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

Diagnosis: decreased mobility
Treatment:  Personal care worker (PCW) service 7 hours x 5 days and 4 hours x 2 days (total of 43 hours)
The insurer denied Personal care worker (PCW) service 7 hours x 5 days and 4 hours x 2 days (total of 43 hours)
The health plan's determination is overturned.

This is a case review for a female with medical history notable for chronic obstructive pulmonary disease (COPD), bronchiectasis, peripheral neuropathy, dementia, and gait instability. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient lives alone and requires personal care assistance for day-to-day activities. The physician states that the patient requires extensive assistance with bathing, hygiene, cooking, medications, and walking due to gate difficulties. Dementia places her at high risk for malnourishment if she does not have prompting for meals and appropriate preparation. She also requires assistance to go to appointments. The physician reports that her current hours are inadequate for her needs.

The requested Personal care worker (PCW) service 7 hours x 5 days and 4 hours x 2 days (total of 43 hours) is medically necessary for this patient.
The letters provided demonstrate that the patient has had worsening cognitive and physical functioning. Her daughter provides a great deal of informal support, and the request for a total of 43 hours is to allow coverage during the gaps when her daughter is not available. The patient's numerous falls are evidence of unmet personal care needs. Furthermore, personal care needs such as toileting (for which the patient requires extensive assistance) and incontinence care can be expected to be unscheduled throughout the day. Therefore, the requested increase to a total of 43 hours per week of personal care worker services is medically necessary for the patient. Failure to provide for these personal care needs could result in additional falls, injury, and/or other forms of morbidity.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Gallstones
Treatment: Reltone
The insurer denied Reltone
The health plan's determination is upheld. 

The patient is a female. An Ultrasound showed a 6 millimeter (mm) gallbladder sludge ball versus shadowing stone; she has not had right upper quadrant pain, nausea, or postprandial pain. Reltone 400 milligrams (mg) is being prescribed to dissolve the gallstone. 

A formulary exception is not indicated in this case. There is literature to support the use of ursodiol for the prevention of gallstone disease after bariatric surgery, and less definitive support for the use of ursodiol for the dissolution of gallstones. Ursodiol is considered to be relatively safe. However, the use of Reltone 400 mg capsules over the formulary alternative of ursodiol 300 mg is not supported by current medical literature. Based on the submitted documentation, the formulary alternative has not been ineffective, would not be less effective than the non-formulary drug, and would not have adverse effects.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Hypertension, obesity and hyperlipidemia.
Treatment:  Testosterone 1% (percent) Gel.

The insurer denied Testosterone 1% Gel.  The denial is upheld.

The patient is an adult male with diagnoses of hypertension, obesity and hyperlipidemia. The patient had lab results of Total Testosterone 234 nanograms per deciliter (ng/dl) and Free Testosterone 56.2 picograms per milliliter (pg/mL). The provider prescribed Testosterone 1% Gel.

The health plan should not cover the proposed treatment.

The patient fails to meet general criteria of at least two morning testosterone levels less than 300. In addition, there is no documentation that the patient has tried and failed the required formulary medications or has had reactions to the preferred medications, namely testosterone cypionate or enanthate.

"The serum testosterone concentration fluctuates somewhat even early in the morning, although to a limited degree. If a single 8 to 10 AM value is well within the normal range, testosterone production can be assumed to be normal. If a single 8 to 10 AM value is low or borderline low or does not fit with the clinical findings, the measurement should be repeated once or twice before making the diagnosis of hypogonadism." (Bhasin, et al., 2010)

"Testosterone should be administered only to an adult male who is hypogonadal, as evidenced by clinical symptoms and signs consistent with androgen deficiency and a subnormal morning (8 to 10 AM) serum testosterone concentration on three separate occasions. Ideally, samples should be drawn fasting; in one report, an oral glucose load suppressed serum testosterone concentrations acutely." (Caronia, et al., 2013).

"For men with vague symptoms that could be the result of low testosterone (e.g., fatigue) and a single, but not repeatedly, subnormal serum testosterone concentration, we recommend strongly against testosterone use." (Morales, et al., 2015).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Knee Pain
Treatment: Arthroplasty, right knee.
The insurer denied arthroplasty, right knee.
The determination is upheld.

