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

Diagnosis: Spastic quadriparesis after anoxic brain injury
Treatment: Occupational Therapy - 5 Home health visits (Health Plan has approved 4 home health visits of occupational therapy)
The insurer denied the Occupational Therapy - 5 Home health visits (Health Plan has approved 4 home health visits of occupational therapy).
The denial is upheld.

The patient is a female child with history of prematurity. The child required prolonged NICU (neonatal intensive care unit) stay with history of CPAP (continuous positive airway pressure) support as well as IV (intravenous) antibiotic treatments with PICC (peripherally inserted central catheter) line. Following discharge home, the child developed apneic episode with development of cyanosis as well as bradycardia. The child required intubation and CPR (cardiopulmonary resuscitation) has been administered secondary to cardiac arrest. The child has been diagnosed with hypoxic ischemic encephalopathy, requiring tracheostomy and  gastrostomy tube placement. The child has been diagnosed with Spastic quadriparesis. The child has been prescribed occupational therapy 1 time per week. The child has been receiving home health visits. 

No, the additional occupational therapy is not medically necessary.

Clinical records point out the clinical and functional challenges experienced by this child, however there is no evidence that further skilled goal oriented occupational therapy interventions are needed.

Clinical records do not demonstrate further pediatric skilled occupational therapy needs for this child with multiple co-morbidities and low functioning abilities. Clinical records do not meet medical necessity for further skilled occupational therapy needs at this point in time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis as well as dizziness and giddiness, central hypertension, hypercholesterolemia. 
Treatment: Increase in Personal Care Aide services from 7 days per week, 6 hours per day (42 hours per week) Personal Care Assistant (PCA) to 7 days per week, 12 hours per day (84 hours per week) Personal Care Assistant (PCA). 

The insurer denied coverage for increase in Personal Care Aide services from 7 days per week, 6 hours per day (42 hours per week) Personal Care Assistant (PCA) to 7 days per week, 12 hours per day (84 hours per week) Personal Care Assistant (PCA). 

The denial is overturned. 

This case involves a female who has a history of osteoporosis as well as dizziness and giddiness, central hypertension, hypercholesterolemia, functional urinary incontinence, asthma, iron deficiency anemia, gastroesophageal reflux disease, and aural vertigo.  The documentation indicated she has had multiple episodes of losing her balance with history of falls and a prior shoulder fracture.  She also has hypertension with moderate to severe asthma, an ataxic gait and anxiety with panic attacks.  She has multiple episodes of dizziness and unsteadiness and is considered a high risk of falls needing assistance to ambulate and to perform regular activities of daily living at home.  She had been living with her husband; however, he was recently passed away.  Due to her unsteady gait and high risk of falls as well as recent decompensation with moderate short-term memory loss she is in need of assistance on a daily basis. 

According to the provided documentation, the patient is appropriate to receive the requested services as this will allow her to remain home with daily assistance with the recommended personal care aide services.  The documentation indicated this patient is elderly with multiple comorbidities increasing her fall risk.  The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

Based on the above, the medical necessity for an increase in Personal Care Aide services from 7 days per week, 6 hours per day (42 hours per week) Personal Care Assistant (PCA) to 7 days per week, 12 hours per day (84 hours per week) Personal Care Assistant (PCA) is/ is not substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plantar Fasciitis

Treatment custom foot inserts (L3000 foot orthotics)

The insurer denied coverage for custom foot inserts (L3000 foot orthotics)

The denial is overturned.

The patient is a female with a long history of plantar fasciitis and pain to the feet. Per the records made available, the patient has used orthotics that are over years old and they have lost their integrity and support resulting in recurrent pain. The patient has been doing stretching exercises with no relief and has also taken non-steroidal anti-inflammatory drugs (NSAID) with no results. 

A review of the literature reveals that while there is a vast amount of research with regard to conservative therapy for plantar fasciitis, there is no optimal answer when it comes to specific orthotic therapy for plantar fasciitis (1,2).  While some patients may benefit from over-the-counter orthotics, others may get no better without the use of custom orthotics. In the case of this patient, it is clear from the medical records made available to me that the continued use of the old custom orthotics is contributing to recurrence of her plantar fasciitis.  

