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

Diagnosis:  Heart Failure
Treatment:  Personal care services to 24 hours a day 7 days a week.
The health plan denied Personal care services to 24 hours a day 7 days a week.  The health plan's determination is overturned.

This is a patient with a past medical history of moderate aortic stenosis, diastolic heart failure, atrial fibrillation, hypertension, hearing loss, glaucoma, frequent falls and urinary incontinence, who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week to total 84 hours per week.  The patient had been hospitalized 3 times in the 3 months prior to a rehabilitation stay with discharge to home.  The patient is prescribed diuretic therapy to treat diastolic heart failure and anticoagulation with a history of atrial fibrillation.  The patient had an assessment tool done documenting that she was slow and unsteady with ambulation with a walker and needed to use a wheelchair if outside of the home with reliance on someone to push the wheelchair.  The patient was noted to need total assistance with ordinary housework, stairs and maximal assistance with tasks of meal preparation, managing finances, shopping, bathing, dressing lower extremity, walking, locomotion and toilet transfer.  In addition, the tasks of managing medication, phone use, equipment assistance, dressing upper extremity, toilet use, bed mobility and eating were assessed at extensive assistance needed.  There were no prior assessments available for review.  The patient saw her provider, and he recommended that the patient have "a companion at night".  The health plan denied the personal care services 24 hours/day, 7 days/week and the issue under review is whether these services were medically necessary.

The increase in personal care services to 24 hours a day 7 days a week is medically necessary.

According to the assessment, the patient was unsteady and off balance with slow movement and required maximum assistance for walking, however, given her medical condition she would need total assistance.  The patient does not have informal helpers and has unscheduled needs during the night time hours.  The patient is on diuretic therapy to treat underlying diastolic heart failure which would cause her to need increased assistance with bed mobility, toilet use and toilet transfer which all would occur outside of the hours of current PCA service hours (in the overnight hours).
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Liver disease

Treatment: Baraclude 

The insurer denied coverage for Baraclude. The denial is upheld. 

This patient is a male with a history of a liver disease. The letter dated indicated the patient had been followed for liver diseases.  He had been treated for liver disease with Baraclude brand for several years. His prescription insurance denied his brand Baraclude and he started taking Baraclude generic (entecavir).  For the last several weeks, he had been experiencing nausea, lightheadedness, dizziness, and weakness in the arms and legs.  

The insurer denied the coverage and has the plan approved non-formulary marketplace exception (H MS) criteria cover the drug when there is an adverse reaction to the generic drug due to an inactive ingredient.  The patient's use of the drug did not meet the requirement.  Examples of formulary alternatives were: Baraclude solution, Entecavir tablet, Epivir solution, and Lamivudine tablet/solution.

The formulary drug is not likely to cause the patient an adverse reaction. There is no indication that the formulary drug has been ineffective based on the patient's clinical history. There is no evidence the requested drug would be more effective than the formulary drug.

Generic Entecavir is widely used instead of Baraclude and is very well tolerated and equally effective.  The mild intolerance from the medication noted in the patient is unlikely to persist.  An alternative generic formulation can also be used instead.  

Based on the above, the denial of Formulary Exception for Baraclude is upheld.
Appeal type: Medical necessity
Decision: Overturned

Skin Disorders
Pharmacy/Prescription Drugs

Diagnosis: Psoriasis. Treatment: Otezla. The insurer denied Otezla. The health plan's decision is overturned. 

The patient is a female with psoriasis, treated with topicals and Otezla samples. The provider is requesting continuation of Otezla. 

Otezla is medically necessary for this patient.
The health plan requires a trial and failure to methotrexate, cyclosporine or acitretin. This patient is a female of childbearing potential which makes all of these therapies relatively contraindicated. No proton pump inhibitor was listed for her medications, but this is contraindicated with methotrexate. Cyclosporine and acitretin are also not used for plaque psoriasis. Cyclosporine is only used as a "bridge" therapy between agents and for very severe flares of psoriasis. It can only be used for up to one year. Soriatane is primarily indicated for palmo-plantar and pustular psoriasis and is limited by its far inferior efficacy in psoriasis.
Therefore, as methotrexate, cyclosporine and acitretin are contraindicated/not appropriate, Otezla is medically necessary.
A recent review concluded that Otezla is one of the most effective therapies for psoriasis. Otezla (apremilast) is a phosphodiesterase inhibitor, and therefore its mechanism of action is different from injectable biologics. Apremilast works intracellularly to modulate pro- and anti-inflammatory mediators.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems
Dental/Orthodontic Procedure

Diagnosis: Impacted Tooth
Treatment: Braces. The insurer denied braces. The health plan's determination is overturned. 

