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

Diagnosis: Atrial fibrillation
Treatment: inpatient stay
The insurer denied inpatient stay
The determination is upheld

This is a female patient who presented to the emergency department (ED) complaining of chest and back pain, diffuse body aches, dry cough and sore throat. Her medical history was remarkable for hypertension, morbid obesity, obstructive sleep apnea, paroxysmal atrial tachycardia and endometrial cancer. She was afebrile. An electrocardiogram showed atrial fibrillation with a ventricular rate of 110 beats/minute.  A chest computed tomography (CT) scan showed right upper lobe pneumonia. A rapid strep test was positive. The patient was treated with intravenous antibiotics and oral diltiazem and was admitted to the hospital. An echocardiogram showed a left ventricular ejection fraction of 50 percent (%); there was no significant valve disease. She intermittently had ventricular rates up to the 130s. She was seen in consultation by a cardiologist who recommended oral diltiazem, apixaban and a transesophageal echocardiogram (TEE) and electrical cardioversion after the weekend. She underwent a transesophageal echocardiogram (TEE), cardioversion and implantation of an implantable loop recorder. She was then discharged. At issue is the medical necessity of an inpatient admission.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with a cough, sore throat and diffuse body aches. She was found to be in atrial fibrillation (AF) with a rapid ventricular rate. In addition, she was diagnosed with right upper lobe pneumonia.
Regarding the patient's atrial fibrillation (AF): The patient was hemodynamically stable. There was no evidence of acute ischemia or decompensated heart failure. The patient's ventricular rate was controlled with oral diltiazem. Her resting rate was 90-100 beats/minute. The records provided do not indicate that she had marked tachycardia with activity. Based on the documentation provided an inpatient level of care was not medically necessary for management of this patient's AF. The medical record does not indicate that there was a medical reason for the delay in performing the transesophageal echocardiogram.
Regarding the patient's pneumonia: A chest CT scan showed evidence of right upper lobe pneumonia. She did not have high risk features such as tachypnea, hypoxia, hyponatremia, altered mental status, hypotension or hypo- or hyperthermia. She was at low risk for major adverse events.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension.

Treatment: Inpatient hospital.

The insurer denied coverage for the inpatient hospital.

The denial is overturned.
 

Asked to review the case of an adult gentleman who was sent to the hospital for treatment of poorly controlled hypertension. Following arrival, he reported chest pain, he was treated with nitroglycerin, and the symptoms resolved. Past medical history was significant for cocaine abuse disorder, hypertension, diabetes, and coronary artery disease. The patient underwent percutaneous intervention to the right coronary artery one month before admission. On arrival at the hospital, the patient was hypertensive: Blood Pressure (BP) - 210/109. Pulse was 90.  A physical exam revealed no significant abnormality.  12 lead electrocardiogram (EKG) demonstrated sinus rhythm with left ventricular hypertrophy, ST depressions, and T wave inversions in the inferior leads and ST elevations and hyperacute T waves in the anterior precordial leads.  Serum blood testing was significant for elevated potassium (5.1). High-sensitivity troponin was not elevated (10). The patient was admitted to the hospital for treatment of hypertensive emergency and acute coronary syndrome. A recent echocardiogram demonstrated an ejection fraction of 45-55%. The patient was treated with nitroglycerin and carvedilol therapy and was ultimately discharged once BP was controlled.  

A hypertensive emergency is defined as BP>180/120 with target organ damage. (Reference 1) This patient presented with a systolic BP of 210. He developed chest pain and had EKG abnormalities consistent with left ventricular target organ damage. The goals of treatment of hypertensive emergency are to minimize progressive or additional target organ damage while preventing the consequence of rapid BP correction. (Reference 2) Admission to the hospital for aggressive blood pressure management was necessary in this case. American Heart Association guidelines recommend admission to the intensive care unit (ICU) for the management of hypertensive emergencies (Reference 1).  Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine abuse, found that patients over age 50, had an elevated risk of major adverse cardiac events and mortality. They concluded that such patients required hospital admission. (3). 

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental Disorder.
Treatment:  Braces and monthly visits.