Given the available literature on this topic and this patient's history, continued use of custom orthotics is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the custom foot inserts (L3000 foot orthotics) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hidradenitis Suppurativa

Treatment Humira Pen-CD (crohn's disease)/UC (ulcerative colitis)/HS (hidradenitis suppurativa) Starter 40 milligrams per 0.8 milliliters subcutaneous PNKT (pen injector kit)

The insurer denied coverage for Humira Pen-CD/UC/HS Starter 40 milligrams per 0.8 milliliters subcutaneous PNKT

The denial is overturned

The patient is a female with a diagnosis of hidradenitis suppurativa affecting the groin and axilla.  She has failed therapy with doxycycline, levofloxacin, metronidazole, rifampin and hibiclens.  The patient was given a trial of Humira recently with positive improvement noted.  The requested medication is Humira.  

Based on the submitted documentation, Humira is medically necessary for the patient's condition, hidradenitis suppurativa (HS). The patient has failed numerous oral antibiotics as well as topical antibacterial agents.  Humira is FDA (Food and Drug Administration) approved for the treatment of HS. The patient has had a short trial of Humira for the treatment of her condition and has improved based on the provided documentation.  

The standard of care for failure of medications known to treat HS has been met based on the reported history.  As such, the use of Humira is 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 Humira Pen-CD/UC/HS Starter 40 milligrams per 0.8 milliliters subcutaneous PNKT is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This is the case of a female with a history of cholelithiasis who presented with right upper quadrant pain. She was found to have uncomplicated acute cholecystitis. She was admitted, underwent an uncomplicated laparoscopic cholecystectomy, and was discharged.

The inpatient hospital stay was not medically necessary.

This patient had a laparoscopic cholecystectomy for uncomplicated cholecystitis. Laparoscopic cholecystectomy is now an outpatient procedure the vast majority of the time. There were no complications to warrant an inpatient level of care for this patient.

In addition, the InterQual Acute Adult criteria are not met. InterQual is mentioned because it is a peer reviewed source of guidance on level of care. The patient was hemodynamically stable, had no evidence of cholangitis or biliary obstruction. The patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory 
Treatment: Skilled Nursing Facility 
The insurer denied skilled nursing facility.  
The denial is overturned in whole. 

The patient is a female who suffered a COVID-19 (Coronavirus Disease 2019) infection requiring mechanical ventilation, multiple hospitalizations with subsequent skilled nursing facility stays. The subject under review is the medical necessity for skilled nursing facility.

The health plan's determination is overturned. 

The requested service of skilled nursing facility stay is medically necessary and appropriate for this patient. The patient continues to have daily skilled nursing needs. She has a stage four (IV) wound requiring treatment 2x (times)/day, is dependent on tube feedings and requires tracheostomy care every shift and as needed. Additionally, while progress has been slow, she is requiring mechanical ventilation less and less.

The patient suffered a COVID-19 infection requiring mechanical ventilation and has been unable to be weaned from the ventilator. Following this initial hospital admission, she has been readmitted multiple times to acute care hospitals secondary to bacteremia. Documentation consistently shows that the patient has continued to require daily skilled nursing care. She has a stage IV sacral ulcer requiring wound care twice a day, is dependent on tube feedings for her primary source of nutrition and is still requiring frequent tracheostomy aspirations. As noted "tracheostomy care is provided every shift and as needed, suction Ballard is changed every 72 hours and as needed, inner cannula is changed at 6:00 PM daily and as needed, heat moisture exchange (HME) is changed every 24 hours and as needed, bacterial/viral filter is changed every 48 hours and as needed and oral/trach suctioning is done every shift and as needed." In addition, while slow, there has been documented progress. For example, notes stated that patient "currently has orders to wean as tolerated with continuous positive airway pressure (CPAP) 15/+5/40% fraction of inspired oxygen (FiO2) x 18 hours." She is not medically stable nor at a point of custodial care as her needs continue to change. Therefore, this stay is medically necessary, appropriate and within generally accepted standards of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient had choriocarcinoma and was on chemotherapy. She presented with abdominal pain, vomiting, and diarrhea. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. She had a colostomy. She had a white blood count (WBC) count of 35 but was on Zarix which causes leukocytosis. Intravenous (IV) hydration was given. The vomiting stopped while in the hospital. The renal function was normal. A computed axial tomography (CAT) scan of the abdomen was negative for obstruction. She was diagnosed with a gastroenteritis. She was given pain control. She left the hospital against medical advice.

