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

Diagnosis: Obstructive Sleep Apnea 
Treatment: Durable Medical Equipment - BiPAP (bi-level positive airway pressure)
The insurer denied Durable Medical Equipment - BiPAP.
The health plan's determination is overturned. 

The patient is a male with a body mass index (BMI) of 56. Sleep study noted an apnea hypopnea index (AHI) of 41.8. The patient was titrated to a bi-level positive airway pressure (BiPAP) pressure of 20/16. The patient tried and failed continuous positive airway pressure (CPAP) on the sleep study. Home sleep test noted a respiratory event index (REI) of 62.6.
At issue is the medical necessity of Durable Medical Equipment - BiPAP (bi-level positive airway pressure).

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Durable Medical Equipment - BiPAP (bi-level positive airway pressure) is medically necessary for this patient.
The patient has severe obstructive sleep apnea that was diagnosed and was titrated to BiPAP (bi-level positive airway pressure) after the patient tried and failed CPAP (continuous positive airway pressure) during the titration study. This meets all appropriate criteria for the prescription of BiPAP (bi-level positive airway pressure). Per current literature and standard of care, the patient was appropriate to have a titration study. The patient was started on CPAP (continuous positive airway pressure), and this did not treat the patient's obstructive sleep apnea (OSA), so the patient was transitioned to BiPAP ((bi-level positive airway pressure) during the titration study. When BiPAP (bi-level positive airway pressure) pressure was optimized, this completely treated the patient's OSA (obstructive sleep apnea). This criteria is well accepted for BiPAP where the patient has been tried and failed on CPAP during a titration study. 
Therefore, the requested health service/treatment of Durable Medical Equipment - BiPAP (bi-level positive airway pressure) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder
Treatment: Braces, monthly visit and retainer 
The insurer denied Braces, monthly visit and retainer.
The determination is upheld.

This is a female patient with a Class II occlusion with a 3 millimeter (mm) overjet and 5 millimeter (mm) overbite. The maxillary and mandibular arches have moderate spacing. Teeth 20 and 29 are missing. Teeth K and T are retained and are severely broken down. It also appears that teeth 24 and 25 are missing and teeth O and P are both retained and have significant wear. She is treatment planned for orthodontics. Braces, monthly visit and retainer were denied by the health plan and are under review for medical necessity.

There is no medical reason to correct the patient's malocclusion with braces. The patient does have a deep bite, however, that alone is not a medical necessity to treat. There are functional problems that can occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) This patient presents with none of those conditions. The photographs do not illustrate any damage to the teeth or soft tissue damage from their current position. The patient has a 3 mm overjet but this amount of overjet does not affect oral health related quality of life. (2) If her teeth were aligned it would provide a minor esthetic improvement but it would not create a medically significant improvement to the patient's health. The requested orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient had the diagnosis of gastroenteritis. The patient had a history of hypertension and vertigo. The patient presented to the emergency room (ER) with the complaints of vomiting and diarrhea. Imaging revealed diffuse hepatic steatosis. The patient was admitted with the diagnosis of gastroenteritis. It was noted the patient was encouraged to continue oral (PO) intake. Treatment involved telemetry monitoring, lab work, serial abdominal examinations, and intravenous (IV) fluids. The patient was discharged after a period of hemodynamic stability.

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth (NPO) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level, such as observation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/ Other/ Unstable Angina, Coronary Artery Disease Involving Native Heart with Unstable Angina Pectoris, Unspecified Vessel or Lesion Type
Inpatient Hospital/ Inpatient hospital Admission
The health plan has denied the requested treatment, inpatient hospital admission, as not medically necessary. 
The health plan's determination is upheld.

This man presented to the emergency department (ED) after an episode of chest pain that woke him from sleep and resolved after taking aspirin. His medical history was remarkable for hypertension, heart failure with reduced ejection fraction (35%), coronary artery disease, and percutaneous coronary intervention. In the ED, his blood pressure was 125/74 millimeters of mercury (mmHg) with a heart rate of 75 beats per minute. His room air oxygen saturation was 97 percent (%). An electrocardiogram showed sinus rhythm without acute changes. His serum troponin level was normal. His brain (or B-type) natriuretic peptide (BNP) level was 139 picograms per milliliter (pg/ml). The patient was treated with aspirin and enoxaparin and was admitted to the hospital. His serum troponin level remained normal. He was seen by a Cardiologist who recommended cardiac catheterization to be performed the next day. The patient left the hospital against medical advice.

