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

Diagnosis: Acute enteritis with small bowel obstruction
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
The patient is an adult who presented with several days of  abdominal pain, nausea and bloating. On presentation, the patient was noted to have a temperature of 100.8 degrees Fahrenheit. The patient was noted to be tender to palpation of the right lower quadrant with guarding. The laboratories reveal leukocytosis of 17.8 K (thousand). Computed tomography (CT) scan of the abdomen and pelvis revealed fluid filled loops of small bowel in the mid lower abdomen with surrounding fat stranding. The patient was made NPO (nothing by mouth) and was given antiemetics and narcotics. The patient improved and was discharged.

The inpatient admission is considered medically necessary for this patient. The patient was noted to have significant abdominal pain, fever and a CT scan revealed which seem to be an acute enteritis. The patient was noted to have evidence of a small bowel obstruction as well. The patient could not tolerate fluids given orally and needed to be made nil per os (NPO). It was medically necessary for the patient to be admitted.

"Gastroenteritis is a diarrheal disease characterized by an increase in bowel movement frequency with or without fever, vomiting, and abdominal pain." (Sattar et al., 2022)

"The acute diarrheal disease is generally self-limited. In the United States, infectious gastroenteritis can lead to significant morbidity, especially for young or elderly patients, and in underdeveloped countries, these diseases are a significant cause of death, especially in infants. According to the Centers for Disease Control, viral gastroenteritis infections account for over 200,000 childhood deaths per year worldwide. Viral gastroenteritis commonly causes nausea, vomiting, diarrhea, anorexia, weight loss, and dehydration. Isolated cases can occur, but viral gastroenteritis more commonly occurs in outbreaks within close communities such as daycare centers, nursing facilities, and cruise ships." (Stuempfig et al., 2023)                                                         

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Musculoskeletal injury due to physical assault
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with no known past medical history who presented to the emergency department (ED) after reportedly being abused by the father of her child. The patient claims that she was beaten to her back. The review of systems was positive for chest pain, joint pain and neck pain. 
The patient was admitted for musculoskeletal injury due to physical assault. A chest x-ray was negative. Computed tomography (CT) scan of the chest and spine were negative for fractures. The patient was treated for pain with Tylenol number (#) 3 and Toradol. The creatine phosphokinase (CPK) was 255.
At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care.
The patient was admitted for musculoskeletal injury due to physical assault. There were no signs of acute injury or fractures on imaging. Additionally, the patient was hemodynamically stable and had no electrolyte derangements.
The patient's CPK was 255 without clinical signs of rhabdomyolysis. The patient was admitted for an elevated CPK without evidence of electrolyte abnormalities or acute kidney injury. The isolated elevation in CPK in conjunction with a negative trauma workup did not warrant inpatient level of care. The outcomes following rhabdomyolysis are variable, ranging from asymptomatic elevations of creatine phosphokinase (CPK) concentration to life-threatening electrolyte abnormalities and acute kidney injury (AKI) requiring hemodialysis or continuous renal replacement therapy (RRT). Acute kidney injury is usually the feared and common complication of rhabdomyolysis, occurring in 13 percent (%) to 50% of patients. In-hospital mortality is higher in patients with acute kidney injury (AKI) (22.5% versus (vs) 7.1%, probability (P) less than [<] .001), and clinical conditions with the highest rates of the composite outcome of RRT or in-hospital mortality were compartment syndrome (41.2%), sepsis (39.3%), neuroleptic malignant syndrome (36.4%), abdominal or thoracic surgery (27.4%), and following cardiac arrest (58.5%) [4]. In this particular case, the patient had no signs of AKI and did not have any of the aforementioned clinical condition that would increase in-hospital morbidity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission. 
The determination is upheld. 