The insurer denied braces and monthly visits.  The determination is overturned.

The patient is a female with a Class II malocclusion with severely crowded arches. Tooth number 10 is in anterior crossbite. The patient is treatment planned for 30-36 months of orthodontics to correct the crowding and crossbite. At issue is the medical necessity of braces and monthly visits.

Treatment is medically necessary. Tooth 22 is already developing recession, and if the patient's bite is not corrected with orthodontics the recession will get worse. Tooth 10 is in crossbite with tooth 22. Additionally, tooth 22 is being pushed labially in the dental arch and is developing recession. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3) These problems are much more time-consuming to correct than the patient's current orthodontic problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ataxia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.  The denial is upheld.

This case involves a patient, who presented to the emergency department (ED) as a transfer from an outside facility for the evaluation of neurologic symptoms. The patient had been having progressive weakness in their arms and legs with some tremors. The patient went to an outside facility due to chest pain, frontal headache, left arm tingling, and some perceived difficulty with their speech since waking up. A computed tomography (CT) of the head and laboratory studies were unremarkable from the outside facility, and the patient was sent for transfer for further evaluation. 

According to the history and physical, the patient presented with worsening ataxia, new onset of left-hand numbness, frontal headache and dysarthria. The patient reported persistent frontal non-radiating headache that was rated as 5/10. In addition, the patient's husband noted that their speech was not as clear, and the patient also thinks that their speech was not as clear. The patient was initially evaluated at an outside hospital and underwent CT and laboratory evaluation which was unremarkable. The patient was referred for admission due to unsteady gait and for further evaluation.

The patient was discharged home with a diagnosis of ataxia and weakness. 

In this case, the patient presented to the ED as a transfer from an outside facility for the evaluation of neurologic symptoms. The patient had been having progressive weakness in their arms and legs with some tremors. The patient went to an outside facility due to chest pain, frontal headache, left arm tingling, and some perceived difficulty with their speech since waking up. A CT of the head and laboratory studies were unremarkable form the outside facility and the patient was sent for transfer for further evaluation. Troponin was negative, comprehensive metabolic panel (CMP) was without acute findings, prothrombin time (PT)/partial thromboplastin time (PTT) was within normal limits, and CT brain without contrast was also unremarkable. 

Although the patient was sent for transfer for further evaluation, diagnostic services and laboratory services can be done in a lower level of care such in an observation. Troponin negative, CMP without acute findings, PT/PTT within normal limits, CT brain without contrast were unremarkable from the sending facility. 

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

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

The patient is a female, who was admitted for a skin infection in the left leg. She was found to have leukocytosis and was started on antibiotics for cellulitis. A doppler study of the lower extremities was negative for deep venous thrombosis. An electrocardiogram was negative for acute ischemia or arrhythmia. She had normal vital signs, and her condition improved as expected. She was discharged in stable condition.

The full hospital admission was not medically necessary. 
The patient was admitted for leg cellulitis, and her condition improved in 48 hours. She remained hemodynamically stable without signs of significant sepsis. Work up was negative including venous doppler and blood cultures.
Reviews and evidence-based guidelines suggest that adult patients with cellulitis who are not seriously systemically ill (the majority of patients) may be treated on an outpatient basis with empiric oral therapy.
Database analysis of 2,126,340 commercially insured patients who had a skin and soft tissue infection diagnosed in an outpatient setting found that only 1.5% (percent) of patients required inpatient care. A retrospective multicenter review of 725 patients (average age 38 years) seen in the emergency department for purulent skin and soft tissue infection found that 86% were able to be discharged from the emergency department or from the emergency department observation unit.
Based on the patient's presenting signs/symptoms and the predictability of something adverse that will occur to the patient based on these presenting signs/symptoms, her condition could have been treated safely under a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral palsy
Treatment: 16 Physical Therapy Visits
The insurer denied: 16 Physical Therapy Visits
The denial is upheld.