Clinical indications for admission for Gastroenteritis (MCG [Milliman Care Guideline] M-170) include having a suspected severe infection such as bloody diarrhea, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, severe electrolyte abnormalities, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

Clinical indications for admission for Dehydration (MCG M-123) include hemodynamic instability, persistent vomiting, dehydration resulting in acute kidney injury, and severe electrolyte abnormalities. The patient did not have these conditions.

This patient had a gastroenteritis. IV hydration and antiemetics could have been given in the emergency room (ER) with observation status. The vomiting did not persist while in the hospital. She did not meet MCG criteria for admission for either Gastroenteritis or dehydration. The health care plan acted reasonably and with sound medical judgement. An inpatient admission was not medically necessary.

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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vision. 
Treatment: Surgical Services. 
The insurer denied Repair of ectropion; extensive (e.g., tarsal strip operations). 
The denial was overturned. 

The patient is a female, for whom bilateral lower eyelid canalicular repair and ectropion repair was performed.
It states that there are no functional impairments that will improve or resolve by repair of ectropion. Therefore, the health plan considers the procedure cosmetic. A letter from the provider to the health plan, appeals the decision. The records indicate the patient had documented bilateral exposure keratopathy, refractory to topical medications. The record also notes blurry vision and difficulty with reading. The operative note  reviews the diagnosis, includes objective findings of refractory exposure keratopathy, and epiphora, resulting in blurred vision and difficulty reading (subjective findings). Also noted is nasolacrimal duct obstruction from occluded canaliculi and punctae. 
At issue is the medical necessity of Repair of ectropion; extensive (e.g., tarsal strip operations).

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

The requested health service/treatment of Repair of ectropion; extensive (e.g., tarsal strip operations) is medically necessary for this patient.
Based on review of the documentation the treatment of repair of ectropion is medically necessary for this patient. Per the provider documentation, the objective and subjective criteria were met for functional impairment as shown by the operative note as well as photographic evidence of the pre-operative ectropion abnormality. Therefore, all criteria for the health plan have been met. The best interest of the patient, was to proceed with surgical ectropion repair, especially given her keratopathy was refractory to topical medications as noted in the record. Uncorrected exposure keratopathy can lead to permanent corneal damage and permanent visual impairment. In this instance, surgery is the definitive treatment.
Therefore, the requested health service/treatment of Repair of ectropion; extensive (e.g., tarsal strip operations) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia, polyosteoarthritis, diabetes, neuropathy

Treatment: Consumer directed personal care assistance (CDPAS) 9 hours per day/63 hours per week.

The insurer denied coverage for consumer directed personal care assistance (CDPAS) 9 hours per day/63 hours per week.

The denial is upheld.

The patient has a history of dementia, polyosteoarthritis, diabetes, neuropathy, heart disease and hypertension. UAS (Uniform Assessment System) was done and notes overall stability. The patient is able to go out occasionally, is incontinent of bladder and wears pullups. The patient has formal and informal support. Cognition is good. The patient needs limited-extensive assistance with activities of daily living (ADLs). There are formal and informal caregivers. 

The patient is receiving 8 hours per day/56 hours per week of consumer-directed personal care assistance services (CDPAS). An increase to 9 hours per day (63 hours per week) is requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."

The patient is an elderly patient with impairments as noted above. The UAS done in show no clear deterioration in function. The plan has taken the patient's impairments into account in assessing hours, and adding additional hours. The record does not support an increase from 8 to 9 hours/day. 