At issue is the medical necessity for an inpatient hospital admission.
I uphold, in whole, the determination that an inpatient level of care was not medically necessary.

Based on the documentation provided, an inpatient level of care was not medically necessary.
This man, with known coronary artery disease, presented with symptoms that were thought to be suspicious for acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under an alternate level of care. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE)/The American College of Chest Physicians (CHEST)/Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis.
Treatment: Humira 40mg (milligrams).

The insurer denied: Humira 40mg (milligrams).  The denial is overturned.

This patient is an adult female with history of rheumatoid arthritis. The patient has previously tried and failed non-steroidal anti-inflammatory drug (NSAID) nabumetone and conventional disease modifying anti-rheumatic drug (DMARD) methotrexate. The request for Humira was initially denied due to documentation not supporting that the patient has had a tuberculosis test done within the last six months. It was then denied again due to policy not allowing coverage of Humira for rheumatoid arthritis, unless one of the following conditions is met: "a) the patient has been tested for either the rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP) biomarker and the test was positive or b) the patient has been tested for ALL the following biomarkers: RF, anti-CCP, and C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR)." The reason the provider is appealing the determination is because the patient has now had a negative tuberculosis test 2 months ago.

The proposed treatment is medically necessary.

The patient has a history of rheumatoid arthritis and has already tried and failed methotrexate. The patient has a negative tuberculosis test. Patients with rheumatoid arthritis can be either seropositive or seronegative meaning that they may have a positive rheumatoid factor and/or cyclic citrullinated peptide (CCP) antibody or they may both be negative. Both seropositive and seronegative rheumatoid arthritis patients are treated the exact same way. After failure of conventional disease modifying anti-rheumatic drugs (DMARDs), such as methotrexate, it is common then to add on a biologic disease modifying anti-rheumatic drug (DMARD), such as Humira. Despite not knowing if the patient has been tested for rheumatoid factor or cyclic 
citrullinated peptide antibody or the inflammatory markers, the patient's management of her disease would not change at this time, and therefore it is not necessary to have these labs in order to determine if advancement to Humira is medically necessary. Based on the patient having rheumatoid arthritis diagnosis and having tried and failed methotrexate, it would be medically necessary for this patient to then advance to a biologic disease modifying anti-rheumatic drug (DMARD) Humira.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Legal Blindness. 
Treatment: Consumer Direct Personal Care Aide for 50 Hours per Week. 

The insurer denied: Consumer Direct Personal Care Aide for 50 Hours per Week. 
The denial is upheld. 

This adult male patient has medical conditions that include legal blindness. He lives with his brother, mother, and father. Denial of consumer direct personal care aide for 50 hours per week is being appealed. The health plan approved 25 hours per week.
Uniform Assessment System evaluation completed five months ago shows independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, stairs, transportation, and bathing; limited assistance with phone use, lower body dressing, walking, and locomotion; and independent with personal hygiene, upper body dressing, toileting, bed mobility, and eating. A letter from the Provider notes the patient is legally blind resulting in a need for increased hours. A letter from another Provider notes the patient is unable to complete everyday tasks due to being legally blind. A letter from a third Provider notes the patient is unable to complete daily chores due to legal blindness. A letter from a fourth Provider notes the patient needs assistance with activities of daily living (ADLs) due to legal blindness. 

The proposed treatment 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. This patient is legally blind. He lives with his brother, mother, and father. Denial of consumer direct personal care aide for 50 hours per week is being appealed. The health plan approved 25 hours per week. Uniform Assessment System evaluation completed five months ago shows the patient needs assistance with meal preparation, housework, shopping, managing finances and medications, stairs, transportation, bathing, phone use, lower body dressing, walking, and 
locomotion. Appeals statements recommend an increase in hours of assistance due to blindness. Personal care services are not indicated for safety supervision or when no tasks are being performed. The needed assistance with activities of daily living can be accomplished with the approved personal care aide of 25 hours per week. The patient is able to split hours as needed. 

