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

Diagnosis: dementia, atrial fibrillation and coronary artery disease

Treatment: Personal Care Aide (PCA) Level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week

The denial is upheld

 
This is an elderly male with chronic medical problems including dementia, atrial fibrillation and coronary artery disease. He lives alone in a 1 bedroom apartment. The insurer increased his personal care aide (PCA) services from PCA level 2: 6 hours/day, 7 days/week for a total of 42 hours/week to PCA level 2: 8 hours/day, 7 days/week for a total of 56 hours/week. However, the request was for PCA level 2: 12 hours/day, 7 days/week for a total of 84 hours/week ; leading to an external review.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired. He is reportedly total dependent to maximal assistance for performing much of his Instrumental Activities of Daily Living (lADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for activities of daily living (ADL) tasks including bathing, personal hygiene, dressing, eating, bed mobility, locomotion, toilet transfer/use and ambulation. The patient is reportedly occasionally incontinent of bladder and continent of bowel. His ADL status and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There have been no reported falls over prior 90 days. The patient's functional ability has modestly declined compared to the prior UAS.

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the PCA services Personal Care Aide (PCA) Level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week. This physician would agree that the patient may benefit from additional monitoring; particularly due to his reported cognitive decline and falls risk. However, safety monitoring under PCA services does not include monitoring an individual (e.g., with dementia) when no other Level I or Level II personal care services task is being provided. Based on the documents reviewed, the patient's functional needs can be appropriately provided and maintained with the recent increase in PCA services to 8 hours/day, 7 days/week, total 56 hours/week. The patient also has the option of restructuring and flexibly using the 56 PCA hours weekly to better maintain and meet his functional needs.

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 Personal Care Aide (PCA) Level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: left basal ganglia hemorrhage

Treatment: Subacute Rehabilitation

The insurer denied coverage for Subacute Rehabilitation.

The denial is modified.

 
This is an adult male with diagnosed left basal ganglia hemorrhage. He lives alone in a 6th floor walk-up apartment. Under review is the medical necessity of continued subacute rehabilitation stay at a Non-Skilled level of care.

The patient's clinical condition and functional ability were not at a level to support subacute rehabilitation stay at a Non-Skilled level of care for part of the time frame under review. However, the clinical records demonstrate a level of continued improvement that supported his continued stay for rehabilitation at a Non-Skilled level of care for a few more weeks. According to the case notes, the patient was independent with dressing/footwear and supervision for toilet transfer/toileting. He was only ambulating approximately 25 feet with a walker and supervision. He continued to improve and the patient was able to ambulation 175 feet with a rolling walker, and at the "set-up" level for toileting, bathing and dressing and bathing. Given the patient's living situation (lives alone in 6 floor walk-up), minimal community support and continued improvement; subacute rehabilitation stay at a Non-Skilled level of care for additional days was clinically appropriate. However, he could have been safely discharged home with home care services a few days sooner. 

Based on the above, the insurer's denial must be modified. 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 Subacute Rehabilitation stay at a Non-Skilled level of care the entire length of stay is not substantiated. However, subacute rehabilitation stay at a Non-Skilled level of care for a few more weeks was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Liver Disease (Ascites)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

This patient is an adult male with alcohol related cirrhosis who presented with abdominal distension, abdominal pain, and shortness of breath. Upon presentation, his sodium was 122 and 
he had large volume ascites and anasarca. He received intravenous diuresis with minimal response and ultimately required large volume paracentesis with 9.3 liters removed. During the hospitalization, he remained persistently hyponatremic. The patient was followed by nephrology. He also had acute hypoxic respiratory failure requiring prolonged oxygen, nebulizer treatments, and prolonged respiratory monitoring. The patient required an extended course of intravenous antibiotics for cellulitis (Zosyn) given persistent/worsening erythema and up-trending inflammatory markers despite appropriate antibiotic treatment. The patient required follow up by Infectious Disease. For the history of alcohol (EtOH) abuse, the patient required serial Clinical Institute Withdrawal Assessment (CIWA) assessments. General surgery was consulted for umbilical hernia in the setting of ascites. 
On day #4, the patient reported leaking from the paracentesis site. The nephrology note stated, "Continue to manage with fluid restriction. Continue furosemide, suggest increasing to 40mg twice daily or switching to torsemide 40mg daily." The patient also reported some muscle soreness/pain in the lower abdominal region.

