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

Diagnosis: Respiratory System-Pneumonia
Treatment: Inpatient hospital stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

The patient has hypertension (HTN), and diabetes mellitus (DM) and presented with fever, chills, myalgias, weakness, nausea, vomiting, hiccups and tested positive for COVID previously.
In the emergency department (ED), his temperature was 102, blood pressure (BP) 111/68, heart rate (HR) 114, respiratory rate (RR) 19, and peripheral capillary oxygen saturation (spo2) 98% (percent) on room air (RA). He was not in distress, breathing comfortably, had no wheezes/rales/rhonchi (w/r/r), and was alert and oriented. A chest x-ray (CXR) resulted with left mid-lung consolidation. He was given ceftriaxone, dexamethasone, and intravenous (IV) fluids.
He was diagnosed with COVID-19 pneumonia with superimposed bacterial pneumonia and was started on dexamethasone, ceftriaxone, and azithromycin.
He was seen by infectious disease (ID) and was noted to be feeling better. He was saturating well on room air (RA). ID recommended continuing antibiotics and checking a computed tomography scan (CT) of the thorax. The patient revealed there'd been a miscommunication and that he had not tested positive for COVID as an outpatient; hospital testing was negative. Dexamethasone was stopped. The CT scan of the thorax found a large, left apical interstitial opacity and likely reactive lymphadenopathy. He continued to feel better. Antibiotics were continued. He was feeling better and saturating well on RA. He continued to feel well and saturate well on RA and was eventually discharged on cefpodoxime.

An inpatient stay was not medically necessary. An admission at a lower level of care would have been reasonable.
 
While COVID was an initial concern, he was ultimately diagnosed with and treated for a community acquired pneumonia. He was not severely ill at presentation (no encephalopathy, hemodynamic instability, respiratory distress or gas exchange abnormality, acute kidney injury or marked electrolyte abnormality). Routine scoring systems would predict he had a low risk of worsening or needing Intensive Care Unit (ICU) care. He improved within a lower level of care time frame. Even if COVID had been a concern, he recovered quickly and was not hypoxemic, was not severely ill at presentation, and was at low risk of worsening. With a low severity at presentation, low risk of worsening, and lack of additional or alternative diagnoses, he did not require inpatient only testing, monitoring, or treatment. Given this and his improvement an inpatient admission was not medically necessary. A lower level of care admission would have been reasonable.
Appeal type: Medical necessity
Decision: Overturned in Part


Diagnosis: Childbirth
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned in part (3 additional days are medically necessary).

This patient presented to the hospital for scheduled repeat cesarean delivery. The patient was a female who presented at 37-0/7 weeks gestation. The patient denied contractions, vaginal bleeding or leakage of fluid. She reported that the baby was moving as was usual. She had prenatal care with a total of 10 visits. Her previous history was noted for a term cesarean, a preterm 23 week delivery with classical cesarean delivery (a preterm delivery in that case was 23-24 week twins), and then the current pregnancy. The patient was being delivered early as she had a previous history of classical cesarean delivery. At presentation, the patient was alert and oriented and without any complaints. The patient was noted to have an estimated fetal weight of 2200 g (grams) and cephalic presentation. Amniotic fluid index was normal and fetal heartbeat was present. The placenta was posterior. The patient was admitted for a planned repeat cesarean delivery. Her placental evaluation had been noted for no evidence of accreta. The patient was admitted to labor and delivery for planned delivery. She had routine admission labs and intravenous (IV) fluid hydration. She was at risk for postpartum hemorrhage and a moderate risk was noted resulting in a type and hold for blood being sent. Pain management was planned. The patient was to have venadines for deep vein thrombosis (DVT) prophylaxis.

The inpatient stay was medically necessary for 3 additional days. From this point forward, the inpatient stay was not medically necessary.
Based upon a review of the medical records in this case and the complex presentation of the patient and patient care in the setting of a spontaneous uterine rupture at cesarean with occult, delayed presentation of maternal bladder injury leading to large volume ascites in the maternal peritoneal compartment, the inpatient stay was medically necessary for the additional days.
For the following dates, there was no ongoing need for acute inpatient level of care given the patient had recovered from surgery. Placement of Nexplaneon is an outpatient procedure and not an indication for admission to acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hidradenitis Suppurative.
Treatment: Seysara, Pre-service.
The insurer denied the Seysara, Pre-service.
The denial is upheld.

The patient is a woman with severe hidradenitis suppurativa for whom sarecycline is requested. She has tried and failed or has an intolerance to multiple systemic antibiotics.

