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

Diagnosis: Hypertension, coronary artery disease, diabetes, osteoarthritis and neuralgia
Treatment: Personal Care Assistance Service for a Total of 34 Hours Per Week
The insurer denied: Personal Care Assistance Service for a Total of 34 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include hypertension, coronary artery disease, diabetes, osteoarthritis and neuralgia. Denial of an increase personal care assistance service for a total of 34 hours per week is being appealed. The health plan approved 15 hours per week. She lives with her son, who assists at nighttime and on weekends. The patient's Uniform Assessment System (UAS) evaluation completed eight months ago shows modified independent cognition and functional status: maximal assistance with shopping and housework; extensive assistance with meal preparation and transportation; limited assistance with managing finances and medications, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting; and independent with bed mobility and eating. She has 
frequent bladder incontinence. No falls in the prior 90 days are noted. A letter from the patient's provider reports the patient has multiple chronic conditions. Osteoarthritis arthritis of the joints and hand numbness due to carpal tunnel affect the ability to 
complete ADLs (activities of daily living) without assistance.

The requested increase in Personal Care Assistance Service for a Total of 34 Hours Per Week is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of an increase personal care assistance service for a total of 34 hours per week is being appealed. This patient has multiple chronic conditions. However, reports show her limitations are due to osteoarthritis. She lives with her son who assists at nighttime and on weekends. Uniform Assessment System (UAS) evaluation completed eight months ago shows she is independent with bed mobility and eating. She requires limited assistance with managing finances and medications, phone use, bathing, personal hygiene, dressing, walking, locomotion, and toileting. The appeal letter recommends an increase in PCA (personal care assistance) hours due to 
osteoarthritis and carpal tunnel affecting her ability to complete ADLs (activities of daily living). The patient requires assistance with all ADLs (activities of daily living), except bed mobility and 
eating. She has informal support only at nighttime. Based on the patient's functional limitations, the requested increase personal care assistance 34 hours is medically necessary for assistance 
with ADLs (activities of daily living).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a medical history including morbid obesity, sleep apnea, and hypothyroidism who presented with right sided abdominal pain. The patient had right lower quadrant tenderness and a positive Rovsing's sign on exam. A computed tomography (CT) scan was consistent with acute appendicitis. An ultrasound demonstrated gallbladder distention without stones, thickening or pericholecystic fluid. The patient was admitted to the surgical service. It was felt that surgery would be extremely difficult due to his body habitus. The patient was placed on intravenous (IV) antibiotics and was given a clear liquid diet. The patient was admitted to the surgical service. The patient was rounded on by the surgical team. The patient were no acute events overnight. The pain was well controlled. The patient was tolerating a diet with gas and bowel movements. Mild right sided tenderness was noted on exam. The patient continued on a clear liquid diet with intravenous (IV) antibiotics. Later that day, the attending physician advanced the patient to soft diet. The patient was doing well and was discharged home with a possible interval appendectomy. At issue is the medical necessity of an inpatient stay.
The patient's full hospital admission was medically necessary for this patient who was morbidly obese with acute appendicitis. The patient met the criteria listed in the MCG guidelines for Gastroenterology. This guidelines states that Acute appendicitis with planned nonoperative management or interval appendectomy meets criteria when "Appendectomy not preferred for uncomplicated appendicitis." In the records, the patient was treated with antibiotics with plans for interval appendectomy due to the patient's morbid obesity. Patients with appendicitis are typically admitted to the hospital at an inpatient level of care for intravenous (IV) antibiotics, intravenous (IV) fluids, and for careful monitoring of their abdominal exams. These decisions are determined by the medical team seeing the patient and are the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obstructive jaundice
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is an adult male. He had been seen at an outside hospital three days prior to presentation for jaundice, and he was told that he had cholangitis. He also had a suspension mass in the biliary tract on his abdomen / pelvis computed tomography (CT) scan. The patient was admitted to the hospital. The patient had a verified obstruction on his computed tomography scan. His white blood cell count was 13.6. The bilirubin was 3.8. His level enzymes were elevated. He was started on Augmentin, intravenous fluids, dexamethasone, and pantoprazole. On day #2, the patient was noted to have atrial fibrillation overnight and was seen by cardiology. He underwent endoscopic retrograde cholangiopancreatography (ERCP) that showed multiple gallstones and one short stricture at the origin of the left duct. There was choledocholithiasis that was partially removed with balloon extraction. One stent was placed in the left hepatic and one in the right hepatic duct. Cytology was sent. The patient was put on Eliquis anticoagulation for his hepatic vein thrombosis and atrial fibrillation. He was discharged on day #3.

The requested Inpatient admission was not medically necessary.