This is a female patient diagnosed with right knee arthritis. There is a request for right knee arthroplasty. The patient presented regarding chronic bilateral knee pain worse on the right. The patient was diagnosed with bilateral medial compartment arthritis and had been treated conservatively over the past 5 years. The treatment included analgesics, anti-inflammatories, physical therapy, and multiple corticosteroids and viscosupplementation injections. The provider stated that there was constant severe bilateral knee pain which interfered with ambulation and sleep. There was comorbid diabetes. The patient was a current smoker. An exam of the right knee documented medial joint line tenderness, motion of 0-130 degrees (), and no instability. An exam of the left knee documented medial joint line tenderness, no instability, and motion of 0-130. The provider stated x-rays demonstrated mild medial compartment degenerative arthritis. A magnetic resonance imaging (MRI) scan of the right knee documented mucoid degeneration of the medial meniscus and tricompartmental cartilage loss most pronounced in the medial and patellofemoral compartment. The provider recommended a right partial knee replacement of the medial compartment. An x-ray report of the bilateral knees documented mild osteoarthritis greatest in the medial compartment. At issue is the medical necessity of arthroplasty, right knee.
The requested right knee arthroplasty is not medically necessary. The current medical literature supports partial knee arthroplasty for symptomatic knee arthritis isolated to a single compartment which is not improved with initial conservative treatments. Medical literature does not recommend arthroplasty in the setting of current tobacco use.  While there is evidence of symptomatic knee arthritis not improved with conservative treatments, progression to medial compartment arthroplasty is not supported as there is not isolated arthritis in the medial compartment. Imaging reports tricompartmental arthritic changes. Additionally, the patient is a current tobacco user and arthroplasty is contraindicated in the setting of tobacco use due to increased morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Mechanical fall
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with a history of hydrocephalus who presented to the emergency ward with the complaint of mechanical fall on the day of presentation and repeated falls over the previous months. Computed tomography (CT) of the brain and magnetic resonance imaging (MRI) of the brain and lumbar spine showed no acute pathology. At presentation, the patient had full strength in all extremities. He was admitted to the acute inpatient level of care for further evaluation and management. Magnetic resonance imaging of the cervical spine after admission showed stable stenosis without change from previous.

The requested health service was not medically necessary.

The patient presented after a fall. There was no focal deficit on neurological examination. There were no signs of cord compression on examination (1). The neuro-imaging completed at presentation did not demonstrate any acute changes. The patient could have been safely and effectively managed at a lower level of care (2).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer
Treatment: Home Health Services, personal care aid level 2 health services of 84 hours per week, 12 hours per day, 7 days per week.
The insurer denied personal care aid level 2 health services of 84 hours per week, 12 hours per day, 7 days per week.
The health plan's determination is upheld.

This is a case review for a female with a medical history notable for breast cancer. The patient and her care team requested an increase to 12 hours per day, 7 days per week (84 hours per week). This denial is the subject under review.
Per a letter from the patient's physician,  the patient was diagnosed with breast cancer during a recent pregnancy and is now undergoing chemotherapy and radiation while postpartum. She is very weak and unable to care for herself and her family. The physician recommends 12 hours per day to address her needs.
The patient's case worker provided a letter of support. The letter states that the patient was diagnosed with stage 4 breast cancer at 34 weeks of pregnancy. She is receiving chemotherapy every two weeks. She is tired and nauseous. Her husband is gone working all day, and she has six children to care for. She has difficulty grooming herself.
The patient provided a letter of support on her own behalf. The letter states that she has been dealing with weakness, fatigue, and nausea from her treatments. She has six children at home and is unable to do any cooking, bathing, or other tasks.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient lives with her spouse and children in an apartment. She is alert and oriented with independent decision-making. For her instrumental activities of daily living (IADL), she requires maximal assistance for meal preparation and housework. She requires extensive assistance for shopping and limited assistance for stairs. She is independent in other domains. For her activities of daily living (ADL), she requires maximal assistance with toilet transfer. She requires limited assistance for bathing, dressing lower body, and bed mobility. She is independent in all other domains. The patient's sister assists her with daily meals for the children. She ambulates without an assistive device. She occasionally receives assistance from her spouse with transferring out of bed or to the toilet due to fatigue. She is continent of urine and stool. A task tool recommended 13.94 hours per week to address her personal care needs.

