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

Diagnosis: Cellulitis.
Treatment: Hospital admission.

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

This is the case of a female with a history of von Willebrand's disease, who presented to the emergency room (ER) for evaluation of left ankle swelling.  Six days prior she noticed small red nodules on bilateral shins.  The lesions began as multiple pruritic bumps, thought to be insect bites, but erythema nodosum (a noninfectious immune mediated inflammatory disorder) was considered in the differential diagnosis. 

Several clinical features in the patient's history indicate that there was no emergent need for intravenous (IV) antibiotic therapy:  1) Vital signs were normal, 2) No Fever, chills, 3) No pain on weight bearing or ambulation when standing, 4) No decreased range of motion, 5) There was mild swilling and warmth over the left lateral ankle (above the malleolus), but this may have been one of the erythema nodosa lesions.  This area was not raised, no crepitus, bullae or red streaking lines, no point tenderness. NOTE there appears to be an error in the documentation on page 13, in the Pediatric History and Physical, where the band of erythema is written as extending to the femoral head, but more likely refers to the lateral tibial tuberosity, and 6) Lab parameters were within normal limits, except for mild neutrophilia 74% (percent) and mild elevation of c-reactive protein (CRP) 1.65.

There is no documentation of medical decision-making that provides adequate clinical justification for admission to inpatient level of care.  The diagnosis was cellulitis with the portal of entry being the skin.  She did not fulfill systemic inflammatory response syndrome (SIRS) criteria and did not look sick or toxic.  The evidence for lack of need for parenteral therapy is detailed in the skin and soft tissue infection (SSTI) review articles/guidelines referenced.  Specifically, the UCSF (University of California San Francisco) guideline (3) states oral antibiotic therapy for management of non-purulent SSTI.

The patient could have been discharged from observation with an ambulatory plan of care.  Clindamycin could have been administered safely as an outpatient by the oral route following an initial parenteral dose received in the ER. Incidentally, vancomycin was unnecessary.

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

The hospital admission was not medically necessary.

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

Diagnosis: Significantly impaired memory and cognition. 
Treatment: Temporary Personal Care Assistance 10 Hours Per Week in Lieu of Social Day Care. 

The insurer denied the Temporary Personal Care Assistance 10 Hours Per Week in Lieu of Social Day Care. 
The denial is upheld. 

The patient is a male has multiple chronic medical conditions. Denial of temporary personal care assistance 10 hours per week in lieu of social day care is being appealed. The patient has been approved for PCA (personal care aide) 56 hours per week. 

UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, managing finances, and shopping; extensive assistance with managing medications, phone use, transportation, bathing, personal hygiene, dressing, walking, locomotion, and toileting; limited assistance with bed mobility; and independent with eating. He has frequent urinary incontinence. 

An appeal letter from the patient's provider notes the patient has multiple medication conditions and is on multiple medications. Notes he requires supervision with medications and meals. Notes the patient has significantly impaired memory and cognition, which is declining. Notes the patient requires more assistance with ADLs (activities of daily living). 

No, the requested health service is not 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 temporary personal care assistance 10 hours per week in lieu of social day care is being appealed. The patient has been approved for PCA (personal care aide) 56 hours per week. 

This patient has multiple chronic medical conditions. UAS (Uniform Assessment System) evaluation completed shows the patient requires extensive to maximal assistance with ADLs (activities of daily living), the exception of bed mobility and eating. He has frequent urinary incontinence. The appeal letter from his provider notes the patient needs assistance with ADLs (activities of daily living) and has declining cognition and needs supervision with medications and meals. Personal care services are not indicated for supervision or when no services are being provided. The approved PCA (personal care aide) 56 hours per week is adequate to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed temporary PCA (personal care assistance) 10 hours per week in lieu of social day care is not medically necessary. 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Oligodontia. 
Treatment: D6010 Implant placement to tooth 14, tooth 15, tooth 18, tooth 19, tooth 30, tooth 31, and tooth 5. 

The insurer denied coverage for D6010 implant placement to tooth 14, tooth 15, tooth 18, tooth 19, tooth 30, tooth 31, and tooth 5. 

The denial is upheld. 