Braces are medically necessary for this patient. Approximately 10% of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. The panoramic radiograph for this patient appears to indicate a high chance that tooth 29 will damage the roots of teeth 28 and/or 30 without treatment. If left untreated, the damage that can occur to the patient's teeth will be more time consuming and difficult to correct than the patient's existing orthodontic problem. For this reason, braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System
Inpatient Hospital

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

The patient is a female with a history of anxiety, bipolar disorder and post-traumatic stress disorder (PTSD) who presented to the emergency department (ED) with a complaint of tingling in both hands and left lip. Symptoms began while she was at the social service building. She felt lightheaded and zoned out. She also reported right sided chest pain for 3 days. She reported intermittent compliance with her antipsychotics. 

The Inpatient Hospital Admission was not medically necessary for this patient. This patient was hemodynamically stable with a normal physical examination and normal imaging studies. Mild leukocytosis and temperature of 100.4 F without any other signs or symptoms of infection are very non-specific. Appropriately, the patient did not require intravenous antibiotics. There were no clinical needs that would have required an inpatient stay. Further monitoring and testing could have been performed at a lower level of care with subsequent outpatient follow-up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gluteal Abscess
Issue under review: Inpatient admission

Determination:
The health plan denied Inpatient admission. The health plan's denial is upheld.

The patient is an adult male. His medical history included hypertension, diabetes mellitus, dyslipidemia, nephrolithiasis, erectile dysfunction, eczema, and tobacco use. His surgical history included cataract extraction. The patient presented to an emergency room with a two-week history of left gluteal abscess. 

The patient's vitals were temperature 97.7, pulse 92, blood pressure 107/55, respirations 18, and oxygenation 100%. Physical examination demonstrated perianal abscess in association with an anal fistula and surrounding cellulitis. Serum laboratories demonstrated leukocytosis to 20.4. Computed tomography demonstrated a 6.8-cm left perianal abscess in association with an anal fistula and surrounding cellulitis. 

The patient was admitted at an acute inpatient level of care with a diagnosis of perianal abscess in association with an anal fistula and surrounding cellulitis. He was made nil per os [NPO], and provided with intravenous fluids, antibiotics, analgesics, and anti-emetics. The patient underwent exam-under-anesthesia and incision-and-drainage. Surgery and recovery were uncomplicated. 

On the final date of service under review, having returned to his baseline health and function, the patient was discharged home in good and stable condition with prescriptions for oral antibiotics and stool softeners, wound-care instructions, and home nursing services. 

Guidelines from the Infectious Diseases Society of America are clear -- for patients with abscesses, treatment includes the following: incision and drainage with associated wound care, abscess culture, and a short-course of antibiotics [STEVENS ET AL.]. All of these interventions may be provided at lower level of care. In fact, according to the Infectious Diseases Society of America, "Outpatient therapy is recommended for patients who do not have SIRS, altered mental status, or hemodynamic instability." As this patient did not have SIRS (Systemic Inflammatory Response Syndrome), altered mental status, or hemodynamic instability, he did not require hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastrointestinal (GI) bleed

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services.  The denial is reversed. 

This case involves a female patient who presented to the Emergency Department (ED) via the Emergency Medical Services (EMS).  The patient had complaints of generalized body aches as well as weakness and dizziness.  The patient had a history of stage IV breast cancer with metastasis to the bone as well as gastritis, hyperlipidemia, deep vein thrombosis and hypertension. The patient was referred to the ED from her primary care physician office for concern of a gastrointestinal (GI) bleed.  The patient stated that for several days prior she had a dark stool.  The patient complained of mild bilateral lower abdominal pain and had a hemoglobin level of 7.9 at her last check.  The patient also reported one episode of vomiting 3 days prior to this ED presentation.  On physical examination, the patient was in no acute distress; the patient had normal breath sounds, and the vital signs showed oxygen saturation of 95% with a blood pressure of 94/50.