The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, or peritoneal signs. The patient did not require identification of etiology or finding or evaluation requiring the patient to not eat or drink for extended period (e.g., more than 24 hours). The patient did not have inability to maintain oral hydration (e.g., needs intravenous fluid 
support) that persisted and did not have suspected toxic megacolon. The patient did not have bacteremia. The patient did not require a procedure that could not have been performed at a 
lower level of care. The patient did not have any complications as a result of the procedure that he underwent (endoscopic retrograde cholangiopancreatography). Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Laparoscopic cholecystectomy
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who presented to the emergency department with complaints of back and abdominal pain of two days duration. She had been seen previously at another facility for similar complaints. Her past medical history is notable for no chronic medical health conditions. Vital signs were normal at the time of presentation. The patient was evaluated with abdominal ultrasound that identified gallstones and a sonographic Murphy sign. Lab data identified a normal white blood cell count of 9.2 thousand and elevated serum transaminases (541/339) with 
elevated bilirubin (1.2). The patient was admitted to the hospital. The surgical history and physical is dated the next day and this documents a normal white blood cell count of 8.7 thousand with normal liver enzymes and bilirubin. Magnetic resonance cholangiopancreatogram (MRCP) was performed showed a hyperemic gallbladder without common bile duct stones. The common duct was 7 millimeters in diameter. Laparoscopic cholecystectomy was recommended and planned. The patient was started on intravenous antibiotics. Surgery was performed on day #3. The operative notes describe laparoscopic cholecystectomy that was performed without complication. 
On the day following surgery, the diet was advanced, and pain was controlled with oral medications. On post operative day #1, vital signs were normal. The patient remained clinically stable and was discharged from the inpatient setting. 

The inpatient care was not medically necessary in this case.

The care provided could have been rendered with a lower level of care. A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of 
intravenous fluid, surgical consultation, and performance of cholecystectomy. The indication for cholecystectomy was established on day #2. There were no peri-procedure complications or other clinical issues. In this case, the patient presented with symptoms related to cholelithiasis/cholecystitis. The evaluation and the indication for cholecystectomy was established on day #2. While the initial liver enzymes were elevated, there was no common duct stone as identified by magnetic resonance cholangiopancreatogram. The cholecystectomy procedure was performed on day #3 without complication. The operative report does not detail findings of acute cholecystitis or other surgical pathology and no cholangiogram was performed. The patient was stable for discharge from the hospital on the first post-surgical day. The patient responded promptly and without complication to the prescribed therapy (cholecystectomy). The above noted conditions did not exist to warrant an inpatient level of care. The patient's presenting condition at the hospital and clinical course did not justify an inpatient level of care. The care provided could have appropriately been rendered with a lower level of care. Therefore, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Covid.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This is a case of a female admitted for diagnosis of acute respiratory syndrome coronavirus 2. The patient presented with a positive COVID (coronavirus) test two days prior to admission. She had weakness, and palpitations. Physical exam showed no distress or altered mental status. Temperature was 98.7 F (degrees Fahrenheit) with O2 (oxygen) saturation 98% (percent) on room air. She was hemodynamically stable. White blood cell count was 8.2 with hemoglobin 12.1. Following the day of admission, she was noted to be asymptomatic. Chest x-ray showed clear lungs. Troponin was negative. Echocardiogram showed ejection fraction 60 to 65%. She was treated with remdesivir and then able to be discharged. 

The inpatient hospital admission was not medically necessary. The patient in this case was admitted for COVID but did not have a complication such as acute respiratory distress syndrome. She did not need mechanical ventilation or supplemental oxygen as her O2 saturation was 98% on room air. She did not have arrhythmia, acute cardiac injury, acute kidney injury, thromboembolic event or shock. The day following admission she was noted to be asymptomatic. She had an echocardiogram which showed preserved ejection fraction. There was no hemodynamic instability or hypoxia. 
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.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hyperkalemia.
Treatment:  Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is overturned.

The patient is a male with a history of diabetes with neuropathy, chronic kidney disease stage III, hypertension, opioid disorder, who presented to the emergency department (ED) for findings of hyperkalemia on outpatient labs. The review of systems was positive for missing diuretics and noted bilateral pitting edema.
The patient was admitted for hyperkalemia and was treated with intravenous (IV) dextrose and insulin, Veltassa, Lasix and calcium gluconate. The etiology of hyperkalemia was due to missed diuretics. The initial electrocardiogram (EKG) showed peaked T waves. At issue is the medical necessity of an inpatient level of care.
The requested health service/treatment of inpatient hospital admission was medically necessary.
Based on the documentation, the patient was admitted for severe hyperkalemia in the setting of underlying renal disease. Inpatient level of care was necessary for rapid correction of potassium and monitoring of renal function.
In this case, the patient was admitted for severe hyperkalemia in a setting of a declining glomerular filtration rate and worsened renal insufficiency. Therefore, the patient was at risk for long term worsened outcomes. This warranted urgent treatment to prevent the deleterious effects of hyperkalemia. The mortality risk is progressively increased in patients with hyperkalemia who also have underlying chronic kidney disease, diabetes, and congestive heart failure. The in-hospital mortality rate was 18 percent (%) as compared to 4% for patients with normal potassium levels.
Generally speaking, patients with hyperkalemia can be easily treated and transitioned to outpatient settings. However, hyperkalemia is more complicated to treat in patients with advanced chronic kidney disease (CKD) because the kidney is the major route of potassium excretion. Not only is potassium excretion reduced, but underlying heart failure, diabetes and the use of angiotensin converting enzyme (ACE)- inhibitors such as lisinopril complicate the management even further. As such, significant treatment strategies are necessary to overcome the pathophysiologic effects of the etiologies. The patient's treatment plan necessitated the use of multiple pharmacologic therapies to promote excretion of potassium. The patient's potassium levels were severe enough to cause cardiac abnormalities and warranted inpatient management for rapid correction.
Given the patient's comorbidities, CKD, severe hyperkalemia, and the need for urgent treatment interventions, it was reasonable and medically necessary to admit patient to the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abnormal Post-Menopausal Bleeding.
Treatment:  Gene test - procedure codes: 81292, 81294, 81295, 81297,81298, 81300, 81317 and 81319.