The requested health service was medically necessary.

Inpatient admission was medically necessary in order to manage cellulitis with intravenous antibiotics, monitor electrolytes, and manage the large volume ascites with diuretics and paracentesis. Therefore, the requested health service is medically necessary. 
The medical records do support that the acute inpatient admission was medically necessary. The patient did require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was medically necessary for the dates of service in question as it required the intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes
Treatment: Formulary exception for Mounjaro
The insurer denied: Formulary exception for Mounjaro
The denial is upheld.

The patient is an adult female. She has a diagnosis of Type 2 diabetes mellitus with hyperglycemia. Her A1c (glycated hemoglobin) was 6% (percent), and glucose was 156 milligrams/deciliter last month. There is no other clinical information submitted. The provider prescribed Mounjaro.

The health plan should not cover the Formulary exception for Mounjaro.

There is no objective evidence in the provided records that the patient has diabetes based on the A1c (glycated hemoglobin) of 6.0%. If the patient were to have diabetes, an A1c (glycated hemoglobin) of 6.0% is not uncontrolled. There is no evidence that the patient has tried and failed Ozempic, Rybelsus, Trulicity, and Victoza.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea, Orthopnea
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency department (ED) complaining of dyspnea, a cough and orthopnea. Her medical history was remarkable for coronary artery disease, heart failure with mid-range ejection fraction, chronic kidney disease, diabetes, and hypertension. A chest x-ray showed small bilateral pleural effusions. The patient was treated with intravenous furosemide and was admitted to the hospital for management of decompensated heart failure. Inpatient progress notes were not provided for review. She was discharged. At issue is the medical necessity of an inpatient admission.
Based on the documentation provided. An inpatient admission was not medically necessary.
This patient presented with decompensated heart failure. She was hemodynamically stable and did not have high risk features such as systolic blood pressure less than (<) 100 millimeters of mercury (mm Hg); significant cardiac troponin elevation; serum creatinine level greater than (>) 3 mg/dL; or significant hyponatremia (< 135 milliequivalents per liter (mEq/L)). Based on her Emergency Heart Failure Mortality Risk Grade score, her 7-day mortality risk was low. In stable heart failure patients, such as this patient, without high-risk features, studies have shown that lower-level care is safe and effective, with similar outcomes, including readmission, repeat emergency department visits and 30 day mortality, when compared to those treated as inpatients. Thus, in this instance, a lower level of care would have been sufficient; an inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: substance use
Treatment: inpatient stay
The insurer denied an inpatient stay.
The health plan's determination is upheld. 

The patient is a female who presented to the psychiatric emergency department (ED) for detoxification from heroin. The patient had prolonged QT and was transferred to the medical ED. Her past medical history was significant for bipolar disorder, schizophrenia, hepatitis C, microcytic anemia, neuropathy, ETOH (alcohol), cocaine and opiate abuse.

The requested Inpatient Hospital Admission was not medically necessary for this patient.
The patient presented for detoxication from heroin and cocaine and ETOH. The patient had prolonged QT interval, but it was corrected after potassium supplementation. The patient underwent detox with methadone, and she had some symptoms of withdrawal, and tremor. Symptoms resolved after 20 milligrams (mg) of methadone were given.
The patient was at risk of adverse events with prolonged QT interval, such as ventricular arrhythmia. However, she did not develop arrhythmia, her QT was closely monitored, and she remained stable until detox was completed and she was discharged.
Because no actual arrhythmia occurred, the patient did not meet inpatient admission criteria. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: Braces
The insurer denied: Braces
The denial is overturned.

The patient is an adolescent male. The request is for orthodontic benefits. He has a Class I malocclusion with mild upper spacing and mild lower jaw crowding. He has a severe overjet. The health plan denied coverage of the request due to the patient having a handicapping index score of 11 points. The denial is being appealed.