This is a female patient with a past medical history (PMH) of generalized anxiety disorder (GAD) and major depressive disorder (MDD) who was admitted with complaints of (c/o) a witnessed seizure. Her vital signs were notable for tachycardia. The physical exam noted she was postictal, which resolved on admission. Imaging studies, a computed tomography (CT) scan of the head showed no acute intracranial pathology, a chest x-ray (CXR) showed no acute cardiopulmonary disease, an electroencephalogram (EEG) was within normal limits (WNL), Magnetic resonance imaging (MRI) of the brain showed no significant pathology. The patient was diagnosed with new onset seizure, possibly secondary to recently started Wellbutrin, and treated with intravenous fluids (IVF), benzodiazepines (BZDs), Keppra, and an electroencephalogram (EEG) with neurology consultation. The patient was discharged on in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) after suffering a witnessed seizure. The patient's mental status was documented to recover on admission documentation from a post-ictal state. The patient was hemodynamically stable, there was no hypoxia, respiratory failure or distress, apnea, intentional overdose/exposure, disruptive/uncooperative behavior, other acute co-existing illness, persistent/high fever, significant trauma, focal deficits or unstable vital signs. In addition, there was no status epilepticus, poorly controlled repetitive seizures, delirium tremens, need for immediate surgical intervention, acute/subacute stroke, intracranial bleed, encephalitis, eclampsia, or alcohol withdrawal seizures. The patient received IVF, BZDs, Keppra, and EEG with neurology consultation, and these interventions could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diverticulitis.
Treatment:  Inpatient Hospital.

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

This is a female patient with a past medical history of obesity, sleeve gastrectomy, and hypothyroidism, who presented to the emergency department (ED) for lower abdominal pain, nausea and black stools. The review of systems was negative for additional symptoms.
The physical examination was remarkable for tenderness to palpation over the lower abdomen.
The patient was admitted for mild clinical acute diverticulitis and by mouth (PO) intolerance. A computed tomography (CT) scan of the abdomen and pelvis revealed acute sigmoid diverticulitis and minimal contrast passing through the right colon. The patient was treated with intravenous (IV) Clindamycin.
At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care.
The patient was admitted for acute uncomplicated diverticulitis without signs and symptoms of sepsis or systemic inflammatory response syndrome (SIRS). In those with minimal symptoms, outpatient management with or without oral antibiotics to cover colonic flora (including gram negative rods and anaerobes) is often sufficient. Patients with fever, systemic symptoms, or persistence intolerance to oral intake, inpatient treatment with intravenous antibiotics and a short period of bowel rest may be appropriate. Inpatient admission may be necessary to assess clinical improvement to avoid complications such as abscess and intestinal perforation. In this case, the patient had no leukocytosis or fever, no clear documentation of prolonged intolerance to oral intake. She was hemodynamically stable, and she did not have worsening signs of sepsis or complications. Furthermore, the patient was not immunocompromised or had risk factor for treatment failure or complications. The patient did not have radiographic findings of abscess or perforation which represent features of complicated diverticulitis.
In patients with acute uncomplicated diverticulitis, hospitalization should be considered if patients have signs of peritonitis or there is suspicion of complicated diverticulitis, or difficulty with oral food intake. In this case, the patient did not have the aforementioned clinical signs, therefore, an inpatient level of care was not necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hidradenitis suppurativa.
Treatment:  Inflectra.

The insurer denied Inflectra.  The determination is overturned.

The patient is a female with hidradenitis suppurativa (HS). She has tried Keflex, spironolactone, Humira, metformin, and finasteride. She has also tried chlorhexidine and clindamycin. The medication under review for medical necessity is Inflectra.
The requested health service/treatment of Inflectra (infliximab) is medically necessary for this patient.
The patient has failed all the standard treatments. Therefore, Inflectra at the requested dosing is medically necessary. Based on the evidence-based literature, the injection infliximab is medically necessary. According to the current dermatology literature, infliximab is effective for the treatment of hidradenitis suppurativa (1-3). Grant et al. writes in "Infliximab therapy for patients with moderate to severe hidradenitis suppurativa: a randomized, double-blind, placebo-controlled crossover trial" that, "this clinical study represents the first formal assessment of infliximab (IFX) for treatment of moderate to severe HS. IFX was well tolerated, no unexpected safety issues were identified, and improvements in pain intensity, disease severity, and quality of life were demonstrated with concomitant reduction in clinical markers of inflammation" (2). Fernandez-Vozmediano et al. writes "infliximab was shown to be an effective therapeutic alternative for severe extensive forms of hidradenitis suppurativa when it is used as monotherapy" (3). Therefore, according to the evidence-based literature, infliximab is an effective treatment for hidradenitis suppurativa. Given that the patient has failed all the conventional therapies, including Keflex, spironolactone, Humira, infliximab is medically necessary in this patient. It is noted that the requested dosing is higher than the Food and Drug Administration (FDA) recommended dosing. However, Ghias et al. recently published in the Journal of the American Academy of Dermatology, in their paper "High-dose, high-frequency infliximab: A novel treatment paradigm for hidradenitis suppurativa" that "Initiation of IFX 7.5 every 4 weeks, with possible dose escalation to IFX 10, if needed, provides optimal mitigation of HS-related disease activity" (4). Therefore, the request, including the dosage request, is medically necessary and appropriate in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke

