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

Diagnosis: Multiple Sclerosis
Treatment: Consumer Directed Personal Assistance Services
The insurer denied Consumer Directed Personal Assistance Services - 24 Hours per Day, 7 Days per Week (Split-Shift): Total of 168 hours per week. The health plan's determination is overturned. 

The patient is a female with past medical history of multiple sclerosis, restless leg syndrome, urinary incontinence, osteoarthritis, hearing loss, legal blindness secondary to glaucoma and macular degeneration, hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), anxiety, history of colon cancer, wheelchair status, and bedbound status who had a fall with a left hip fracture. Recently, the patient was admitted to the hospital with respiratory distress and urinary tract infection. There was a request to increase Consumer Directed Personal Assistance Services (CDPAS) and the patient underwent a telephonic assessment tool assessing the patient at total assistance with stairs and transportation while maximum assistance with tasks of meal preparation, ordinary housework, managing finances, shopping, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating. The patient was assessed at extensive assistance with tasks of managing medication and phone use. 

Consumer Directed Personal Assistance Services - 24 Hours per Day, 7 Days per Week (Split-Shift): Total of 168 hours per week medically necessary for this patient.
There is documented progressive chronic medical conditions including multiple sclerosis and osteoarthritis. The patient is documented to be legally blind. The patient is wheelchair and bedbound. The telephonic health assessment stated the patient required at least extensive assistance with all ADLs/IADLs. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The current CDPAS hours, and/or medical supplies, and/or adaptive equipment are not sufficient to meet the patient's ADL/IADL care needs. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Overnight logs provided in report indicate the patient requires assistance with ADLs at least every 2-1/2 hours which would not allow a CDPAS 5 hours of uninterrupted sleep. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAS services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: repeated falls

Treatment: continued residential long term care.

The insurer is denied coverage for continued residential long term care.

The denial is upheld. 

This male patient has a history of type 2 diabetes mellitus, chronic atrial fibrillation, unspecified repeated falls, alcohol abuse, gastro-esophageal reflux disease, essential (primary) hypertension, chronic embolism and thrombosis of other specified veins.  The patient has been a resident where he has received nursing services as well rehabilitation.

Continued residential long term care is not considered medically necessary for this patient.  The patient's medical conditions are stable.  The patient is fully alert and oriented x 3 and is independent with activities of daily living (ADLs) at this time.  Also, patient's pain is well-controlled at this time.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the continued residential long term care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia, pubic and acetabular fracture after a fall. 

Treatment: Personal Care Assistant (PCA) Services of 7 days times 24 hours (continuous service) per week. 

The insurer denied coverage for PCA Services of 7 days times 24 hours (continuous service) per week. 

The denial is overturned. 

This is a female patient with a past medical history of Parkinson's disease, dementia, thrombocytopenia, hypertension, high cholesterol, diabetes mellitus and a recent pubic and acetabular fracture after a fall.  The patient is in hospice care.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY) report, the patient and her daughter were present on the call.  This UAS-NY was conducted as a post-hospital assessment.  The patient was admitted for a fracture of unspecified parts of the lumbosacral spine and pelvis.  She was discharged to Sub-acute rehabilitation.  The patient was then admitted to hospice care.  Her functional capacity has declined since the recent fall. 

The patient's needs are: 

-	The patient is bed-bound. 
-	Total dependence for meal preparation, ordinary housework, managing finances, managing medications, phone use, stairs, shopping, transportation, bathing, personal hygiene, dressing her upper and lower body, bed mobility and toilet use;
-	Maximal assistance for eating;
-	Cognition: There is severe impairment. 
-	Continence: There is urinary and bowel incontinence. Changed in bed. 

An increase in personal care assistant (PCA) services from 24-hour live-in to 7 days times 24 hours (continuous service) per week is being requested. 

At issue is the medical necessity of personal care assistant (PCA) services of 7 days times 24 hours (continuous service) per week.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The services are medically necessary as requested.

The patient is bed-bound, totally dependent and incontinent and needs changing in bed.  There are no scheduled informal care givers.  Nighttime Needs Log shows she needed turning and positioning (T&P) regularly and changing at least once and often more frequently at night. 

The provision of diapers and Durable Medical Equipment (DME) such as the hospital bed she has is not by itself adequate for prevention of pressure sores.  As noted in "Preventing pressure ulcers" changing diapers regularly and positioning are also necessary. 

The patient has repeated unscheduled nighttime personal care needs that support 24-hour care (continuous), as the patient should not be left up to 5 hours with soiled diapers/bed).  
The insurer's denial of coverage for the requested Personal Care Assistant (PCA) Services of 7 days times 24 hours (continuous service) per week is overturned.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders/Abcess
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male who presented to the hospital with a right inner gluteal abscess. The patient had previously had an incision and drainage (I&D) several times. There was a 3x7cm area of induration on exam. His white blood cell count (WBC) was 13.3. Covid test was positive. A computed tomography (CT) scan demonstrated a perirectal abscess. The patient was made nothing by mouth (NPO). The patient was treated with Zosyn. The surgery team was consulted, and the patient was setup for surgery in the operating room. The patient underwent abscess drainage and seton placement. The patient left against medical advice (AMA) not long after surgery.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity should be upheld, in whole.

