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

Diagnosis:  Chest Pain.
Treatment:  Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female with history of hypertension. She presented with chest pain and was diagnosed with pneumonia.

The patient was started on IV (intravenous) antibiotics. The acute inpatient level of care was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

The patient was diagnosed with pneumonia. The patient received intravenous antibiotics. On admission, the patient was hemodynamically stable and afebrile without hypoxia on room air. The patient continued intravenous antibiotics. Infectious disease was consulted. Leukocytosis resolved, and the patient reported symptomatic improvement within 24 hours of admission. The inpatient admission was not medically necessary.

Given that the patient's signs and symptoms due to pneumonia improved significantly with ER (emergency room) care, the patient's treatment course would have been expected to be safe and effective at a lower level of care. The treatment provided in this patient was reasonably expected to be provided but does not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple sclerosis.
Treatment:  Additional power wheelchair accessories, three units codes E2300 power seat elevation system, any type.

The insurer denied coverage for additional power wheelchair accessories, three units codes E2300 power seat elevation system, any type.  The denial is overturned.
 
This is an adult with multiple sclerosis and associated neuromuscular deficits including left dominate plegia. Under review is durable medical equipment (DME) with power seat elevation system.

The requested DME with a power seat elevation component for the motorized wheelchair is not a convenience item. This physician strongly agrees with the treating physical therapist. The elevating seating function is medically necessary to assist with transferring and optimal positioning for routine care and transfer tasks. The patient clearly has neuromuscular deficits and would benefit from an elevating seating system for assistance with activities of daily living (ADL). Denying this request would only serve to increased risk for falling injury, increased pain and decreased functional ability of this individual with progressive multiple sclerosis.  

Based on the above, the insurer's denial must be overturned. 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 additional power wheelchair accessories, three units codes E2300 power seat elevation system, any type is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neurofibromatosis type 1
Treatment: Genetic Lab Test (81403x1)
The insurer denied coverage for Genetic Lab Test (81403x1)
The denial is upheld 

This patient is an adult with known neurofibromatosis type 1 (NF1). The treating provider performed genetic testing. Limited records were provided for review.

The treating provider has not provided any information to support genetic testing for this patient. If this patient has a known NF1, it is unknown why there was a need to repeat genetic testing. Due to lack of clinical documentation, the request cannot be determined to be medically necessary, at this time.     

Neurofibromatosis type 1, inherited in an autosomal dominant pattern, is characterized by multiple cafe-au-lait macules (CALMs), skinfold freckling (more correctly termed lentiginous macules since they occur in non-sun exposed areas), iris Lisch nodules, tumors of the nervous system, and other features (1, 2). Disease manifestations can occur in any body system. There is a significantly increased risk of certain cancers, including female breast cancer < (less than) 50 years, malignant peripheral nerve sheath tumors (MPNSTs), and brain tumors (Legius, E. et al. 2021).

Neurofibromatosis-1 (NF-1), or Von Recklinghausen disease, is one of the inheritable neurocutaneous disorders manifested by developmental changes in the nervous system, bones, and skin. It is an autosomal dominant disorder. Additionally, it is the most common amongst all the hamartoma neoplastic syndromes, including tuberous sclerosis, Gardner, and Cowden syndromes.

Genetic testing is not mandatory for the diagnosis. It can be utilized for establishing the diagnosis in questionable presentations, screening of family members, and prenatal screening. Ninety-five percent of mutations can be detected by genetic testing in individuals with NF-1 clinical diagnosis. A negative test does not exclude the disease, as mosaicism may be possible, as in segmental NF-1. Affected individuals should receive multidisciplinary care from geneticists, pediatricians, pediatric neurologists, ophthalmologists, psychiatrists, and psychologists to identify the disorder and related complications, provide the treatment, and need psychosocial support and guidance (Adil, A. et al. 2022).                                                         