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

Based on the above, the medical necessity for the consumer directed personal care assistance (CDPAS) 9 hours per day/63 hours per week is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This is a female with a history of migraine headaches who presented to the emergency department for abdominal pain times four day. The lipase level was elevated at 1831.   Computed tomography (CT) of the abdomen showed a normal pancreas.  The patient was diagnosed with possible acute pancreatitis. The patient was treated with intravenous (IV) fluids, analgesia,  and Dilaudid.  Gastroenterology (GI) consult evaluated the patient - diagnosis of acute pancreatitis was not established based on normal computed tomography (CT) scan.  Other potential causes were duodenal ulceration, renal injury and drug induced, per gastroenterology (GI) note.  

No, the proposed inpatient admission was not medically necessary.
The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting.

An inpatient level of stay was not medically necessary since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have electrolyte derangement needing intravenous replacement, did not have fevers, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.

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

Based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Family history of cancer.
Treatment: Genetic Testing for Lynch Syndrome.
The insurer denied the Genetic Testing for Lynch Syndrome.
The denial is overturned.

The patient is a male. Denial of genetic testing for Lynch syndrome is being appealed.

The request was previously denied by the health plan due to lack of medical records.  Per clinical note, the patient's family history is as follows:  Mother - breast cancer; maternal grandfather with possible colon; paternal grandfather with throat cancer; paternal grandmother with lung cancer.  Order form for testing includes uncle with colon cancer.  The patient had a colonoscopy with removal of 2 colonic polyps with unremarkable pathology.

Yes, the Genetic Testing for Lynch Syndrome is medically necessary.
Lynch syndrome is the most common form of genetically determined colon cancer predisposition. Revised Bethesda Guidelines for Lynch syndrome screening include the following:
1)	Younger than 50 years when diagnosed with colorectal cancer;
2)	Has or had a second colorectal cancer or another cancer linked to Lynch syndrome;
3)	Younger than 60 years, and the cancer has certain characteristics seen with Lynch syndrome when it's viewed under a microscope;
4)	Has a first-degree relative younger than 50 who was diagnosed with colorectal cancer or another cancer linked to Lynch syndrome (endometrial, stomach, pancreas, small intestine, bile duct, ovary, kidney or brain); or
5)	Has 2 or more first- or second-degree relatives who had colorectal cancer or another Lynch syndrome-related cancer at any age.

This patient does not have a personal history of colorectal cancer. However, he has a family history of colorectal cancer in 2 second degree relatives in paternal grandfather and uncle. Therefore, given the above, the Genetic Testing for Lynch Syndrome is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Experimental/Investigational
Decision: Overturned in Part

Diagnosis: Gastroesophageal Reflux Disease/GERD
Treatment: LINX Procedure and Full Hospital Admission
The insurer denied the LINX Procedure and Full Hospital Admission. The health plan's determination is upheld. 

The patient is a female with a history of gastroesophageal reflux. She is described as having gastroesophageal reflux disease (GERD) despite Dexilant 60 milligrams (mg) proton pump inhibitor (PPI) therapy.
A pH (potential hydrogen) study demonstrated abnormal acid exposure in the esophagus with a DeMeester score of 21.8. Esophageal motility study was normal. She has a body mass index (BMI) of 22. Upper gastrointestinal (GI) contrast study shows no hiatal hernia per the reading, although the surgeon describes a "tiny" hiatal hernia. An esophagogastroduodenoscopy (EGD) showed a normal esophagus and stomach. Distal esophagus biopsy showed no abnormal cells or esophagitis.
This review concerns the proposed LINX procedure and associated hospital stay for the treatment of her GERD.

The LINX procedure and Full hospital admission are not likely to be more beneficial than standard treatment for this patient's GERD. Current standard treatments include diet and behavior modification, PPI medication therapy, and surgical fundoplication. Numerous studies have evaluated the LINX procedure and found results for reflux control similar to surgery in the short term, but with unanswered concerns about longer term dysphagia and erosion.

Given a long history of late complications from encircling devices around the esophagus and gastroesophageal junction, there is reason for concern. As Kirkham writes in a 2020 systematic review, "Most studies on MSA (magnetic sphincter augmentation) lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness".
In summary, the proposed LINX procedure is not likely to be more beneficial than standard therapy, and may in fact be worse over the long term if late erosions and dysphagia manifest in longer term analyses.