The patient is an adult male with history of Cerebral Palsy. He is noted to have spasticity, with uncoordinated movements, poor gait, etc. In addition, he is noted to have scoliosis, peripheral neuropathy, weakness of bilateral upper and lower extremities, poor balance, vertigo, tremors, hereditary motor and sensory neuropathy, etc. Continued PT (physical therapy) was requested to prevent worsening contractures, improve gait/balance, etc.
At the PT (physical therapy) assessment visit number 2 months ago, the patient was noted to be able to perform most ADLs (activities of daily living) independently. His ROM (range of 
motion) was within 90% of normal. He was able to ambulate two blocks, negotiate 10 steps with difficulty, and perform heavy home chores / ADLs (activities of daily living) with less difficulty.
The patient has completed more than 12 weeks of PT (physical therapy).

The 16 Physical Therapy Visits are not medically necessary.

The request for continuation was towards the maintenance of a range of motion and gait without transition to a home exercise program after more than 238 visits. As of visit number 238, the patient was able to perform most ADLs (activities of daily 
living) independently. His ROM (range of motion) was within 90% of normal. He was able to ambulate two blocks, negotiate 10 steps with difficulty, and perform heavy home chores/ADLs (activities of daily living) with less difficulty. The patient has completed more than 12 weeks of PT (physical therapy). The option for continuous PT (physical therapy) or OT (occupational therapy) has no clinical basis, as progress in PT (physical therapy) and OT (occupational therapy) is followed by the transition to home exercise program. There is no evidence that the family or patient has followed through adequately with the home exercise program. Continuous PT/OT (physical therapy/occupational therapy) two to three times per week for lifetime in Cerebral Palsy has no clinical basis. Therefore, the request is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental malocclusion

Treatment: Braces

The insurer denied coverage for braces

The denial is upheld

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to deep impinging overbite, among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of deep impinging overbite with severe soft tissue damage to support orthodontic necessity. 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 on the HLD index attaining 17 points by internal reviewers. 

Upon review of the submitted documentation, (study models were not provided for review), 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, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of deep impinging overbite with severe soft tissue damage. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of soft tissue damage severe or otherwise and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Uphold denial as the clinical circumstance as presented does not substantiate medical/dental necessity of orthodontic care.

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 braces is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Ptosis.
Treatment:  Upper eyelid surgery (blepharoplasty).

The insurer denied coverage for Upper eyelid surgery (blepharoplasty).  The denial is overturned. 

The insurer has denied coverage for upper eyelid surgery (blepharoplasty). The patient writes that they had weak eye muscles from a corneal condition, which interfered with their vision and ability to perform activities of daily living.

The patient's visual acuities were 20/25 right eye (OD) and 20/40 (pinhole to 20/30) left eye (OS).  The exam showed 2+ ptosis OD.  Visual field testing showed superior defect OD that improved 80% (percent) with taping of the lids. The patient underwent upper eyelid ptosis repair with posterior approach OD. The visual acuities were 20/40 in both eyes.  

"Ptosis is known as the drooping of the upper eyelid, and the patient usually presents with the complaint of the defect in vision and cosmesis. It can be congenital or acquired, or it can be neurogenic, myogenic, aponeurotic, mechanical, or traumatic in origin. Proper evaluation, diagnosis, and accordingly, treatment are the key to prompt management of ptosis.

Treatment of ptosis depends upon the underlying etiology, the degree of ptosis, and the function of the levator muscle. In mechanical ptosis, removal of the abnormal structure, i.e., a chalazion, is all that is needed. However, surgical correction is the mainstay of treatment" (Shahzad B, Siccardi MA., et al.).

The patient has visually significant ptosis, as demonstrated by clinical exam, external photographs and visual field testing. The requested upper eyelid surgery (blepharoplasty) is medically necessary for this patient. The medical documentation shows right ptosis obstructing the visual axis. External and lateral external photographs confirm ptosis affecting the visual axis. Visual field testing showed superior visual field defect in the right eye, with improvement after taping the lids. The patient's clinical exam, visual field testing, and photo documentation support a diagnosis of ptosis that is functionally and visually significant. The eyelid procedure is medically necessary to improve vision and function.