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist has recommended endosteal implants in areas as enumerated above.  The dentist is requesting implants over removable partial dentures presumably due to patients reported dysphagia and nausea. 

Upon review of the objective documentation which primarily consists of the
panoramic radiograph, the patient exhibits oligodontia in the maxilla and mandible. As 
regards endosteal implant placement, although implants are an acceptable treatment to
restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants.  Alternative appropriate treatment would include conventional removable dentures. Further the documentation provided does not support, justify, or substantiate the requested treatment.  Therefore, as removable dentures (full and partial removable) remain. a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary. 

The health care plan acted reasonably and with sound medical judgement and in
the best interest of the patient. D6010 implant placement on teeth:  #5 #14, #15, #18, #19, #30 and #31 is not considered medically necessary for this patient. 

Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures, Therefore, as other acceptable alternative treatments are appropriate, and the documentation provide does not support the recommended treatment. this renders the endosteal implants and associated services not medically necessary. 

The insurer's denial of coverage for D6010 implant placement to tooth 14, tooth 15, tooth 18, tooth 19, tooth 30, tooth 31, and tooth #5 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anemia. 
Treatment: Inpatient admission. 

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

The patient is a male with metastatic rectal cancer and multiple other problems (VTE [venous thromboembolism], dementia, seizure). He was sent from a nursing home for low Hgb (hemoglobin) of 4.8 g/dl (grams per deciliter) with elevated LFTs (liver function tests). 

The patient's EKG (electrocardiogram) and CXR (chest x-ray) were unremarkable. He was given 2 units packed red blood cells. A CT (computed tomography) scan showed worsening cancer since prior imaging. He was admitted to the hospital. A colonoscopy confirmed the source of bleeding. His CT (computed tomography) scan showed worsening cortical atrophy. He was stabilized and discharged. 

Yes, the Inpatient admission was medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

This patient presented to the ER (emergency room) with severe anemia. His Hgb (hemoglobin) was 4.6 g/dl (grams per deciliter). This would be considered a critical Hgb (hemoglobin). MCG (Milliman care guidelines)/Interqual do support acute level care for an individual presenting to the hospital with a critical Hgb (hemoglobin) on blood thinners.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status Post Fall
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient was seen in the emergency room for a fall.  There was a new diagnosis of a sacral fracture. She had a previous medical history of compression fractures.  She was being treated for chronic pain for this and already had a outpatient MRI (magnetic resonance imaging) scan ordered.  Pain was controlled by medicines.  There was no instability noted of the fracture or the patient.  The patient was subsequently admitted to the hospital. The previous review denied the hospitalization based on the inability to demonstrate in the medical record reason for need for inpatient care.

This is a female patient that was admitted to the hospital due to a fall.  According to the record provided the patient's heart rate, blood pressure and temperature were all normal.  Her breathing rate and oxygen level were also normal.  Work-up showed a new sacral bone fracture.  It did not show any nerve impingement symptoms or inability to pass urine or walk. There was no neuropathy noted on exam. The appropriate level of care demonstrated follow-up for further imaging.  The patient was observed without any decline in her condition.  Based on the record provided, there was no indication for hospital admission. Therefore, inpatient hospital admission was not medically necessary.

Yes, the health plan did act reasonably with some medical judgment based on the care documented in the records provided to this reviewer.
As stated above, there was no documentation of any element, pain, complication of the fracture or complication of the patient that deemed inpatient care was needed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain, myalgia, sciatica, spinal stenosis and difficulty walking
Treatment: Personal Care Aide Level II, 84 Hours/Week, 12 Hours x 7 Days, Pre-service
The insurer denied the Personal Care Aide Level II, 84 Hours/Week, 12 Hours x 7 Days, Pre-service.
The denial is upheld.

The patient is a female with medical conditions including low back pain, myalgia, sciatica, spinal stenosis and difficulty walking. She lives alone. Denial of PCA (personal care aide) 84 hours/week, 12 hours x (times) 7 days is being appealed. She has been approved for 42 hours per week.

The most recent assessment shows that the patient needs assistance with bathing, personal hygiene, dressing, toileting and managing medications. She needs little assistance to get up from chair to walk. She can eat if food is set up. She needs a lot of assistance with meal preparation, shopping, and housework. She has a history of a recent fall.