No, the requested Seysara is not medically necessary.
The patient has severe hidradenitis suppurativa. SEYSARA (sarecycline) tablet, is indicated for the treatment of inflammatory lesions of non-nodular moderate to severe acne vulgaris in patients 9 years of age and older. There is no published peer-reviewed literature available to support off-label use of sarecycline in the treatment of hidradenitis suppurativa. Therefore, the safety and efficacy of this treatment approach is unknown and medical necessity cannot be established.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
There is no published data to support the use of sarecycline in hidradenitis suppurativa.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Constipation/IBS
Treatment: Formulary exception for Motegrity
The insurer denied the Formulary exception for Motegrity
The denial is overturned

The patient is a male with constipation. He has tried and failed Amitiza 24 mcg (micrograms) twice daily x 6 months, and Linzess 145 mcg (micrograms) and 290 mcg (micrograms) for 1 month each daily.  He was placed on Motegrity 2 mg (milligrams) daily and is doing well on this medication.

Yes, the health plan should cover the Formulary exception for Motegrity.
The formulary drugs have been ineffective for this patient, and they would not be as effective as the requested non-formulary drug.  The side effects of formulary and non-formulary are the same.

The patient has failed Amitiza, and therefore would not have benefit from generic Amitiza. The patient has already had benefit from the requested Motegrity.

Prucalopride is a selective 5-HT4 (5-Hydroxytryptamine 4) receptor agonist with colonic prokinetic activity which is FDA (United States Food and Drug Administration)-approved for the treatment of chronic idiopathic constipation. The FDA (United States Food and Drug Administration) approval of Motegrity was based on six double-blind, placebo-controlled, randomized, multicenter clinical studies lasting 12 weeks (studies 1-5) or 24 weeks (study 6) conducted in 2,484 adults. During studies, significantly more patients taking Motegrity achieved the primary endpoint than those in the placebo group across five of six trials. A rapid response was seen with Motegrity as early as week 1, with improvements maintained throughout 12 weeks of treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, lupus and depression.
Treatment partially denied coverage for Home Care/Personal Care HHC (home health care)- Level 2 Personal Care Services, per 15 minutes increase to 150 Hour(s) per week; the partial denial is for an increase in Consumer Directed Personal Assistance Services (CDPAS) from 85 hours to 150 hours per week

The insurer partially denied coverage for Home Care/Personal Care HHC- Level 2 Personal Care Services, per 15 minutes increase to 150 Hour(s) per week; the partial denial is for an increase in Consumer Directed Personal Assistance Services (CDPAS) from 85 hours to 150 hours per week

The denial is overturned 

This is a patient with chronic medical problems including diabetes mellitus, lupus and depression.  She lives with her daughter, who is the personal assistant care giver.  Under review is the medical necessity of requested increase in Consumer Directed Personal Assistance Services (CDPAS) from 85 hours to 150 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's ability to perform activities of daily living (ADL) tasks and self-sufficiency have declined or deteriorated over the past few days.  The patient has severe cognitive and functional deficits which support the medical necessity of requested CDPAS of 150/week.  According to the report the patient is only oriented to self; "Decisions consistently poor or unsafe; cues/supervision required at all times."  She is totally dependent for activities that include meal preparation, ordinary housework, managing finances, shopping, and ambulation (including stairs).  ADL tasks range from extensive assistance to total dependence (e.g., bathing, personal hygiene, dressing and toileting).  The requested increased (CDPAS) will allow the patient to continue to safely live at home.  

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

From a physical medicine and rehabilitation perspective, the requested increase in Consumer Directed Personal Assistance Services (CDPAS) from 85 hours to 150 hours per week is medically necessary.

The insurer's denial of coverage for Home Care/Personal Care HHC- Level 2 Personal Care Services, per 15 minutes increase to 150 Hour(s) per week; the partial denial is for an increase in Consumer Directed Personal Assistance Services (CDPAS) from 85 hours to 150 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, dementia.
Treatment: Personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours a week.
The insurer denied coverage for personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours a week.

The denial is overturned.