The insurer denied coverage for gene test - procedure codes: 81292, 81294, 81295, 81297,81298, 81300, 81317 and 81319.  The denial is upheld.

The insurer has denied coverage for gene test - procedure codes: 81292, 81294, 81295, 81297,81298, 81300, 81317 and 81319. In their Final Adverse Determination letter, the insurer writes that the information they have does not show high-risk personal or familial criteria are met based on genetic counseling records in this case. For this reason, the request is denied as not medically necessary.

The patient is appealing. In an appeal letter it is noted that the provider ordered the COLARIS with MyRisk because the patient was having abnormal postmenopausal bleeding.

According to the submitted information, the patient underwent the COLARIS test. The patient has no personal history of cancer. However, both the patient's mother and maternal aunt were diagnosed with breast cancer.  In addition, the patient's father and paternal grandmother were both diagnosed with colon cancer.

COLARIS is a genetic test that assesses a person's risk of developing hereditary colorectal cancer and a woman's risk of developing hereditary uterine cancer. COLARIS detects disease-causing mutations that are responsible for the majority of Lynch syndrome and MYH-associated polyposis cases. Lynch syndrome, also known as hereditary nonpolyposis colorectal cancer and is the most common of the hereditary colon cancer syndromes (Centers for Disease Control and Prevention, 2023). COLARIS is a test for Lynch syndrome. Knowing the results may help patients and their physicians take steps to prevent cancer before it has a chance to develop.

According to the Centers for Disease Control and Prevention (CDC), genetic testing is available for Lynch syndrome. However, most colorectal cancer is not caused by inherited mutations, so Lynch syndrome testing will not benefit most people with a family health history of colorectal cancer who have not had cancer themselves. Genetic testing will not identify the cause for some hereditary colorectal cancers, because the genes affected in these cancers are not yet known.

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 gene test - procedure codes: 81292, 81294, 81295, 81297,81298, 81300, 81317 and 81319 is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heartburn and dysphagia.
Treatment: Inpatient Hospital Stay.

The insurer denied Inpatient Hospital Stay.  The determination is upheld.

This is a female patient with a history of a prior sleeve gastrectomy and anterior hiatal hernia repair several years prior. She has complaints of worsening heartburn and dysphagia. She was evaluated with an upper endoscopy performed that showed mild sleeve herniation without esophagitis. She is currently treated with Omeprazole for heartburn symptoms. 
Her provider has proposed operative treatment to include laparoscopic repair of the recurrent hiatal hernia. An inpatient level of care has also been requested.
At issue is the medical necessity of pre-elective inpatient admission.
Pre-elective inpatient hospital admission is not medically necessary based on the submitted clinical documentation. This patient has the presurgical diagnosis of gastroesophageal reflux disease (GERD) and a recurrent hiatal hernia in the setting of prior sleeve gastrectomy and prior anterior crural closure. She has comorbid health conditions of morbid obesity, rheumatoid arthritis, diabetes and polycystic ovary syndrome (PCOS).
The records submitted do not establish the medical necessity of inpatient admission as the diagnosis of diagnosis of a paraesophageal hiatal hernia is not confirmed. The upper endoscopy performed by the treating surgeon states that there is mild herniation of the sleeve stomach into the mediastinum. While the diagnosis of a paraesophageal hiatal hernia (rather than a sliding hiatal hernia) is associated with an inpatient designation, in this case the presurgical diagnosis of a paraesophageal type of hiatal hernia is not established. The patient has not yet had this proposed operation so there is no complication of surgery or anesthesia. Her comorbid disease states do not mandate an inpatient level of care.
An inpatient level of care is not medically necessary for this patient as a lower level of care would be anticipated to satisfy the needs of this patient proximate to the planned surgical procedure.
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 attaining 18 points on the HLD index by internal reviewers.

A provider is appealing on behalf of the patient.

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.

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.