A letter from the patient's doctor notes the patient has difficulty standing and walking. She ambulates with a rolling walker and cane. She has fallen several times.

A letter from another doctor notes the patient has major neurocognitive disorder and depressive disorder. She has hallucinations and delusions. Notes her functioning is impaired by physical debility. States she is at imminent risk of burning down her apartment in attempting to cook, major fall, or exacerbation of depressive symptoms.

No, the Personal Care Aide Level II, 84 Hours/Week, 12 Hours x 7 Days is not medically necessary.

Personal Care 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 PCA (personal care aide) 84 hours per week, 12 hours x 7 days, is being appealed. She has been approved for 42 hours per week. The health plan denied the additional hours, stating that the benefits do not cover constant generally safety supervision or companionship.

The patient has several chronic conditions. She lives alone. Evaluation shows the patient needs assistance with meal preparation, shopping, housework, bathing, personal hygiene, dressing, toileting, managing medications. She needs little assistance to get up from chair to walk. Appeal letters note there is a decline in the patient's physical functioning and has fallen. Notes that she has major neurocognitive disorder depressive disorder and at risk if left alone. PCA (personal care aide) services are not indicated for supervision or when no tasks are being performed. The approved 42 hours per week is sufficient to meet the patient's needs for assistance with ADLs/IADLs (activities of daily living/instrumental activities of daily living). The proposed increase in personal care aide to a total 84 per week is not medically necessary to meet this patient's needs for assistance with ADLs and IADLs.

Yes, the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral arterial disease
Treatment: Abdominal Arteries CT Angiography, Pre-service
The insurer denied the Abdominal Arteries CT Angiography, Pre-service.
The denial is upheld.

The patient is a male with multiple medical problems including morbid obesity, sleep apnea, cardiac disease, diabetes, diabetic neuropathy, spinal disease. The patient has moderate occlusive disease based on ABI (Ankle Brachial Index). The patient has no evidence of critical limb ischemia.

No, the Abdominal Arteries CT (computed tomography) Angiography is not medically necessary.

The patient is a morbidly obese male with history of diabetes, hypertension, hyperlipidemia, COPD (chronic obstructive pulmonary disease) with sleep apnea, cardiomyopathy, lumbar/cervical disc disease and peripheral arterial disease. The patient has intermittent moderate pain and muscle spasm of the left shoulder. The patient has lower back pain. The patient has bilateral leg weakness and tiredness when walking. The patient has shortness of breath, as well. The patient has stopped smoking.

Arterial Doppler study duplex scan shows ABI (Ankle Brachial Index) of .54 on the right and 0.52 on the left. There is occlusion of the left common iliac artery, as well as near occlusive plaque involving the right superficial femoral artery.

The patient does not meet the medical necessity criteria for requested procedures since the patient has no evidence of critical limb ischemia such as rest pain, ulceration or gangrene. The patient has no evidence of disabling claudication that has not responded to conservative therapy and aggressive medical management. The patient is morbidly obese with numerous medical problems including morbid obesity, back pain, spinal stenosis and diabetic neuropathy, which is contributing to his symptoms. ABI (Ankle Brachial Index) is consistent with moderate occlusive disease bilaterally.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 1 diabetes mellitus

Treatment: Apidra

The insurer denied coverage for Apidra.

The denial is overturned. 

This female patient has a history of type 1 diabetes mellitus.

The formulary drug options are likely to cause the claimant an adverse reaction. The patient has tried and failed NovoLog per the provider, and Fiasp is similar to NovoLog molecularly, therefore, the effects of Fiasp would be expected to work in the manner NovoLog did.      

Fiasp has not been tried, however, as it has similar molecular structure as NovoLog, it would be expected that the patient would respond to Fiasp as she did with NovoLog-which was uncontrolled glucose levels. So, Fiasp would not be reasonable to trial in this claimant.     

The patient has responded well to Apidra. She has tried and failed NovoLog. In addition, this request is for continuity of care with a drug for a patient who has responded well, without adverse events and is successfully controlled.

Based on the medical facts from the available records, claim documentation, and any additional information obtained from the treating provider(s) from the Endocrinology, Diabetes, & Metabolism/Internal Medicine, the requested drug is likely to produce a more clinically beneficial outcome.