The inpatient stay was not medically necessary. While the patient appears to have had a rectal abscess, the patient does not appear to have utilized hospital services at the inpatient level of care. The patient was identified to have a rectal abscess which was drained surgically and the patient left shortly after. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Class II malocclusion.
Treatment: Braces/monthly visits.
The insurer denied the braces/monthly visits. 
The health plan's determination is upheld. 

The patient in question is a female. She has a Class II malocclusion with minor maxillary spacing and minor mandibular crowding. She has been treatment planned for orthodontics to treat her crowding. 

Braces and monthly visits are not medically necessary.
The patient has spacing in the maxilla but she also has appropriate overjet and overbite and there is no functional deficit that would require orthodontic correction to improve. The patient does have some spacing, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 2 millimeter (mm) overjet but this amount of overjet does not negatively affect oral health related quality of life. If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Sleep apnea.
Treatment: Continued rental of Bi-Level Positive Airway Pressure Device With Heated Humidifier (procedure codes E0470 and E0562).
The insurer denied the Continued rental of Bi-Level Positive Airway Pressure Device With Heated Humidifier (procedure codes E0470 and E0562).
The denial is partially overturned.

The patient is a male with Duchenne Muscular Dystrophy with sleep apnea and respiratory failure associated with his neuromuscular condition. His AHI (apnea hypopnea index) is 29. He does not show CO2 (carbon dioxide) retention.  He has been prescribed BiPAP (bi-level positive airway pressure) after Titration suggested better efficacy than CPAP (continuous positive airway pressure). On receipt of the machine in February, the patient reported problems of mask fit.

In review of the patient's compliance data, there is progression in use, but not achievement of 4 hours for 70% of nights at the end of monitoring. When used, the patient does demonstrate improvement in baseline AHI (apnea hypopnea index).

Yes, in part. The Continued rental of Bi-Level Positive Airway Pressure Device With Heated Humidifier (procedure codes E0470 and E0562) is medically necessary, in part.
Given the patient's underlying medical condition with anticipated progression of disease and consequent respiratory insufficiency, a new 90-days trial of the BiPAP (bi-level positive airway pressure) device is medically necessary for this patient.

The plan appropriately followed its policy for continuation of therapy based on compliance, but this patient's medical condition necessitates another trial period in the interest of the patient's health.  A new 90 day trial should be authorized, and the provider encouraged to closely monitor usage by the patient to achieve the greatest potential benefit from the medical device.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines.
Treatment: Formulary exception for Ubrelvy, Pre-service.
The insurer denied the Formulary exception for Ubrelvy, Pre-service.
The denial is upheld. 

The patient has migraine headache disorder. The patient has tried and failed sumatriptan and eletriptan for abortive therapy. The provider is requesting Ubrelvy.  The requested medication was denied coverage, as the patient has not tried all of the preferred agents.

No, the health plan should not cover the Formulary exception for Ubrelvy.
There is no documented reason as to why the patient cannot be treated with the preferred triptan agents for the acute treatment of migraine (almotriptan, rizatriptan, naratriptan, zolmitriptan, Nurtec). All of the preferred agents are FDA (United States Food and Drug Administration)-approved for acute treatment of migraine headaches and are considered first line, standard of care, abortive agents (Thorlund et al.,; Lipton et al.,).

The clinical trial leading to the FDA (United States Food and Drug Administration) approval of Ubrelvy for the acute treatment of migraine (Dodick et al.) tested efficacy against placebo. There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred agents. There is no evidence that the preferred agents are more likely to have adverse effects for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems-Other-Malocclusion
Treatment: Dental/Orthodontic Procedure-Braces and monthly visits X 9
The health plan denied the proposed service as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient in question has a Class II occlusion with 6 millimeter (mm) overjet and a deep overbite. The maxillary and mandibular have very minor crowding. She is treatment planned for orthodontics with elastics to correct her malocclusion. At issue is the medical necessity of the treatment of Braces and monthly visits times (X) 9.

The patient has minimal crowding. Her bite is deep, but there is no indication of damage to the incisors or the palate in the photographs. Her cephalometric radiograph shows that the lower incisors are contacting the maxillary teeth in occlusion, not the palate. There is no indication from the photographs provided that there is severe soft tissue damage (or any soft tissue damage) on this patient. 

There is no medical reason to correct her malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. Although the narrative indicates a posterior crossbite, the supplied photos do not show any crossbites. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 6mm overjet, but this amount of overjet does not affect oral health-related quality of life. (2) If her teeth were aligned it would provide a minor esthetic improvement, but it would not create a medically significant improvement to the patient's health. Orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Full hospital admission

The insurer denied coverage for the full hospital admission.

The denial is upheld.