The information provided does not support that the patient has functional needs that require an increase in personal care aide from 25 hours per week to 50 hours per week.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer (metastases)
Treatment: Radiation Therapy
The insurer denied: Radiation Therapy
The denial is overturned.

The patient is an adult female with a diagnosis of loco-regionally advanced sarcoma involving the left posterior gluteus/posterior thigh status post neoadjuvant chemotherapy followed by resection of the primary. Definitive radiation to the unresectable pelvic nodes was recommended and IMRT (intensity-modulated radiation therapy) was requested. The case was initially denied because it was not considered medically necessary. 

The proposed treatment is medically necessary. 

In this case, the required dose of at least 50-60 Gy biologic effective dose is higher than the tolerance of the surrounding critical structures such as small bowel, femur, rectum and bladder. Although medical data for this exact clinical scenario is limited, there is clinical and dosimetric data showing that IMRT ((intensity-modulated radiation therapy) is superior compared to conventional conformal radiation in terms of normal tissue sparing for pelvic radiation. A 2013 study analyzed 177 patients with rectal cancer treated with either three dimensional (3D) or IMRT (intensity-modulated radiation therapy). The authors concluded that "all patients who were treated with 3DCRT had higher rates of grade 2+ diarrhea" compared to IMRT (intensity-modulated radiation therapy) patients. IMRT (intensity-modulated radiation therapy) is the best available technology that would allow adequate dose delivery to the target while minimize exposure to the surrounding organs. A more recent 2020 study performed a systemic review of nine studies (4785 subjects) evaluating the late GI (gastrointestinal) toxicity after pelvic radiotherapy for rectal cancer. The authors concluded that "Preoperative treatment approaches and more advance radiotherapy techniques such as intensity-modulated and image-guided radiotherapy (IMRT) and volumetric modulated arc therapy (VMAT) turn out to result in lower late gastrointestinal toxicity rates". IMRT (intensity-modulated radiation therapy), therefore, is an appropriate treatment in order to minimize the risk of bowel toxicity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Major Depressive Disorder.
Treatment: Social Day Care Increase to 3 Day(s) per Week.
The insurer denied Social Day Care Increase to 3 Day(s) per Week.
The determination is upheld.


This is a female patient with a medical history notable for major depressive disorder. The patient is approved for 19 hours per week of personal care service and two (2) days per week of social day care (SDC). The patient and her care team requested an increase to three (3) days per week of social day care, and this request was denied by the health plan.
The patient's psychiatrist provided a letter of support for this appeal. The letter states that the patient has depression and anxiety. The letter reports that she also has medical conditions which impact her functioning. The physician requests an increase in home health aide personal care hours. There was a request for Social Day Care in the letter.
The patient's nurse practitioner provided a letter of support for this appeal. The letter states that the patient has valvular heart disease, hypertension, and depression. She lives alone. The letter states that "per my professional opinion, the patient would greatly benefit from SDC, Social Day Care, three times a week." No further details were provided.
A Uniform Assessment System (UAS) was completed was available for review. The patient lives alone. She was alert and oriented with procedural memory intact. Her recall was 0/3 at five minutes. For her Instrumental activities of daily living (IADLs), she requires extensive or maximal assistance for all. A task tool associated with the UAS recommended 17.5 hours per week to address her personal care needs. At issue is the medical necessity of Social Day Care SDC - Center-Based Day Care Services; per diem Increase to 3 Day(s) per Week.

The requested health service of Social Day Care SDC - Center-Based Day Care Services; per diem Increase to 3 Day(s) per Week has not been demonstrated to be medically necessary for this patient.
The patient is receiving personal care hours which should be sufficient as recommended by the UAS task tool. Her psychiatrist's letter recommends additional home health hours, but this is not the question under review. The letter does not state which personal care needs, if any, are not being met with her current allotment of hours. The letter from the patient's primary nurse practitioner recommends the requested increase in Social Day Care as something that would "greatly benefit" the patient but does not provide any detail as to what benefit that would provide and if the increase is medically necessary. Therefore, there is insufficient evidence that the requested increase is medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Atopic dermatitis. 
Treatment: Opzelura 1.5% (percent) External (EX) Cream. 
The insurer denied coverage for Opzelura 1.5% External (EX) Cream. 
The denial is overturned. 
 