The requested Braces are medically necessary.

The patient has a deep, impinging overbite with soft tissue damage to the palatal gum tissues. This is an automatic qualifier according to the handicapping index scale. This case has medical necessity, and orthodontic treatment is needed to correct the patient's overbite. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Malocclusion.
Treatment:  Braces and Monthly Visit.

The insurer denied Braces and Monthly Visit.  The denial is overturned.

The patient is an adolescent female. The request is for orthodontic benefits with monthly visits. She has a Class I malocclusion with moderate upper and mild lower crowding. She has a deep bite. The health plan denied coverage of the request due to the patient having a score of 16 points on the handicapping index scale. The denial is being appealed.

The requested Braces and Monthly Visit are medically necessary.

The patient has an impacted permanent anterior tooth (# [number] 11 upper left canine) where extraction is not indicated. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this problem. Therefore, the request is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back and leg pain.
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

The patient is a female who presented with low back pain and right greater than left (R>L) leg pain. She also has associated numbness and tingling in her right (R) foot. The physical exam is notable for a positive (+) straight leg raise (SLR) on the right (R).
Lumbar x-rays demonstrated grade 1 anterolisthesis lumbar (L) 4/5 which is mobile on flexion and extension views. A lumbar magnetic resonance imaging scan (MRI) shows grade 1 spondylolisthesis at L4/5 with severe stenosis centrally and foraminally. She has tried Tylenol, non-steroidal anti-inflammatory drugs (NSAIDs), Lyrica, steroids, gabapentin, a home exercise program, and the passage of time. The patient was recommended L4/5 decompression and fusion. At issue is the medical necessity of the requested inpatient procedure (back surgery).
The inpatient procedure is medically necessary. The patient has low back and R>L lower extremity pain. A radiology reports document grade 1 anterior listhesis L4-5 that is mobile with dynamic films and MRI shows significant central and neuroforaminal. Based on clinical documentation, the patient has tried and failed conservative management. She was recommended L4-5 transforaminal lumbar interbody fusion (TLIF). The standard of care would be to perform decompression and fusion at the L4-5 level to relieve the patient's symptomatic radiculopathy as well as stabilize her spondylolisthesis, thus necessitating the fusion. Lumbar fusion benchmark length of stay is 1-3 days, and the standard of care is to perform this as an inpatient (further supported by inpatient-only status by the Centers for Medicare and Medicaid Services (CMS)).  Given the invasive nature of this major surgical procedure and the necessary post-operative care, inpatient care is medically necessary postoperatively.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cerebral vascular accident
Treatment: Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 84 Hours per Week 
The insurer denied Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 84 Hours per Week 
The health plan's determination is overturned.

The patient is a female with past medical history of hyperlipidemia, hypertension, osteoarthritis, depression, memory impairment, chronic constipation, urinary incontinence, and hemorrhagic stroke with residual right-sided hemiparesis. Who had been assigned CDPAS (Care Consumer Directed Personal Assistance Services) services based on an assessment that assessed the patient at total assistance with task of ordinary housework and maximum assistance with tasks of meal preparation, shopping, and dressing lower body. 

Home Care / Personal Care Consumer Directed Personal Assistance Services (CDPAS) Increase to 84 Hours per Week are medically necessary for this patient.
There is documentation of a change in physical functioning and mental capacity following hemorrhagic stroke. There is documentation from the patient's medical provider of medical necessity of increased CDPAS services. The patient does not have informal support outside of the currently assigned CDPAS service hours. The patient requires at least maximum assistance with tasks of locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time. The insurer failed to document a plan to meet these unpredictable and unscheduled care needs. Because the patient has 24-hour care needs, a tasking tool should not have been utilized to calculate service hours. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, The requested CDPAS services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Spastic quadriplegic cerebral palsy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient was seen with a chief complaint of Spastic quadriplegic cerebral palsy, central dislocation of left hip. 

