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

Diagnosis: Dementia
Treatment:  increase in personal care services from 40 hours to 56 hours per week
The insurer denied increase in personal care services from 40 hours to 56 hours per week
The determination is overturned.


This is a female patient with a medical history notable for arthritis, coronary artery disease, multiple myeloma, incontinence and dementia. The patient is approved for 40 hours per week of personal care services. The patient and her care team requested an increase to 56 hours per week, and this request was denied by the health plan.
There were no letters or medical records provided as part of this review. The request for appeal states that the patient is requesting additional hours to allow the same care plan for assistance from 10 AM - 6 PM on Thursday and Sunday.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives in an apartment and her daughter lives in the same building. The patient was alert and oriented to person and place only with cognitive impairment. She requires total dependence for all instrumental activities of daily living. For her activities of daily living (ADLs), she requires maximal assistance for bathing an dressing lower body. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for bed mobility and eating. She requires significant weight bearing assistance for toileting and ambulating. She is frequently incontinent of urine and continent of stool. She has no pressure ulcers. Compared with a prior assessment, the patient showed a functional decline. A task tool associated with the assessment recommended 40.83 hours per week to address her personal care needs. At issue is the medical necessity of an inpatient stay.

The requested health service of increase in personal care services from 40 hours to 56 hours per week is medically necessary for this patient.
The patient has dementia and incontinence. She requires hands on assistance for all activities of daily living including transfers, ambulating, and toileting. She will require assistance every day of the week. Given her level of need, 8 hours per day 7 days per week is medically necessary and reasonable for the patient. The task tool can serve as a starting point or minimum number of hours, but given the pervasiveness of the patient's needs (including unscheduled needs like toileting), it is likely that she requires additional personal aide care time.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiomyopathy. 
Treatment: Mexiletine Hydrochloride 150 mg (milligrams) Capsule. 
The insurer denied Mexiletine Hydrochloride 150 mg Capsule. 
The health plan's determination is overturned. 

The patient is a man with a history of nonischemic cardiomyopathy, heart failure with reduced ejection fraction, hypertension, hyperlipidemia, obstructive sleep apnea, stroke and obesity. 7 years prior to presentation, he suffered a cardiac arrest due to ventricular tachycardia. He underwent implantation of an implantable cardioverter defibrillator. He was treated with amiodarone for suppression of recurrent ventricular tachycardia until it was discontinued due to worsening hyperthyroidism despite therapy with methimazole. 

The formulary alternatives are amiodarone, dofetilide, flecainide, propafenone and sotalol. All would be expected to have adverse effects in this instance. 
This patient has previously been treated with amiodarone which was discontinued due to hyperthyroidism. Thus, it would not be appropriate to re-start it given its adverse effects.
Dofetilide is a Class III antiarrhythmic drug that results in prolongation of the QT interval. Excessive prolongation can lead to malignant ventricular arrhythmias. Several months prior to presentation this man's QT interval was significantly prolonged. Dofetilide is contraindicated in this instance. 
Flecainide and propafenone are Class IC antiarrhythmic drugs. They are contraindicated in patients with congestive heart failure and left ventricular systolic dysfunction due to the risk for worsening heart failure and ventricular arrhythmias. This patient has a severely reduced left ventricular ejection and was recently hospitalized with decompensated heart failure. Thus, flecainide and propafenone are contraindicated.
Sotalol, like dofetilide, is a Class III antiarrhythmic drug. It is contraindicated in patients with significant baseline QT interval prolongation. It also has the potential for worsening or precipitating heart failure in patients with reduced systolic function. Thus, it would not be appropriate for this man with a prolonged QT interval and recent hospitalization for decompensated heart failure. 
Mexiletine is a Class IB antiarrhythmic drug. It does not significantly prolong the QT interval and does not significantly worsen heart failure. It would be expected to be safer than the formulary alternatives in this instance.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diarrhea

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Patient is an adult female with past medical history significant for seizure disorder and recent Clostridium difficile (C difficile) infection (on vancomycin) who presented to the emergency department (ED) with complaints of diarrhea.

Vitals on presentation included: Temperature 98.6 degrees F (Fahrenheit), Blood Pressure 148/94, Pulse 112, Respiratory Rate 16, oxygen (O2) saturation 95% (percent) on Room Air. Laboratory values were notable for the following: White Blood Cells (WBC)-7.6, Hemoglobin (Hgb)-14.5, Hematocrit (Hct)-45.4, creatinine-0.82, glucose-80, lactate-0.85.