The requested health service of 84 hours per week, 12 hours per day per 7 days per week, personal care aide level 2, has not been demonstrated to be medically necessary for this patient.
The patient requires assistance with IADL's and occasionally with ADL's. The task tool recommends 14 hours per week. The patient has a great deal of childcare duties, and the documentation describes that she has significant family social support for this. Her own personal care needs should be covered by the allowance of hours that was granted by the plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia
Treatment: stair lift
The insurer denied the stair lift.
The health plan's determination is overturned.

This is a case review for a female with a medical history notable for Parkinson's disease and dementia. The patient and her care team requested approval for a durable medical equipment order for a stair lift, and coverage was denied by the health plan. This denial is the subject under review.
The patient's granddaughter provided a letter for this appeal. The letter states that she has been having to manually lift her grandmother, which has taken a physical toll on her. She is requesting the device to prevent injury. The steps are constructed with a steep uphill incline that cannot be corrected because of the foundation of the home. They are unable to have her leave the house via a wheelchair. Prior attempts have resulted in having to call Emergency Medical Services (EMS). The patient's granddaughter states that she has herniated discs from attempts to get her out of the basement without a lift. Additionally, the patient has had to miss appointments with specialists due to not having a lift. The letter addresses the plan's assertion that the patient should be moved to a different floor; she reports that there are no ramp-accessible measures in place on other floors and moving her will therefore not be possible or practical.
A Uniform Assessment System (UAS) was completed a few months ago.  The patient resides in the basement apartment of the private home of her granddaughter. Her cognition was severely impaired. She is not self-directing and is not able to make her needs known. For her instrumental activities of daily living (IADL), she requires total dependence for all. For her activities of daily living, she requires total dependence or maximal assistance for essentially all. She is incontinent of both urine and stool, with no control present.

The requested health service of Durable medical equipment (stair lift) is medically necessary for this patient.
The documentation provided demonstrates that the stair lift is medically necessary to address the patient's personal care needs. She is physically not able to be moved into and out of her living space, and prior attempts have resulted in injury to family members. The device will allow her to be safely transferred into and out of her apartment. This will also allow her to make medical appointments as scheduled. Therefore, the request is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male who presented to the emergency department (ED) with shortness of breath and chest pain. The patient had exertional chest pressure and dyspnea for a few months. His chest pain was 6/10.

The patient was seen by his PCP (primary care provider) and his blood work revealed elevated triglyceride levels. The patient also had nausea and vomiting every morning. The patient has a history of chronic obstructive pulmonary disease (COPD), human immunodeficiency virus (HIV), and liver cirrhosis.

His lung computed tomography (CT) revealed emphysema and sub 3 millimeter (mm) left lower lobe (LLL) nodules. His last echocardiogram and stress test were unremarkable. The patient drinks 3 beers every day. The patient is a smoker.

He was not in distress. There was expiratory wheezing on lung exam. Heart was regular, with no murmur. Abdomen was soft non-tender. Musculoskeletal exam was normal.

His electrocardiogram (ECG) revealed sinus rhythm, and premature ventricular contraction (PVC). A chest x-ray (CXR) was interpreted as "compatible with chronic obstructive pulmonary disease (COPD)".

The inpatient hospital admission was not medically necessary for this patient. The patient presented with chest pain and he had multiple coronary risk factors, including smoking and dyslipidemia. His ECG and troponin were negative for acute coronary syndrome. The patient remained stable, with normal blood pressure (BP) and without respiratory or hemodynamic compromise. His serial troponin was negative. His coronary angiography was unremarkable. His right heart catheter did not reveal pulmonary hypertension.

The patient was treated with oral medications. His COPD exacerbation was mild. He did not have evidence of ethyl alcohol (ETOH) withdrawal or clinically significant HIV symptoms.