The patient's pulse was 98 bpm, and the physician indicated that the patient should be admitted for further work-up.  It was recommended that the patient undergo additional laboratory diagnostic study.  The laboratory study revealed a white blood cell count of 1.2 with hemoglobin level of 5.2.  The patient's potassium was 3.2 and calcium was 7.0.  The patient was treated with 2 units of packed red blood cells for her anemia.  The patient treated with Kcentra for her elevated protime (PT) of 18.1.  The patient was also given one liter of intravenous (IV) fluid bolus. The patient's esophagogastroduodenoscopy (EGD) was done for concern of an ulcer. The patient's EGD revealed a single healed antral ulcer with acute gastritis. The patient was continuously treated with IV fluid and the patient's complete blood count was trended daily. The patient's post-transfusion hemoglobin was 7.4. The patient's hemoglobin level stayed stable with 8.5. The patient's PT level stabilized to 12.7 after treatment. 

The patient continued with ongoing treatment and no further adverse events was noted during this patient's inpatient stay.  The patient was discharged on with instruction to follow-up as outpatient.

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

The carrier's denial of coverage for inpatient hospital services reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe anxiety 

Treatment: Continued inpatient mental health treatment

The insurer denied coverage for the continued inpatient mental health treatment as not medically necessary.  The denial is upheld. 

This patient was a male, based on the review of the medical record he was admitted to inpatient mental health treatment due to severe anxiety after being robbed and assaulted a few weeks prior to admission, passive suicidal thoughts, depressive symptoms and nightmares. The patient past history was significant for suicide attempt by jumping out a window. The patient was noted to have a diagnosis of Major Depressive Disorder with psychotic feature, and required psychiatric hospitalization in the past. The patient was treated with Mirtazepine and Risperidone, and was discharged. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Major Depressive Disorders report that the least restrictive level of care for safe and effective treatment is appropriate and that patients with suicidal plan or intent or behaviors, or inability to adequately care for basic needs are candidates for hospitalization.  In this case, this patient initially presented with suicidal thoughts, sad mood and anxiety that interfered with his functioning. The patient had a recent incident of being robbed and assaulted a few weeks prior to admission that triggered these acute symptoms. While this patient met the clinical criteria for inpatient admission, the patient's symptoms improved with treatment. As of a certain date, the patient did not report suicidal thoughts or symptoms of severe depression. Notes reported that the patient showed much improvement, had no psychosis, denied suicidal or homicidal ideation, hallucinations, had good appetite, denied intrusive thoughts, was cooperative and in behavioral control.  Other notes reported that the patient had no impulsivity, aggression, psychosis, hopelessness, suicidal or homicidal ideation, or hallucinations.  

The patient was discharged.  As of a specified date, the patient's medical chart does not provide specific evidence that the patient was an imminent danger to self or others or unable to adequately care for his basic needs.  Also, as of then, there were no reports of specific identifiable or quantifiable treatment goals or objectives that could only be achieved in a 24 hour acute psychiatric hospital setting or that could not be achieved in a less restrictive setting. Thus, continued inpatient level of care was not medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for the continued inpatient mental health treatment is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Substance Use.
Treatment:  Inpatient rehabilitation.

The insurer denied coverage for inpatient rehabilitation.  The denial is reversed.

This patient is a male who was admitted to inpatient substance rehabilitation treatment due to the need for substance rehabilitation.  The patient was drinking vodka and beer daily, snorting heroin daily even while taking Methadone Maintenance Treatment, and he was using 2 mg of Xanax a few times per week.  The patient was also homeless.  The patient's history was significant for multiple inpatient substance treatments, and this patient's continuous use of substances and alcohol.  

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders report that inpatient treatment is indicated primarily for individuals whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting.  In this case, this patient's history of substance use and recurrent relapse requiring inpatient detoxification warranted 24-hour substance rehabilitation treatment.  This patient was using large amounts of alcohol daily and using serious substances daily, including heroin as well as Xanax a few times per week.  This pattern of substance use put this patient at a high risk for overdose and life-threatening withdrawals.  The patient was also noted to be homeless and lacked the coping skills and the ability to identify relapse triggers to stop use.  