The patient is an adult female with a history of atopic dermatitis. The patient has failed therapy with topical steroids as well as systemic Dupixent, Cellcept, and Hydroxyzine.  The request is for topical Opzelura as a formulary exception for treatment of atopic dermatitis. 

Based on the submitted documentation, the use of Opzelura to treat atopic dermatitis is medically necessary. The patient has failed multiple topical therapies for the treatment of atopic dermatitis as well as several systemic agents, including Dupixent and mycophenolate. Opzelura is Food and Drug Administration (FDA) approved for atopic dermatitis treatment and its use would be expected to be more effective than formulary alternatives. Formulary alternatives have thus far been ineffective for this patient and the use of Opzelura is not expected to have greater side effects than formulary alternatives. The use of Opzelura is approved as a formulary exception based on the documentation submitted. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication. 

The formulary drug is expected to be ineffective. 

The non- formulary drug is expected to be more effective than the formulary alternatives. 
The carrier's denial of a request for a Formulary Exception for Opzelura 1.5% (percent) |(External) EX Cream to treat atopic dermatitis is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coughing and wheezing. 
Treatment: Inpatient admission. 
The insurer denied coverage for inpatient admission. 
The denial is upheld. 

This is an infant who had been sick for 8 days with coughing. The child was born at 31 weeks gestation with Respiratory Distress syndrome weighing 1445 grams and required hospitalization in the neonatal intensive care unit (NICU) for 1 month. There have been multiple episodes of wheezing in the past. Nine days prior to the admission the child had been seen by the pediatrician and was started on amoxicillin for an otitis media. Eight days prior to admission she was seen in the emergency room (ER) and was diagnosed with viral croup and was found to be positive for respiratory syncytial virus (RSV) and parainfluenza. She was discharged on albuterol and decadron. On the day of admission the mother noted increased work of breathing with an increased respiratory rate so she brought the child to the urgicare center. The child was recommended to go to the hospital for additional treatment. 

In the emergency room (ER) she was noted to have tachypnea and increased work of breathing. The pulse oximeter reading was 99% on room air and remained normal during the entire period of observation in the emergency room (ER). The child was administered one dose of albuterol with some improvement noted. The medical record indicated that the child was appearing comfortable with minimal wheezing noted following the albuterol. The medical record indicated that the decision was made to admit the child for monitoring and assessment. 

The patient was treated with one dose of albuterol in the emergency room (ER) and the medical record indicates that the child had mild wheezing and looked comfortable. The oxygen saturation was normal and there was no need to place the child on oxygen. The child's record indicates that the child had been on amoxicillin for an otitis media and was prescribed albuterol and steroids for croup. 

The medical record does not indicate that blood testing or additional respiratory viral testing was thought to be necessary. The oxygen saturation was normal during the time that the child was observed in the emergency room (ER) and there was not a plan to administer additional bronchodilator or additional steroids in the emergency room (ER). Although this child had chronic respiratory issues related to prematurity, the medical record does not support that the child was in status asthmaticus or in acute respiratory failure. The medical record does not support the need for admission to the hospital for observation. The child could have been safely discharged on continued treatment with albuterol in the home and a follow up visit with the pediatrician in 24 - 48 hours. 

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

Diagnosis: Pneumonia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The health plan's determination is overturned.

This is a female patient with a history of asthma. Her presenting complaints were dyspnea and respiratory distress in addition to a runny nose, cough, chills, and chest tightness. The physical exam was notable for acute distress with increased work of breathing and respiratory distress and decreased air movement. Lab results were notable for influenza positive. Radiology was notable for computed tomography angiography (CTA) of the chest without emboli but the presence of a left lung infiltrate. The patient was diagnosed with influenza versus community acquired pneumonia along with asthma exacerbation and was admitted. At issue is the medical necessity of an inpatient stay.
The inpatient admission was medically necessary.
The patient presented with a moderate to severe asthma exacerbation evidenced by hypoxia and respiratory distress. Her risk of life-threatening decompensation given that presentation was high and an inpatient level of care was appropriate to monitor and treat the patient's conditions. In isolation, risk scoring mechanisms such as the pneumonia severity index would score her comorbid pneumonia as low risk, however, the entirety of the patient's presentation (including her asthma exacerbation) makes inpatient admission appropriate.