Patient was admitted with worsening diarrhea. Computed tomography (CT) of abdomen/pelvis showed improved, previously demonstrated, cecitis/colitis. She tested positive for C difficile. Patient was admitted for intravenous metronidazole and Fidaxomicin. Infectious Diseases consulted. The patient improved clinically, remained afebrile, hemodynamically stable and was discharged to continue outpatient management on oral vancomycin taper. 

According to documentation, the patient was admitted for recurrence of diarrhea secondary to Clostridium difficile infection (CDI). Otherwise, she was afebrile with unremarkable laboratory results including normal WBC. She had no evidence for a systemic toxicity. Patient met criteria for "non-severe" CDI based on white blood cell count <= (less or equal) 15,000 and serum creatinine <(less )1.5. All patients with fulminant CDI should be admitted to the hospital for stabilization, intravenous hydration, and antibiotic administration. Most patients with mild or non-severe CDI can be managed in the outpatient setting. Hospitalization should be considered in patients with severe CDI or shows signs and symptoms of dehydration or inability to tolerate oral intake. 

This patient did not meet criteria for acute inpatient care but met criteria for observation level of care.

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: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
Treatment: Formulary exception for Contrave
The insurer denied: Formulary exception for Contrave
The denial is upheld.

The patient is an adult male with obesity treated with Wegovy. The request for Contrave is under review. The prior request was denied coverage by the health plan, because the health plan 
formulary requires that the medication not be used at the same time with other weight loss products. The denial is being appealed. The last paid claim for Wegovy was 2 months ago. Per the submitted progress note, this request is to use Contrave in combination with Wegovy.

The health plan should not cover the formulary exception for Contrave.

This request is for Contrave for the treatment of obesity to be used in combination with Wegovy. As outlined in the Contrave prescribing information, the safety and effectiveness of Contrave in combination with other products intended for weight loss has not been established. Contrave has risks, including seizures. Therefore, no, the health plan should not cover the formulary exception for Contrave.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is upheld.

This is a female patient being prescribed Wegovy for the diagnosis of obesity. The health plan denied coverage for the requested medication because it did not meet their criteria. The plan requires that the patient have a body mass index (BMI) of at least 30, which she does. They also require documentation of at least 3 months of enrollment in a comprehensive weight management plan such as Weight Watchers. The patient did not meet this criteria, and coverage was denied. The patient states that she enrolled in the appeal request, but no documentation was provided for this review.

The appeal request states that the patient has atrial fibrillation, sleep apnea, and hypertension. Her physician is recommending weight loss to improve these conditions. Her current BMI is 37.2. She will not be using the medication in combination with any other therapy.

The health plan's prescription drug policy for Wegovy was provided. Their prescribing criteria reflect the Food and Drug Administration (FDA) approved indications for prescribing Wegovy. In addition, they require the aforementioned 3 months of qualified comprehensive weight loss plan. Proof of current and prior participation is required by the plan. The plan considers a weight management plan to be adequate if it includes diet modifications, meal planning, an exercise component, behavioral modifications, and coaching. At issue is the medical necessity of Wegovy.

Wegovy is not medically necessary at this time as it is not being prescribed in concert with a comprehensive weight management plan.

Wegovy is an effective and FDA approved medication for the promotion of weight loss in patients with obesity. It can be considered as part of the comprehensive treatment of patients who are trying to lose weight to promote healthy outcomes. However, it is still recommended by expert opinion that this medication be used in conjunction with active behavioral and lifestyle modifications to promote healthy outcomes. According to Perreault, "thorough and compassionate counseling around healthy eating, physical activity, and health-seeking behavior is essential for every patient seeking weight loss." Therefore, the plan's request that the patient enroll in a comprehensive weight loss program and provide proof of participation is a reasonable request before approving the medication as part of her treatment plan.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low magnesium and low potassium
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient in this case is an adult male with laryngeal cancer who was being treated with chemotherapy and radiation. He was being treated with weekly cisplatin. He was seen by his 
oncologist and labs were done and were notable for serum creatinine of 2, potassium of 3.2, and magnesium of 1.2. He had no acute symptoms. Treatment with chemotherapy was held and the patient was sent to the emergency department. The patient's vital signs, physical examination, and electrocardiogram were all unremarkable. He was admitted and treated with intravenous fluids along with potassium and magnesium replacement. Additional laboratory (serum and urine) testing was performed. While in the hospital the patient was continued on intravenous fluids and laboratory studies were monitored. The patient was discharged on day #3.

The requested health service was not medically necessary.