Based on the above, the inpatient level of care was not medically necessary. A lower level of care would be more appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gunshot wound
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female child who was shot in the right arm. She felt a sting in her right arm and realized that she had been shot. The police were emergently contacted, responded immediately, placed a tourniquet on her arm, and transported her to the emergency department (ED).
 The examination was significant for no acute distress and non-toxic in appearance but in pain, moist mucous membranes, regular heart rate and rhythm, clear lungs, benign abdomen, tenderness, laceration at the site of the gunshot wound, entry wound right forearm medial aspect, exit wound close to the elbow, intact neurovascular exam, non-focal neurologic exam. She was treated with fentanyl, Toradol, and Ancef. X-rays were negative for a fracture but there was subcutaneous emphysema on x-ray. The wound was cleaned and sutured prior to admission.
She was admitted for pain control and further management. Admission orders included maintenance intravenous (IV) fluids, Ancef every eight hours, Tylenol as needed, Toradol as needed, neuro checks every two hours, Orthopedic Surgery consultation, routine vital signs and rest, social services involvement. She did well overnight, no fevers, stable vital signs, neurovascular exam intact with soft compartments. Neuro checks were done every two to four hours with no changes. She was initially given parenteral pain medications, then transitioned to oral medications. She was cleared for discharge. At issue is the medical necessity of an inpatient admission.
An inpatient admission was not medically necessary. The patient could have been safely managed at lower level of care.
This child was shot accidentally, sustaining a wound to the right forearm. Bleeding was controlled on site, and she was hemodynamically stable in the ED with intact movement and sensation. No fracture was noted on x-ray, and there were no retained bullet fragments. The wound was cleaned and sutured in the ED and she was admitted for monitoring and pain management. The pain was well-controlled and there was no evidence of evolving neurovascular compromise. While it was medically necessary and appropriate to monitor her overnight, she was hemodynamically stable with no evidence of evolving compartment syndrome, no need for surgical intervention, no nerve compromise, no fracture. She could have been safely managed at lower level of care, including pain management and consultations.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Dental Disorder.
Treatment: Braces and monthly visits.
The insurer denied Braces and monthly visits.
The determination is upheld.

This is a male patient with a Class I malocclusion; moderate maxillary spacing and moderate mandibular spacing; mild overjet, mild overbite with an ectopically erupting tooth number (#) 6, and retained tooth #C. At issue is the medical necessity of braces and monthly visits.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score an 11 with no auto qualifiers. Auto qualifiers include cleft palate deformity or craniofacial anomaly, deep impinging overbite with severe soft tissue damage, impacted permanent anteriors where extraction is not indicated, anterior crossbite causing clinical attachment loss and recession of the gingival margin, severe traumatic deviations, overjet 9-millimeter (mm) or greater and underbite 3.5 mm or greater. The case requires a score of 26 or more for treatment to be considered medically necessary. The malocclusion in question does not meet the criteria to be classified as handicapping and treatment would not be considered medically necessary. Thus, according to the standard of care, the requested health service/treatment for braces and monthly visits are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypertension
treatment: inpatient hospital
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This is a case of a female admitted for diagnosis of poorly controlled hypertension due to medication noncompliance. The patient presented with chief complaint of high protein in the urine. She was sent from the nephrology clinic for asymptomatic blood pressure of 188/130. The patient did not have any symptoms, but she had been started on steroids for bronchitis. Vital signs demonstrate temperature 36.5C, pulse 70, respiratory rate 16, blood pressure 176/106 and O2 (oxygen) saturation 99%. Physical exam showed no acute distress with non-labored respirations. White blood cell count was 6.4 with creatinine 1.17. Her blood pressure improved to 122/82 overnight and the uncontrolled hypertension was thought to be due to medication noncompliance. She was asymptomatic with no evidence of end organ damage. 

The inpatient hospital admission was not medically necessary.
The patient in this case was admitted for uncontrolled blood pressure but according to the notes there was no evidence of end organ damage and therefore no diagnosis of hypertensive emergency. She did not have elevated blood pressure with a concerning etiology such as ischemic stroke, aortic dissection or intracerebral hemorrhage. Her blood pressure improved overnight with compliance of her home medication regimen. She had a slight elevation of her creatinine at 1.20 which would be classified as mild acute kidney injury.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.