This is a male patient with a past medical history of ischemic heart disease and proximal left anterior descending artery (LAD) stent, who presented to the Emergency Department (ED) complaining of chest pain, left arm numbness and dizziness.  His symptoms were progressing in intensity and the patient reported that his chest pain was exacerbated with exertion and accompanied by dyspnea.  Upon presentation, his pulse was 87 and blood pressure (BP) was 118/78.  Physical examination was within normal limits.  Electrocardiogram (EKG) revealed normal sinus rhythm.  Serum troponin was not elevated.  Echocardiography revealed a preserved left ventricular ejection fraction (LVEF) (60-65%) without wall motion abnormalities.  The patient was treated with intravenous (IV) nitroglycerin and given his continuing chest pain, he was admitted to the Coronary Care Unit (CCU) and scheduled for cardiac catheterization.  While in the CCU, he developed hypotension.  Nitrates were discontinued.  Fluids and pressors were required to treat hypotension.  Ultimately, cardiac catheterization was performed and revealed a patent LAD stent and no significant obstructive disease and the patient was discharged.

Acute inpatient admission was not necessary for this patient.  Although the patient had a history of coronary artery disease, the patient had no abnormalities suggesting acute ischemia on EKG at the time that he reported 10/10 chest pain. Utilizing the HEART [History, EKG, Age, Risk factors, initial Troponin] score he was considered intermediate risk (4 points).  Using the HEART score risk stratification schema, this patient would have an intermediate risk of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation.  These findings are concerning and warrant management and evaluation that includes serial troponin measurement, echocardiography and ischemia work up prior to discharge.  In this case, echocardiogram revealed normal wall motion and serial troponin levels were not elevated.
 
Numerous studies have demonstrated that work up can be performed in an observation unit without the need for hospital admission.  Several investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care.  They found no significant difference in outcome at 30 days between the two groups.  Admission to the hospital to treat an acute cardiac event was not medically necessary.  This patient could have been managed at a lower level of care.

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

The insurer's denial of coverage for the full hospital admission is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pseudoaneurysm of the celiac axis.
Treatment: Inpatient admission.

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

This male was found incidentally to have a 1.9-centimeter (cm) pseudoaneurysm of the celiac axis during workup for possible kidney donation to his niece. Because the aneurysm had a saccular configuration, it was felt to have a high potential for rupture. Endovascular repair was performed under general anesthesia. Two overlapping covered stents were placed from the hepatic artery back to the celiac origin, with planned exclusion of the splenic artery origin. The case was complex and took three hour, 46 minutes. The patient was admitted as an inpatient. His recovery was uneventful, and he was discharged the following day.

The issue under review is the need for inpatient hospital stay. The need for the procedure itself is not under review.

The previous denial was based on Milliman Care Guidelines (MCG), as modified by the patient's plan.  The reason for denial was that the patient did not have "severe problems" during surgery.

Yes, the proposed inpatient admission was medically necessary.

Inpatient stay was medically necessary in this case, for the reasons listed below:
1) The patient underwent endovascular repair of a celiac artery pseudoaneurysm. Treatment of such lesions is inherently complex because of the difficulty of accessing the celiac axis [1-3]. Because of the complexity of the case, it took nearly four hours and required nearly 150 cubic centimeters (cc) of contrast. When endovascular procedures are complex and lengthy, inpatient admission is standard of care (and medically necessary) because of increased risk of complications such as renal failure, stent thrombosis, and access site problems.
2) In this specific case, the splenic artery was intentionally covered. This raises concern for symptomatic splenic infarction or ischemia. Inpatient admission was necessary to monitor for these symptoms.
3) The current procedural terminology (CPT) code for the procedure (CPT 35121) is designated as inpatient-only under Centers for Medicare and Medicaid's (CMS') policy [4]. The inclusion of the procedure on the inpatient-only listing is an acknowledgement of the complexity of the procedure and the risk of complications.

The health plan's previous review failed to take into account the nuances and complexities of the endovascular therapy that was performed in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prostate Cancer.
Treatment: Oncotype DX Prostate Test.

The insurer denied the Oncotype DX Prostate Test.  The denial is upheld.

The patient is a male with prostate cancer. He had the Oncotype DX Prostate Cancer Assay performed. The original biopsy was positive and demonstrated a Gleason 3+3=6 adenocarcinoma in 4 of 13 cores. The clinical stage was T1c (nonpalpable prostate cancer diagnosed by needle biopsy). The PSA (prostate-specific antigen) was <10.

No, the Oncotype DX Prostate Test was not medically necessary.

Per AUA (American Urological Association) Guidelines, "14. Among most low-risk localized prostate cancer patients, tissue based genomic biomarkers have not shown a clear role in the selection of candidates for active surveillance. (Expert Opinion)" (1)

Furthermore, "Guideline Statement 32: Tissue based genomic biomarkers have not shown a clear role in active surveillance for localized prostate cancer and are not necessary for follow up. (Expert Opinion)" (1)

The patient has a low-risk prostate cancer. Therefore, the Oncotype DX Prostate Test was not medically necessary.

NCCN (National Comprehensive Cancer Network) guidelines for prostate cancer (v. 2.) state, "men with low or favorable intermediate-risk disease and life expectancy > 10 years may consider the use of the following tumor-based molecular assays: Decipher, Oncotype Dx Prostate, Prolaris, and ProMark during initial risk stratification. However, there is insufficient comparative effectiveness research to support their clinical utility for better risk stratification of men with prostate cancer." (2)