This case involves an elderly female who has diagnoses that include Parkinson's disease and dementia.  The documentation indicated the patient has been recommended for 24 hours of services daily as she suffers from advanced Parkinson's disease and dementia with functional quadriplegia.  She requires around-the-clock care to assist her with basic bodily functions.  The documentation indicated she is completely incontinent and cannot perform any of her biological physical functions independently.  She cannot dress herself or bathe herself.  She has completely contracted limbs according to the physician and is unable to maneuver her own body to maintain any type of pressure while sitting in a wheelchair.  She is immobile and no longer can stand or walk.  Her cognitive state is in extreme decline, she is confused, and her speech is unintelligible the majority of the time.  There is also little to no recognition of family members.  The documentation indicated she was also scheduled to undergo placement of a PEG (percutaneous endoscopic gastrostomy) tube. Additional submitted documentation does not include an assessment is indicated at this time. The patient was noted to be alert and oriented to self.  She was often confused and disoriented.  She does have daily episodes of bladder incontinence and bowel incontinence related to cognitive deficits and immobility.

The documentation indicated this is elderly female who has Parkinson's in addition to dementia.  She does require assistance due to significant limitations.  It is noted she has completely contracted limbs and the inability to perform activities of daily living.  She continues to decline and remains confused the majority of the time.  She is needing the requested hours as this will likely prevent any adverse incidents and will ameliorate the physical, mental or developmental effects of her condition.  Given the provided care, this will assist her to maintain maximum functional capacity.  Lowering her hours will be insufficient to meet her needs which is not considered safe.  Therefore, the requested personal care services 24 hours a day 7 days a week is considered medically necessary.

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

The insurer's denial of coverage for personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours a week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent Thigh Abscess

Treatment: inpatient level of care

The insurer denied coverage for inpatient level of care

The denial is upheld.

The patient has a past medical history significant for recurrent thigh abscess who was referred to the emergency department with complaints of worsening pain in her right posterior thigh.

Her vital signs on presentation included: temperature 98.2, blood pressure 106/72, pulse 87, respiratory rate 20, and oxygen (O2) saturations 100% (percent) on room air. Laboratory results included the following: white blood cell count (WBC) 7.7, hemoglobin (HGB) 10.8, hematocrit (HCT) 33.9, creatinine 0.83 and glucose 99. The patient was admitted for evaluation of a recurrent thigh abscess. She underwent an incision and drainage procedure by surgery. The patient tolerated procedure well; she remained afebrile and hemodynamically stable. The patient was discharged on oral antibiotics (Augmentin) to continue outpatient management.

According to documentation, the patient was referred to the emergency room for a recurrent thigh abscess. Otherwise, she was afebrile and hemodynamically stable; laboratory results were unremarkable including a normal WBC. The patient did not have any evidence of a disseminated infection and she underwent an incision and drainage procedure. Based on above findings, the patient met criteria for an observation 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 inpatient level of care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rash
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a girl who presented with a rapidly progressing rash. She was well until the day prior to presentation when she developed a rash that spread from her abdomen to her face and the rest of her body. It was itchy and warm and covered most of her body. She had a positive COVID19 test 2 1/2 months previously. She also had some loose stools. She was given Claritin at home, which didn't seem to help. She was brought her to her primary doctor for evaluation, who subsequently referred her to the emergency department for care.
In the emergency department, she was found to have a fever of 102.9. On physical examination, she was described as fussy and irritable and in distress due to itching. She had a generalized, erythematous, blanchable rash covering most of her body including the face and scalp. Laboratory values were drawn, and she was admitted with concern for possible Multisystem inflammatory syndrome in children (MIS-C).

The inpatient hospital admission was medically necessary for this patient. Children with suspected MIS-C require management in the inpatient setting, even if their symptoms are relatively mild initially. This is because children with MIS-C often have rapid worsening of their clinical status as the illness progresses which can lead to serious morbidity.
This is a very young girl who presented with a rapidly progressing erythematous and pruritic rash as well as high fever. She had a prior COVID-19 infection and there was concern for MIS-C. She required hospitalization with prompt initiation of intravenous fluids, full evaluation including repeated laboratory values and an echocardiogram, and careful monitoring for progression of symptoms. In fact, during the hospitalization she continued to have fevers and required parenteral antibiotics while cultures were pending.
The decision making at the time of admission for this patient was consistent with her young age, the presence of rapidly progressing rash with fever, and the need for prompt evaluation with treatments as needed to prevent potentially serious morbidity including myocarditis and encephalitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems. 
Treatment: Braces. 

The insurer denied braces. The health plan's determination is overturned. 

The patient in question is a female with severe crowding. She presents with a skeletal Class I malocclusion. Tooth # (number) 27 is blocked out to the labial and is erupting in anterior crossbite. She is treatment planned for orthodontics (braces) to address the crowding and crossbite, but the treatment was denied due to lack of medical necessity. 

Braces are medically necessary for this patient. 

This patient presents with an anterior crossbite on tooth 27, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. 
If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. If space is not made for tooth 27 it will develop periodontal recession. 