Treatment: Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week - a total of 84 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week - a total of 84 hours per week

The denial is overturned

The participant is an elderly patient who lives with their sister. The patient's personal care aid is their daughter. A letter of request for additional service hours for Consumer Directed Personal Assistance Program (CDPAP) 12 hours a day / 7 days a week, was submitted by the participant's daughter. The patient's daughter noted that the participant is unable to transfer in and out of bed without assistance; unable to transfer for toileting; needs assistance with  perform activities daily living (ADL's); unable to cook, meal prep due to pain to the useful hand. The patient's daughter further noted that herself and her sibling have tried adjusting schedules to provide assistance, but they are no long able to assist due to their jobs.   

A letter of medical necessity submitted by the patient's provider noted that the patient diagnoses are worsening flaccid hemiplegia of the left nondominant side, as late effect of cerebrovascular disease; evident by their grade 3-5 bilateral extremity motor strength. The patient's mobility has substantially decreased from normal. The patient also has chronic atrial fibrillation, long-term anticoagulant, essential hypertension, hypertrophic nonobstructive cardiomyopathy, stage III chronic kidney disease and chronic right-hand pain.  Due to the above noted diagnoses, the patient requires total assistance with activities of daily living including bathing, dressing, grooming, skin care, tolerating current care, transferring from bed to wheelchair, using wheelchair, meal preparation and assistance with self-administration of medication. Based on the patient's needs 12 hours a day, 7 days a week of personal care services is required. The participant lives with their sister who is intellectually disabled and has no informal support to provide personal care.

The plan denied the appeal for Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day-7 day(s) per week; total of 84 hours per week. 

Based on documentation, the patient requires moderate to maximum assistance with Instrumental Activities of Daily Living (IADL) and ADLs, transfers, mobility, locomotion, and medication monitoring. The patient cannot transfer to/from the wheelchair, cannot move the wheelchair. Considering the diagnoses and functional deficits, the patient will require additional hours to safely provide assisted care.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 day(s) per week - a total of 84 hours per week is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: ADHD (attention deficit hyperactivity disorder). 
Treatment: Formulary exception for Focalin XR [dexmethylphenidate ER (extended release)]. 
The insurer denied: Formulary exception for Focalin XR (dexmethylphenidate ER). 
The denial is overturned.. 

The patient is a teenage male diagnosed with ADHD (attention deficit hyperactivity disorder). He has been on brand Focalin XR (extended release) 20 milligrams and 10 milligrams for seven years. The generic version causes side-effects. 

The health plan should cover the Formulary exception for Focalin XR (extended release). 

The patient is diagnosed with ADHD (attention deficit hyperactivity disorder). He has been stable on brand Focalin XR (extended release) for seven years. Generic Focalin XR (extended release) caused side-effects. He needs to continue with treatment to keep him stable. Changing his medication puts him at unnecessary risk of decompensation. Therefore, the health plan should cover the formulary exception for brand Focalin XR (extended release).
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Home health care

Diagnosis: Dementia
Treatment: Home health care
The insurer denied.
The health plan's determination is overturned. 

This is a male patient with a history of dementia, hypertension, coronary artery disease, diabetes, depression, chronic anemia and thrombocytopenia, urine incontinence, significantly diminished vision, dizziness, gait imbalance, and frequent falls. He lives with non-relatives in a room in a 2-bedroom apartment.

Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 60 Hours per Week are medically necessary for this patient.
There is documentation in the recent Uniform Assessment System (UAS) of the patient requiring extensive assistance for task of transfer toilet and limited assistance for tasks of walking, locomotion, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of medical necessity of increased PCA (personal care assistant) services. Although the patient lives with others (non-relatives) and therefore has informal support, the plan cannot assume that the informal support person can provide all needed care outside of the approved PCA hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic migraine
Treatment: Qulipta
The insurer denied Qulipta.
The determination is upheld.