The patient underwent osteotomy of the hip, and left adductor tenotomy for the diagnosis of spastic quadriplegic cerebral palsy and central dislocation of left hip. 

The patient was seen and he is doing well and the mother stated he did well with morphine and valium overnight. Foley removal was also discussed during the visit. It was noted that the patient's pulse was 142. 

The patient was seen by physical therapy / occupational therapy (PT/OT), the patient tolerated OT session fairly well. He was limited by non-weight bearing status of the left lower extremity. 

During the consult, the patient noted that he did not tolerate continuous positive airway pressure (CPAP) overnight, he had mild tachycardia but no desaturations. He reported that the pain was well controlled and was eating well. He had a good oral (PO) intake and was recommended to transition to oral pain and discontinuing intravenous fluid (IVF).

The patient was seen on morning rounds. He had no acute events overnight; pain control was adequate and denied numbness or tingling. Heart rate noted to be 110-138. Post operative course was uncomplicated and the patient was stable. 

In this case, a child with a history of spastic quadriplegic cerebral palsy, left hip dislocation, asthma, epilepsy, neuromuscular respiratory weakness, hypospadias, and obstructive sleep apnea was admitted as a direct admission for an osteotomy of the left hip with left adductor tenotomy. He had a history of several orthopedic surgeries with worsening subluxation of the left hip. He had a left revision proximal femur varus derotational osteotomy with internal fixation, and left revision open adductor longus tenotomy. During hospitalization, the patient required PT/OT evaluation, acetaminophen every (q) 6 hours (h), IV Toradol q 6 h, diazepam, oxycodone, IV morphine q 4 h, IV cefazolin, and IV dextrose. 

The Milliman Care Guideline recommendation for Bone repositioning procedure for congenital deformities, articular damage or deformity, and posttraumatic deformity is ambulatory. 

The appeal letter stated that the patient required admission due to the patient having an American Society of Anesthesiologists (ASA) status of 3. However, the Milliman Care Guidelines Ambulatory Surgery Exception criteria recommends an American Society of Anesthesiologists class IV or greater for inpatient admission.

According to the medical records received, the patient does not have an indication that warrants inpatient care. The service provided can be rendered in an observation status. 

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 inpatient hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: overactive bladder
Treatment: Myrbetriq
The insurer denied Myrbetriq
The health plan's determination is upheld.

The patient is a male with a diagnosis of overactive bladder who has requested coverage for Myrbetriq. He has tried oxybutynin. His father had dementia at age 75. The plan's formulary drugs include oxybutynin, Gemtesa, Tolterodine Darifenacin, Solifenacin, Festerodine and Trospium.

A formulary exception is not indicated in this case. The formulary drugs may be effective and are all Food and Drug Administration (FDA) approved for the treatment of the member's condition.
While all medications have potential side effects, Gemtesa has a similar side effect profile with Myrbetriq but without the side effect of hypertension.
Per American Urological Association (AUA) "Guideline Statement 11:
If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a 3-adrenoceptor agonist may be tried. Clinical Principle"
The plan's formulary agents are acceptable treatment alternatives with a low risk of potentially risky destabilization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Class I malocclusion 
Treatment: Braces and Monthly Visits (x12) 
The insurer denied Braces and Monthly Visits (x12) 
the health plan's determination is overturned. 

The patient in question is a female with an anterior crossbite on tooth 10. She presents with a skeletal Class I malocclusion with severe crowding in the maxilla and mandible. 

Braces and Monthly Visits (x12) are medically necessary for this patient.
This patient presents with an anterior crossbite on tooth 10, 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 costly to correct than the patient's existing orthodontic problem. For this reason, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion 
Treatment: braces/monthly visits
The insurer denied braces/monthly visits
The health plan's determination is overturned. 

Braces and Monthly Visits are medically necessary for this patient.
There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. Orthodontic treatment can make the teeth significantly less protrusive. If orthodontic treatment reduces the protrusion, it will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, there is scientific evidence that oral health quality of life is reduced in patients with 6+mm overjets, which this patient has. For these reasons, the requested orthodontic treatment is deemed medically necessary.