Therefore, braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriatic Arthritis
Treatment: Cimzia 400mg/mL (milligram/milliliter) 2mL Syringe Kit
The insurer denied the Cimzia 400mg/mL 2mL Syringe Kit
The denial is upheld.

This patient is a female with history of psoriatic arthritis.  The patient has previously tried and failed non-steroidal anti-inflammatory drugs (NSAIDs) along with conventional disease modifying anti-rheumatic drug (DMARD) sulfasalazine.  The request for Cimzia was initially denied due to the patient not having tried and failed two of the preferred formulary alternatives including Enbrel, Humira, Stelara, Xeljanz, Cosentyx, Otezla and Tremfya.  The reason the provider is appealing the determination is because the patient has a chance of becoming pregnant and feels that Cimzia would therefore be safest for her.

No, the proposed treatment with Cimzia is not medically necessary.
The patient has a diagnosis of psoriatic arthritis and psoriasis.  The patient has previously tried and failed sulfasalazine.  The patient is needing advanced therapy.  Cimzia was initially denied because the patient has not tried and failed at least two formulary alternatives.  Two formulary alternatives listed include Enbrel and Humira.  Both of these are tumor necrosis factor (TNF) inhibitors that are approved in the first and second trimesters of pregnancy.  Cimzia is the only tumor necrosis factor (TNF) inhibitor that is approved for all three trimesters of pregnancy; however, clinical notes do not support that the patient is actively trying to conceive.  The patient is taking birth control pills although does frequently forget them so does have a higher chance of becoming pregnant; however at this time, it would be safe for the patient to be on Humira or Enbrel if the patient were to become pregnant and then later on the patient could be switched to Cimzia if desired.  Therefore at this time, the proposed treatment is not found to be medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Humira and Enbrel are safe in the first and second trimesters of pregnancy if the patient should become pregnant.  Therefore, there are safe options for this patient that are formulary alternatives and therefore the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus type 2

Treatment: Hospital admission

The insurer denied coverage for the hospital admission

The denial is overturned.

According to the medical records, the patient has a history of morbid obesity, hypertension, asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, and gastroesophageal reflux. The patient presented to the emergency department (ED) with complaints of abdominal pain (for five days), nausea, vertigo, headache, blurry vision, polydipsia, and polyuria. The bloodwork showed significant elevated blood glucose 722 milligrams (mg) per deciliter (dl) and an A1c (glycated hemoglobin) of 14.9 percent (%). The patient received intravenous push (IVP) insulin, subcutaneous (SQ) Levemir 20 units, intravenous (IV) fluid, IVP Pepcid 20 mg. Her blood glucose was still over 400 mg/dl despite IVP insulin and IV fluid. She was admitted for further management of newly diagnosed diabetes mellitus type 2. Two days later she was discharged home, with outpatient endocrinology follow up planned. 

The diagnosis of hyperosmolar state (HHS) is based on the results of venous blood, serum osmolality greater than (>) 320 milliosmole (mOsm)/ kilogram (kg), serum glucose >30 mOsm/ liter (L) or 600 mg/dl, Serum pH (potential of hydrogen) >7.30 and bicarbonate >15 mmol/L (millimoles per liter), and confirmatory tests: capillary ketones less than (<) 3 mmol/L. The patient had severe hyperglycemia with a plasma glucose greater than 700. The patient's calculated serum osmolality was 322, blood gas showed a ph of 7.35, bicarbonate was 24 on admission.  

"Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are acute metabolic complications of diabetes mellitus that can occur in patients with both type 1 and 2 diabetes mellitus. Timely diagnosis, comprehensive clinical and biochemical evaluation, and effective management is key to the successful resolution of DKA and HHS. Critical components of the hyperglycemic crises management include coordinating fluid resuscitation, insulin therapy, and electrolyte replacement along with the continuous patient monitoring using available laboratory tools to predict the resolution of the hyperglycemic crisis. Understanding and prompt awareness of potential of special situations such as DKA or HHS presentation in comatose state, possibility of mixed acid-base disorders obscuring the diagnosis of DKA, and risk of brain edema during the therapy are important to reduce the risks of complications without affecting recovery from hyperglycemic crisis. Identification of factors that precipitated DKA or HHS during the index hospitalization should help prevent subsequent episode of hyperglycemic crisis." (Gosmanov, et al.)

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient met admission criteria for hyperglycemia due to severe hyperglycemia with hyperosmolarity and severe electrolyte abnormalities.      

The insurer's denial of coverage for the hospital admission is overturned. Medical Necessity is substantiated.