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 Genetic Lab Test (81403x1) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection (UTI)/Sepsis.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This adult male, nursing home resident, who is bedbound, presented with fever up to 102.9. Associated symptoms included body aches, headache, and urinary frequency. The patient's vital signs were stable. His maximum temperature was 104.5, pulse was 130, and blood pressure was 95/63. His exam was unremarkable. Pertinent labs included: white blood cell (WBC) count of 19.7 and lactic acid of 3.0. Electrocardiogram (EKG) showed sinus tachycardia. Chest x-ray revealed no acute disease. While in the emergency room he was treated with 
intravenous fluids and intravenous antibiotics. At time of admission, he was afebrile with a heart rate of 104.
The patient was admitted with sepsis for intravenous antibiotics. On Day #2, the patient's temperature was 101.5 and white blood cell count was 13.4. The patient continued intravenous fluids and intravenous antibiotics. On Day #3, the patient was afebrile. His white blood cell count was 7.5. On Day #5, intravenous antibiotics were changed. Blood cultures were negative. The patient was recommended to change to oral (PO) antibiotics for one month at discharge. He was discharged on Day #7.

The proposed treatment is not medically necessary.

The requested inpatient admission was denied because the patient was not hypotensive, did not have high fever, and did not have worsening kidney function. The patient was admitted with urinary tract infection. He was hemodynamically stable. He 
presented to the emergency room with fever and tachycardia. After initiating treatment in the emergency room, his fever and tachycardia defervesced. He did not have an indwelling device. 
He was not immunocompromised. He did not have renal failure. He did not have pyelonephritis. The InterQual Guideline for Urinary Tract Infection (UTI) is not met because the patient did not have worsening findings despite initial treatment; the patient had not failed a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/other
Treatment: Inpatient Hospital

Diagnosis: Cardiac/Circulatory Problems/other/Acute Coronary Syndrome
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. The health plan's determination is upheld.

This woman presented to the emergency department complaining of chest pain and associated dyspnea. Her medical history was remarkable for asthma and obesity. Her blood pressure was 157/91 millimeters of mercury (mmHg) with a heart rate of 72 beats/minute. Her room air oxygen saturation was 99%. She was afebrile. An electrocardiogram showed sinus rhythm with T wave inversions. No old tracings were available for comparison. Her serum troponin and brain natriuretic peptide levels were normal. A chest X-ray showed interstitial infiltrates thought to possibly represent atypical pneumonia. Her white blood cell count was normal. The patient was treated with Aspirin and sublingual Nitroglycerin and her pain resolved. She was admitted to the hospital. Aspirin, antibiotics and an Albuterol inhaler were prescribed. She had no further chest pain and her serum troponin level remained normal. A repeat chest X-ray was unremarkable and the antibiotics were discontinued. An echocardiogram showed normal left ventricular systolic function. Myocardial perfusion imaging revealed a small area of small mild stress-induced ischemia at the apex. The patient was discharged with plans for outpatient cardiology follow-up.
The medical necessity for an inpatient hospital admission is at issue.

I uphold, in whole, the health plan's determination that an inpatient level of care was not medically necessary.

No. Based on the documentation provided, an inpatient level of care was not medically necessary.
This woman 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, she was hemodynamically stable, with normal cardiac biomarkers, and no diagnostic electrocardiographic changes. She did not require intensive monitoring or infusion of intravenous cardioactive medications. Based on her HEART score, her risk for major adverse cardiac events was low. 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 for Echocardiology (ASE)/American Society of Chest Physicians (CHEST)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) Guidelines for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guidelines for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast Cancer
Treatment: positron emission tomography (PET) / computed tomography (CT)
The insurer denied positron emission tomography (PET) / computed tomography (CT).
The determination is overturned.
This is a female patient with metastatic estrogen receptor (ER) positive (+)/ progesterone receptor (PR) +/ human epidermal growth factor receptor 2 (HER2) negative (-) breast cancer. The patient is currently on palbociclib and letrozole. The patient had a magnetic resonance imaging (MRI) scan of the liver with findings concerning for progression - a 5.2 centimeter (cm) lesion in the right hepatic dome. A positron emission tomography (PET) / computed tomography (CT) was obtained to confirm this and is under review for medical necessity.
The patient's magnetic resonance imaging (MRI) demonstrated a suspicious area in the liver. Imaging was otherwise unremarkable for progressive disease. The PET/CT was obtained to assist in determining the status of disease (i.e. progression) given that there was no other clinical or radiographic evidence of progressive disease in this patient. The National Comprehensive Cancer Network (NCCN) Guidelines state "...fludeoxyglucose (FDG) PET/ CT is most helpful in situations where standard staging studies are equivocal or suspicious...." This approach is similarly echoed in the peer-reviewed literature and by the authors of UpToDate.The authors of UpToDate state PET/CT is preferred"...as it has demonstrated high sensitivity and specificity in detecting metastatic disease and can reliably assess response to therapy.." This study was not obtained for convenience nor in the context of a clinical trial. For these reasons, criteria for medical necessity have been satisfied.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alzheimer's disease, asthma and osteoarthritis
Treatment: Home care / personal care HHC (home health care) - level 2 personal care services, per 15 minutes increase to 60 hours per week
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week.
The denial is upheld.