The current medical literature supports coverage of the requested drug as an alternative if the patient has tried and failed Fiasp or NovoLog.

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The carrier's denial of coverage for Apidra is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Stelara 90mg/ml SC SOSY.
The insurer denied the Stelara 90mg/ml SC SOSY.
The denial is overturned.

The patient is a man with psoriasis for whom Stelara 90mg (milligrams) injections are requested. The member is HIV (human immunodeficiency virus) positive and cannot use cyclosporine or methotrexate due to that. There is a drug interaction with cyclosporine and Biktarvy, and methotrexate cannot be used in HIV (human immunodeficiency virus) patients. He has tried and failed topical therapies. He has elbows, knees, trunk, and soles affected.

Yes, the requested Stelara is medically necessary.
The patient has psoriasis that has failed topical steroid and vitamin D derivative therapies. He has a history of latent TB (tuberculosis), hepatitis B infection, and HIV (human immunodeficiency virus) on Biktarvy. There is a drug interaction with cyclosporine and Biktarvy, and methotrexate cannot be used in HIV (human immunodeficiency virus) patients. Due to the location of the psoriasis on multiple body areas, including the soles, phototherapy is not a reasonable option (as the soles cannot be treated while the other body parts are treated in a standing UV [ultraviolet] light box, which is the standard in the industry).

Therefore, given the above, the requested Stelara is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The patient has severe psoriasis for which systemic therapy is indicated. He is not a candidate for phototherapy because of the location of psoriasis on the soles, which cannot be reached by phototherapy. In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin is not the most appropriate first line treatment because their long term safety and efficacy are inferior to biologic therapies. Also, there is a drug interaction with cyclosporine and Biktarvy, and methotrexate cannot be used in HIV (human immunodeficiency virus) patients.

Biologics show superior results to conventional systemic therapies (70% improvement versus 40% improvement) for the treatment of patients with moderate to severe psoriasis, as measured by decrease in simple-measure for assessing psoriasis activity (S-MAPA) (physician global assessment [PGA] multiplied by body surface area) at week 24. These results were observed despite the fact that patients on biologics had a greater baseline severity and had a greater number of previous treatments.

Based on the above data, Stelara is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

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

The patient has a past medical history (PMH) of hypothyroidism, vasovagal episodes, and panic attacks who was admitted after being found unresponsive at the bottom of a flight of stairs. Vital signs were initially notable for a blood pressure (BP) in the 60s/50s, triage BP of 72/40, temperature (T) 94.2 degrees Fahrenheit, respirations (R) 29, and oxygen (O2) 95% on 15 liters (L) nonrebreather mask (NRB). The physical exam was notable for lethargy, lacerations on the arms, scalp, and left forehead. Lab work was notable for a troponin of 0.2958, lactate 2.38, white blood cell count (WBC) 15.6.. A computed tomography (CT) scan of the head showed no acute abnormality, a CT scan of the chest showed right lower lobe (RLL) densities, a CT scan of the abdomen/pelvis showed no acute pathology, a transthoracic echocardiogram (TTE) showed a normal ejection fraction (EF). The patient was diagnosed with syncope versus seizures versus arrhythmia and was treated with intravenous fluids (IVF), telemetry, expert consultations, and a significant clinical work-up. The electroencephalogram (EEG) showed spikes and rhythmic bursts and the patient was started on Keppra. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The inpatient stay was medically necessary at an acute inpatient level of care.
This patient presented to the Emergency Department after an episode of syncope, likely a fall, new altered mental status, and was started on anti-seizure medications. He required an inpatient level of care as the San Francisco Syncope Rule score was not in the low-risk category, indicating that the patient had an increased risk of cardiac death and was high risk for a serious outcome, especially given the patient's positive troponin, which is suggestive of cardiac ischemia, severe hypotension, and new altered mental status. It is standard of care to admit suspected cardiac syncope to a monitored bed. He had an abnormal EEG, for which neurology started the patient on Keppra, indicating another potentially serious cause of his altered mental status and fall. It would have not been medically appropriate to place this patient in a level of care lower than inpatient given the need for this close monitoring during the work-up and this patient could not have been safely treated at a lower level of care.