This is a patient with chronic migraine. Quilipta was denied because the patient has not tried and failed any oral migraine preventative therapies. The patient has tried and failed Ajovy. The patient has also tried and failed various triptans; however, these are for acute treatment and not preventative treatment of migraine. At issue is the medical necessity of  
The requested service of Qulipta is not medically necessary. The plan requires that the patient has tried and failed standard oral migraine, preventative therapies. The plan recognizes various drug classes, including beta blockers, antidepressants, and anticonvulsants. The plan specifically notes that medication such as propranolol, topiramate, valproic acid, amitriptyline, and venlafaxine may be appropriate alternatives to prevent migraine. These medications are all considered effective in the peer review literature for treatment of migraine. There is no documentation from the patient or provider that the patient has ever used an oral migraine, preventative therapy in any one of these classes. Because the patient has not tried and failed any of these therapies, medical necessity is not demonstrated for Qulipta.
Appeal type: Medical necessity
Decision: Overturned

Respiratory
Inpatient hospital

Diagnosis: Respiratory Syncytial Virus (RSV) Infection
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is overturned. 

The patient is a premature infant girl who presented to the emergency department with a cough and increased work of breathing.
She was well until the day prior to presentation when she developed a cough as well as rhinorrhea and eye tearing. She had no fever or vomiting, but her cough worsened so she was brought to the emergency department for care.
In the emergency department, she was found to have tachypnea and deep intercostal retractions with belly breathing and wheezing. She was given saline nebulized treatments and suctioning, but she continued to have retractions and tachypnea with a respiratory rate of 60. She was therefore admitted to the hospital for further care.

Inpatient Hospital Admission was medically necessary for this patient.
This is a young infant who presented with respiratory distress from respiratory syncytial virus (RSV) infection. She was treated appropriately in the emergency department but continued to have significant retractions and tachypnea. She required an inpatient hospital admission for treatment with supplemental oxygen to support her respiratory status, saline nebulized treatments, and suctioning, along with ongoing monitoring with additional treatments as needed.
Hospitalization for is indicated for infants with bronchiolitis who have moderate to severe respiratory distress, which in this patient was manifested by retractions and belly breathing. This patient required support from supplemental oxygen as well as additional treatments and monitoring, which requires an inpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hemiplegia, dysphagia, muscle weakness, osteoarthritis, insomnia, heart failure, and anxiety disorders
Treatment: Personal Care Aide 7 Days x 24 Hours, split shift, Total 168 Hours per Week
The insurer denied: Personal Care Aide 7 Days x 24 Hours, split shift, Total 168 Hours per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include dementia, hemiplegia, dysphagia, muscle weakness, osteoarthritis, insomnia, heart failure, and anxiety disorders. She 
was hospitalized for a week 4 months ago with weakness. She lives alone. Denial of personal care aide seven days x 24 hours, split shift, for a total 168 hours per week is being appealed. The health plan approved seven days x 24 hours, live in. The patient's Uniform Assessment System evaluation completed 2 months ago shows moderately impaired cognition and functional status requiring maximal assistance to total dependence with all activities of daily living (ADLs). She is wheelchair bound and requires overnight care. She has incontinence. She requires assistance with positioning when laying and sitting. A submitted appeal statement indicated the patient requires total dependence with activities of daily living. She requires bihourly turning and repositioning and multiple daily and nightly diaper changes. She is wheelchair dependent. She has bladder and bowel incontinence. Two night logs show the patient frequently calling for assistance due to inability to sleep and infrequent assistance with turning.

The requested Personal Care Aide 7 Days x 24 Hours, split shift, Total 168 Hours per Week, is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous 
or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual who needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of personal care aide seven days x 24 hours, split shift, for a total 168 hours per week is being appealed. The health plan approved seven days x 24 hours, live in. This patient has multiple chronic conditions, including a recent hospitalization with weakness. Uniform Assessment System (UAS) evaluation completed 2 months ago shows the patient requires maximal assistance to total dependence with all activities of daily living. She has incontinence. She is wheelchair bound. The appeal statements support the patient is dependent with all activities of daily living, needs frequent diaper change due to incontinence, and requires bihourly turning and repositioning. This patient has continuous needs that support the requested personal care aide seven days x 24 hours, split shift, for a total 168 hours per week as medically necessary.