According to the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR), this patient met the clinical criteria for inpatient substance rehabilitation treatment, as he continued to use large amounts of alcohol, heroin, and Xanax despite multiple past inpatient substance treatments, as he reportedly had several inpatient substance detoxification treatments.  The patient was also unable to remain abstinent even with the Methadone Maintenance program.  The patient was homeless and lacked sober supports to help the patient maintain abstinence outside of the 24-hour substance rehabilitation treatment.  The patient needed to better identify relapse triggers and develop skills to prevent relapse.  The patient required a structured and supervised therapeutic rehabilitation treatment in order to achieve these goals.  Due to this patient's high risk for relapse, overdose and life-threatening withdrawals, inpatient rehabilitation was medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for the inpatient rehabilitation should be reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth decay
Treatment: Crowns and buildups on teeth #s 10 and 11
The insurer denied the Crowns and buildups on teeth #s 10 and 11.
The denial is upheld.

The Crowns and buildups on teeth #s 10 and 11 were not medically necessary.

The patient is a female.  The x-ray provided does not show any recurrent decay in or fracturing of the teeth. There are no photos showing the reported chipped or cracked areas of the crowns. There is no need to replace the crowns, based upon the documentation presented.
Appeal type: Medical necessity
Decision: Upheld

Primary Diagnosis: Endocrine /metabolic /Other 
Primary Treatment: Ambulance /Air Ambulance 
The denial is: Upheld 

The patient  with a history of type I diabetes, pancreas transplant  which failed , a 
retransplant  with primary non-function, and was subsequently relisted for pancreas transplant. The patient  was contacted  about an organ match. The records indicate that the patient  needed to be at the hospital within 4-6 hours. The patient was transported from her home via ground and air ambulance services. Then patient was admitted for a pancreas transplant and was discharged home The health care plan's determination of medical necessity is upheld in whole..
The requested emergency ground and air ambulance services were not medically necessary for this patient. The patient has a history of type I diabetes mellitus (DM) and has received 2 prior pancreas transplants. The patient was listed for a third pancreas transplant and receive an organ offer . The patient  was transported to receive this organ via emergency ground and air ambulance. However, the  coverage only provides this benefit in the case of an emergency to the nearest hospital where the emergency service can be provided. A pancreas transplant is not considered an emergent procedure. The patient was stably managed on insulin per the documents provided and was at  home at the time of transports not critically ill in an hospital setting. Patients routinely report for pancreas transplants via private vehicle and do not require emergency ambulance transport. In regards to the timing to  be at the hospital  within
4-6, this obviously created some challenges given where  that the patient resided in  state. However, there is no documentation as to why this is the only transplant hospital that  could have been listed at or have received an organ offer from. There are dozens of pancreas transplants hospitals closer to  home that would have been easier for the patient to access an organ offer from. Not receiving this organ offer would not have placed  life at risk, the patient  would have remained stable on  insulin therapy while the patient  awaited another offer.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Epilepsy.
Treatment:  Modafinil.  
The insurer denied Modafinil.  The health plan's determination is upheld. 

This is a female with a history of epilepsy for which she is prescribed Keppra.  She was being seen at a headache center, and was being treated with Botox, medical marijuana and temazepam.  She was described as having cognitive deficits, for which modafinil was recommended, that occurred following a head injury when she was snorkeling and was struck by a motorboat engine.  The specific cognitive problems were not documented.  She had responded to Adderall in the past.

Modafinil 100mg is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.  

This is a patient who is described as having cognitive deficits after a traumatic brain injury.  She also has a history of epilepsy.  Modafinil and armodafinil are bioequivalent medications, the difference being that armodafinil only contains the active enantiomer were as modafinil contains both the active and inactive enantiomers.  Both are FDA-approved for the treatment of the excessive daytime sleepiness due to obstructive sleep apnea-hypopnea syndrome, narcolepsy and shift work sleep disorder.  There is evidence of efficacy in the medical literature for certain forms of idiopathic hypersomnia.  They are commonly used for the non-evidence-based treatment of multiple sclerosis-related fatigue.  The patient's physician provided two references regarding clinical trials for patients with excessive sleepiness due to traumatic brain injury, suggesting but not definitively proving efficacy.  However, the physician did not prescribe modafinil for excessive daytime sleepiness.  He prescribed modafinil for cognitive deficits ("concentration issues").  There is no evidence in the peer-reviewed medical literature that modafinil (or armodafinil) is safe and effective for the for the treatment of concentration disturbances or other cognitive disturbances following a traumatic brain injury.  Therefore, there is no evidence that the use of modafinil would be better than any form of treatment, including no treatment, for the patient's cognitive complaints.