with in normal range.  The patient had had a recent COVID-19 (coronavirus disease) infection.  The weakness and lightheadedness were possibly due to sequelae of the COVID-19 (coronavirus disease) infection.  The patient was admitted to acute in-hospital level of care.  

No, the Inpatient admission was not medically necessary.

The patient did not need acute hospitalization, since the patient was hemodynamically stable.  He was able to ambulate and tolerate oral diet.  The patient did not require supplemental oxygen.  All the testing was performed in the emergency room.  The patient could have been observed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Sleep apnea.
Treatment:  Durable Medical Equipment (oral appliance to be worn during sleep).

The insurer denied the Durable Medical Equipment (oral appliance to be worn during sleep).  The denial is upheld. 

The patient is a male with sleep apnea.  He has an apnea-hypopnea index (AHI) of 9.3 with nadir desaturation of 82%.  There is no documentation of continuous positive airway pressure (CPAP) trial.  In the initial visit, a discussion about mandibular advancement for snoring was documented.  Documentation of a follow-up appointment after the sleep study is not provided.  A prescription was provided showing the request for a mandibular advancement device.  

No, medically necessity for the proposed oral appliance is not established by the provided documentation.

Based on standards of care, considered discussion of post-polysomnogram clinical decision making is not documented to support the medical necessity of the dental appliance.

In the provided documentation, there is no follow-up consultation with the sleep specialist after the sleep study, and related discussion regarding continuous positive airway pressure (CPAP) versus dental appliance.  In the appeal form, there is mention of the patient refusing continuous positive airway pressure CPAP.  However, there is no clinical documentation of that event.

The plan used a considered approach to this case consistent with the standard of care.  There is incomplete documentation of post-polysomnogram clinical decision making to support indication for the mandibular advancement device.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Prescription drug, Stelara at a dose of 90 milligrams every 4 weeks for a diagnosis of Crohn's Disease
The insurer denied coverage for the prescription drug, Stelara at a dose of 90 milligrams every 4 weeks for a diagnosis of Crohn's Disease.
The denial is overturned.

This is a male patient who has Crohn's Disease (CD) described as difficult to treat according to records from his provider. He has tried and failed Remicade, Cimzia and Entyvio. This request is for Stelara (ustekinumab). Scientific evidence in peer-reviewed literature does support a result of improvement in health outcome.

As per Ollech, J.E., et al. (2020), "shortening the ustekinumab 90 mg dose interval to 4 weeks for patients with CD who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity.  Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe."      

According to Fumery M et al. (2020), "the approved maintenance regimens for ustekinumab in Crohn's Disease (CD) are 90 mg every 8 or 12 weeks. Some patients will partially respond to ustekinumab or will experience a secondary loss of response. It remains poorly known if these patients may benefit from shortening the interval between injections...Conclusion: In this multicenter study, two-thirds of patients recaptured response following treatment intensification with ustekinumab 90 mg every 4 weeks."

This patient is a good candidate for the prescription drug, Stelara at a dose of 90 milligrams every 4 weeks for a diagnosis of CD. The prescription drug, Stelara (ustekinumab) at a dose of 90 milligrams every 4 weeks for a diagnosis of Crohn's Disease is the best available treatment for this patient at this time. "Ustekinumab is a novel, promising and relatively safe biological fully human monoclonal antibody for the treatment of moderate to severe CD" (Engel, T., Kopylov, U., 2016).     
  
The patient has a history of Crohn's Disease that has been difficult to treat. He underwent surgical resection of the right colon and terminal ileum in the past. The patient has tried and failed Remicade, Cimzia, and Entyvio due to lack of clinical response and/or adverse events. The patient started taking Stelara every 8 weeks; however, the drug level is low and a computerized tomography (CT) scan of the abdomen pelvis revealed active Crohn's Disease of the small bowel. Because the patient has active Crohn's Disease on Stelara every 8 weeks and low trough on drug levels, it is likely to be more beneficial for the interval of Stelara injections be changed to every 4 weeks in hopes of putting the patient into remission and maintaining remission.                                           

The carrier's denial of the prescription drug, Stelara at a dose of 90 milligrams every 4 weeks for a diagnosis of Crohn's Disease should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Prescription drug, Stelara at a dose of 90 milligrams every 4 weeks for a diagnosis of Crohn's Disease
The insurer denied coverage for the prescription drug, Stelara at a dose of 90 milligrams every 4 weeks for a diagnosis of Crohn's Disease.
The denial is overturned. 

This is a male patient who has Crohn's Disease with a complicated course. He had previously failed Remicade and Cimzia. An ileal resection was done. A computerized axial tomography (CAT) scan revealed active Crohn's Disease of the small intestine. An ustekinumab [Stelara] level was low and he did not have antibiotics. In view the active disease and low drug levels it was advised to shorten the drug interval to every 4 weeks.

Clinical Gastroenterology and Hepatology, 2020 February issue has an article titled "Effectiveness of ustekinumab dose escalation in patients with Crohn's Disease." The conclusion is that shortening the ustekinumab [Stelara] 90 milligrams dose interval to every 4 weeks in Crohn's patients who did not respond to doses every 8 weeks, improved clinical and biologic indices of disease activity. Patients who lose response to the standard dose of ustekinumab [Stelara] might benefit from dose interval shortening which was effective and safe.  

The peer-reviewed literature supports the use of dose escalation and decreasing the interval dosing of ustekinumab [Stelara] to every 4 weeks. The Food and Drug Administration (FDA) recommended dose is 90 milligrams every 8 weeks. However, in this case, the drug level was low, there were no antibodies, and the disease remained active. The patient is a good candidate since he has a low ustekinumab [Stelara] drug level and active disease. It is the best available treatment since he has already failed multiple biologic therapies. Decreasing the drug dosing interval is likely to be more beneficial in achieving a therapeutic drug level to control his Crohn's Disease. 

The carrier's denial of the prescription drug, Stelara at a dose of 90 milligrams every 4 weeks for a diagnosis of Crohn's Disease should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Decubitus Ulcers
Treatment: Skilled Nursing Facility
The insurer denied the Skilled Nursing Facility.
The determination is upheld.

The patient was admitted to a skilled facility for rehabilitation along with treatment of several decubitus ulcers. She has a past medical history significant for paraplegia, hypertension, diabetes, hyperlipidemia, cerebral infarction, obesity, cutaneous mucormycosis. Skilled care included physical therapy and occupational therapy along with wound care treatment.
This review is for the medical necessity of ongoing acute skilled nursing facility services.
The requested health service is not medically necessary for this patient.
This patient has multiple medical problems most concerning include her neurological dysfunction from a previous stroke along with multiple decubitus ulcers. She was receiving physical and occupational therapy. However, those services show a plateau in her functional ability. She has also been treated for decubitus ulcers with wound care dressings along with evaluation and topical treatments. The patient does not require ongoing skilled services for either physical therapy or occupational therapy because her level of function has plateaued. Regarding the treatment of her decubitus ulcers, an evaluation showed that the patient had 6 decubitus ulcers. There are no signs of infection. The largest ulcer was noted to be a stage IV ulcer in the sacral area 6 centimeters (cm) 6.5 cm 2 cm. There was serosanguineous drainage but no odor. The bed had 100% granulation tissue. The recommendation for treatment included wound cleansing and irrigation with normal saline, applying calcium alginate along with a silver nitrate reduction procedure. The patient had daily wound care treatment with cleansing by normal saline along with treatment with calcium alginate. The patient had weekly visits from a wound care physician. However, the patient did not need to remain in a skilled nursing facility for daily wound care dressing changes.