This is a geriatric patient with chronic medical problems including Alzheimer's disease, asthma and osteoarthritis. The patient lives with the daughter in a private residence. The patient is approved for consumer directed personal assistance services (CDPAS) 45 hours per week and the request is for an increase to 60 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "moderately impaired." The patient is fully oriented. The patient reportedly requires maximal to extensive assistance for performing much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing, personal hygiene and toilet transfer/use. Limited assistance is needed for bed mobility, locomotion and ambulation. The patient is frequently incontinent of bladder and continent of bowel. The patient is independent with eating.  

There has been no change in the functional ability or reported falls over the prior 90 days. In addition, the functional ability is much the same; if not modestly improved when compared to the previous UAS. The patient's clinical condition and functional deficits are not at a level or unpredictable as to require CDPAS 60 hours/week.  

This physician would agree the patient may require additional monitoring, particularly due to the reported weakness. However, safety monitoring under personal care services (PCS) does not include monitoring an individual when no other Level 1 or Level 2 personal care service task is being provided. Based on the records reviewed, the patient's health and safety in the home can be appropriately provided and maintained by the currently approved CDPAS 45 hours/week.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.   

From a physical medicine and rehabilitation perspective, the requested home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week is not medically necessary.  

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 home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Heart failure, legally blind, rheumatoid arthritis and ulcerative colitis

Treatment: Personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week

The insurer denied coverage for personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week

The denial is modified

 
This is an elderly patient with chronic medical problems including heart failure, legally blind, rheumatoid arthritis and ulcerative colitis.  She lives with her daughter and son-in-law in a private residence.  The insurer approved personal care services (PCS) 10 hours/day, 7 days/week for a total of 70 hours/week.  The request is for PCS 24 hours per day - 7 days per week (12 hour split shifts) for a total of 168 hours per week.

The patient's cognition is described as "moderately impaired."  She is totally dependent for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She is also reportedly totally dependent for bathing, lower body dressing, locomotion, and toilet transfer/use.  She is frequently incontinent of bowel and bladder.  Maximal assistance is reportedly needed for personal hygiene, upper body dressing, eating and bed mobility.  She has reportedly fallen twice over the past 90 days.  

However, the patient's functional impairments are not at a level of unpredictable as to require the requested PCS 24 hours/day (split shift).  In fact, the physical therapy treatment notes from the skilled nursing facility, documents the patient's higher level of function.  She required only contact guard assistance and minimal assistance for bed mobility and transfer activities (locomotion), respectively.  She was also able to ambulate 75 feet with contact guard assistance.  According to the occupational therapy treatment notes, the patient required only supervision for personal hygiene and contact guard assistance for (upper and lower body) dressing.  Toileting was also at the contact guard level of assistance (not the reported total dependence).  

The patient may benefit from monitoring for safety; particularly due to her reported cognitive deficits and vison impairment  However, PCS for companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service.  Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained at home by modestly increasing PCS to 12 hours/day, 7 days/week totaling 84 hours/week. 

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 personal care services (PCS) 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week services is not substantiated. However, increasing PCS to 12 hours/day, 7 days a week for a total of 84 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis
Treatment: Simponi
The insurer denied Simponi.
The health plan's determination is upheld. 