Based on the above, the insurer's denial must be overturned. 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 upper eyelid surgery (blepharoplasty) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Head injury
Treatment: Acute inpatient rehabilitation
The insurer denied the acute inpatient rehabilitation.
The health plan's determination is overturned. 

This is a female with history of postural orthostatic tachycardia syndrome (POTS) disease, and long course of Coronavirus disease who sustained a head injury. Subsequently, she was confused and diagnosed with post concussive syndrome. Magnetic resonance imaging (MRI) brain was normal. She has been denied acute level inpatient rehabilitation.

Inpatient rehabilitation facility is medically necessary for this patient as it offers the best opportunity for functional and cognitive improvement. It is the standard of care for this patient. Physical therapy (PT)/occupational therapy (OT)/speech therapy (ST) as well as nursing and physician care are required.

The patient is appropriate for acute inpatient rehabilitation. She has sustained a mild brain injury, concussion, and post concussive syndrome. Her functional level is minimal assist for bed mobility, transfers, and ambulation. She has needs for physical therapy, occupational therapy, and speech therapy, and can tolerate 3 hours of therapy daily. She has labile blood pressure from POTS and a long Coronavirus disease exposure. She has anxiety for which she is medicated. She is at risk for deep vein thrombosis due to immobility. This patient should be monitored by nursing and a physician.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: mobility issues
Treatment:  Consumer Directed Personal Care Assistance (CDPAS): 2 x 12 Split Shift, 168 Hours per Week / Continuous Care
The insurer denied Consumer Directed Personal Care Assistance (CDPAS): 2 x 12 Split Shift, 168 Hours per Week / Continuous Care
The health plan's determination is upheld.

This is a case review for a female with medical history notable for dementia, incontinence, and mobility issues. The patient and her care team requested Consumer Directed Personal Care Assistance (CDPAS): 2 x 12 Split Shift, 168 Hours per Week / Continuous Care. 

The requested Consumer Directed Personal Care Assistance (CDPAS): 2 x 12 Split Shift, 168 Hours per Week / Continuous Care has not been clearly demonstrated to be medically necessary for this patient.
The patient requires personal care assistance due to advanced dementia with behavioral disturbance combined with mobility issues and incontinence. As outlined in the notes, she requires assistance with most activities of daily living. The patient does receive sufficient hours now to cover most of the daytime hours and to meet her needs during the day. The night time care logs that were provided demonstrate only occasional waking up and wandering behaviors, but no need for personal care assistance. There were no letters of medical necessity provided which argued for medical necessity for split shift care. Split shift services are reserved for patients who require frequent personal care assistance overnight, and cannot be approved for safety monitoring and supervision. Because the documentation does not clearly define personal care needs which would be of such frequency to require 24-hour continuous split shift care, the requested hours are not medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy 0.25 milligrams per 0.5 milliliter subcutaneous SOAJ (solution prefilled syringe)
The insurer denied: Wegovy 0.25 milligrams per 0.5 milliliter subcutaneous SOAJ (solution prefilled syringe).
The denial is upheld.

This is an adult female diagnosed with Obesity. This request is for Wegovy. As per letter, she has obesity and pre-diabetes. She has been unsuccessful in losing weight despite changing lifestyle factors including diet and exercise. 
Last year her weight was 150 pounds; BMI (body mass index) was 25.8. 
Five months ago, her weight was 182 pounds; BMI (body mass index) was 31.3. 
Five months ago, her A1C was 5.6 % (percent).

The request is not medically necessary. 

Semaglutide is a GLP1R (glucagon-like peptide-1 receptor) agonist [1] that is FDA (Food Drug Administration) approved in the treatment of type II diabetes and obesity [2-4]. Recent studies 
published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity [5-7]. This medication is now available for the treatment of obesity in the form of Wegovy. The standard of care based on multiple societal guidelines [8-13] requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI (body mass index) of 30 or greater or a BMI (body mass index) of 27 or greater with comorbidities such as hypertension, and hyperlipidemia. The patient has a BMI (body mass index) of 31.3. There is no documentation of participation in lifestyle modifications. The request does not meet the standard of care and is, therefore not medically necessary.