The patient is a woman with RA (rheumatoid arthritis). The formulary alternatives are Kevara, Xeljanz, Rinvoq, Humira and Enbrel. Per the patient's provider, the patient has high cholesterol. Labs were reviewed from years prior and the total cholesterol and LDL (low density lipoprotein) cholesterol are both elevated. Per a chart note, the patient is not on treatment for HLD (hyperlipidemia). Prior treatment has included Enbrel and Humira.

Simponi is not medically necessary for this patient.

There is no reason that the patient cannot try the formulary drugs. Cholesterol needs to be monitored closely on both IL-6 (Interleukin 6) antagonists and JAK (Janus kinase) inhibitors but a diagnosis of HLD is not a contraindication to starting one of these medications. Moreover, the high cholesterol level should be addressed (i.e. [that is], up to date labs are needed) and treatment started if appropriate. HLD is not a contraindication to starting one of the formulary medications. If the patient does still have HLD (labs showing HLD are from years ago), this should be addressed and treated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Nasal value collapse. 
Treatment: Repair of Nasal Valve Collapse with Low Energy, Temperature Controlled (radiofrequency- code 30469). 

The insurer denied: Repair of Nasal Valve Collapse with Low Energy, Temperature Controlled (radiofrequency- code 30469). 

The denial is upheld. 

The patient is an adult male with nasal airway obstruction. Medical therapies are not documented. The patient has nasal valve collapse reversible as determined with modified Cottle's maneuver. The patient has right nasal septal deviation noted and turbinate hypertrophy. Radiofrequency ablation is requested (VivAer). The patient also has severe sleep apnea. 

The health plan should not cover the requested health service. 

The requested health service is not more beneficial. The patient has deviated septum, turbinate hypertrophy, and reported nasal valve collapse. There is no documentation of the patient's prior medical therapy to address nasal airway obstruction. Neither 
is there adequate documentation of the contribution of septal deviation and turbinate hypertrophy to airway obstruction versus valve collapse. Therefore, aside from technology issues, there is inadequate clinical indication for isolated treatment of the nasal valve with the submitted medical record.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Nasal value collapse. 
Treatment: Repair of Nasal Valve Collapse with Low Energy, Temperature Controlled (radiofrequency- code 30469). 

The insurer denied: Repair of Nasal Valve Collapse with Low Energy, Temperature Controlled (radiofrequency- code 30469). 

The denial is upheld. 

The patient is an adult male with a history of chronic nasal obstruction and OSA (obstructive sleep apnea). Nasal exam reports a deviated septum, nasal valve stenosis, swell body hypertrophy, inferior and middle turbinate hypertrophy. Medical therapy includes an antibiotic. The provider is requesting coverage of Repair of Nasal Valve Collapse with Low Energy, Temperature Controlled (radiofrequency- CPT 30469). The request was previously denied, and the denial is being appealed. 

The health plan should not cover the requested health service. 

There are multiple nasal areas of pathology noted, including a deviated septum, nasal valve stenosis, swell body hypertrophy, inferior and middle turbinate hypertrophy. There is not documentation of the failure of any medical therapy with an extended course of nasal steroids. There is no nasal valve collapse documented on exam, only nasal valve stenosis associated with a deviated septum. Therefore, the nasal valve surgery code 30469 cannot be confirmed as medically appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
Pharmacy/prescription drug

Diagnosis: Crohn's disease
Treatment: Stelara
The insurer denied Stelara. The health plan's determination is overturned.

This patient is a male with a history of Crohn's disease. He previously tried and failed infliximab and methotrexate. Stelara is being requested and is under review.

Stelara is medically necessary for this patient. Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease.
Chavannes M et al, reported a multi-centered cohort study supporting the safety and efficacy of Stelara in pediatric patients with Crohn's disease.
A report by Dayan JR et al, showed that ustekinumab (Stelara) is efficacious and safe in pediatric patients with inflammatory bowel disease.
The clinical practice guidelines support the use of Stelara in pediatric Crohn's patients who failed tumor necrosis factor (TNF) -alpha inhibitors. Therefore, Stelara use in children with Crohn's disease is appropriate and well supported by peer reviewed evidence.
This patient has already tried and failed the available alternatives. Therefore, Stelara is medically necessary.