This patient had an acute kidney injury as well as reduced potassium and magnesium levels. He was treated with intravenous fluids and electrolyte replacement and was otherwise monitored. He did not have any hemodynamic instability, obstructive uropathy, active infection, active cardiac rhythm disturbance, or any other acute medical issue. He did not require acute care inpatient admission. He could have been safely managed at a lower level of care, such as observation or 
outpatient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth pain
Treatment: D3330 Nerve Treatment on Tooth 19
The insurer denied: D3330 Nerve Treatment on Tooth 19
The denial is upheld.

The patient is an adult female. The request is for root canal treatment on tooth #19. The health plan denied coverage of the request due to the tooth not being an abutment for a partial 
denture or a bridge. The denial is being appealed.

The requested health service is not medically necessary.

The bite wing X-ray of tooth #19 does not show any decay in it. The Panorex X-ray presented does not show any pathology at the root apex requiring a root canal procedure. There is no 
documented history from the provider of pain or discomfort with this tooth. With the limited documentation provided, the need for a root canal procedure is not evidenced.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
Patient is an adult male with a history of polysubstance abuse. The patient presented to the hospital with complaints of worsening shortness of breath (SOB) and cough with productive of yellow green sputum for about 3 days. He also complained of nausea and vomiting.

The patient reported use of Heroin and Cocaine prior to admission. He had recent hospitalization for Paraspinal abscess and Infective Endocarditis. Vital signs at presentation: T 100.9 degrees F,  heart rate 121, Respirations 24, Blood Pressure 145/91. Oxygen saturations 94% on room air. He had rhonchi on lung exam.

White blood cell (WBC) was 7.6, Hemoglobin 12.2, Blood urea nitrogen / Creatinine 12/0.8
Venous blood gas 7.38/45/36.  Chest x-ray (CXR) showed bilateral patchy airspace disease and  multifocal pneumonia (PNA) versus Septic Emboli. Patient also had a history of congestive heart failure (CHF). He was non compliant with Lasix. The patient was treated with intravenous (IV) antibiotics (Abx). The patient left soon after that.

This patient did not need acute inpatient hospitalization for PNA. The patient was afebrile and hemodynamically stable as per the history & physical notes.  There was no hypoxia. WBC was normal. 

He could have been placed in Observation status while diagnostic testing and treatment were initiated. He was tolerating food and fluids. He could have been treated in Observation setting for up to 48 hours and subsequently discharged home on oral (PO) meds. The patient signed out against medical advice (AMA) soon after admission.

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: Gilenya 0.5 milligrams (mg) capsule
The insurer denied Gilenya 0.5 mg capsule.
The health plan's determination is overturned.

The patient is a female with multiple sclerosis. Treatment with Gilenya is requested. The drug was denied. The patient has tried and failed generic Fingolimod for approximately two months. The patient had numerous adverse side effects. The provider has appealed the denial of Gilenya.

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

The requested health service/treatment of Gilenya 0.5mg is medically necessary for this patient. The patient is requesting treatment with Gilenya. The patient has been treated with Gilenya since 2012. This drug is Food and Drug Administration (FDA) approved for treatment of multiple sclerosis. The patient has tried and failed Fingolimod. The patient tried the drug for two months and has adverse side effects such as headache, fatigue, and joint pain. As the patient has tried and failed the generic drug, the use of the brand drug is appropriate. Any other treatment option would require the patient to change to a drug with another mechanism of action. There is no medical reason that the patient should not be treated with Gilenya as this drug prevents neurologic disability.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder

Treatment: Home health care

The insurer denied coverage for Home health care

The denial is overturned

 
This child reportedly had severe developmental delays and a diagnosis of Autism Spectrum Disorder and required assistance in activities of daily living and self care including eating, toileting, and grooming, and it was reported that his mother was having more difficulty controlling him physically. He reportedly had a behavioral specialist and was receiving medications including methylphenidate and guanfacine. He reportedly also had speech, language and physical and occupational therapy services. He reportedly had language impairment, developmental coordination disorder, sensory integration disorder, hyperactivity, feeding problems, and lack of normal physical development. He reportedly lived with his mother and sister and attends school.
  
The insurer denied the request for additional consumer directed personal assistance (CDPAS) hours as 30 hours per week were requested. They stated that the plan approval is for 8.75 hours per week and that the patient did not meet criteria for the additional hours totaling 30 hours of consumer directed personal assistance (CDPAS) services per week.

The medical records for review did support that he required this amount of services and not just the plan approved 8.75 hours per week. The Department of Health reports that personal care services (PCS) helps people with everyday tasks including activities of daily living or household tasks. It also states that personal care attends to the physical needs of people disabled or otherwise unable to take care of themselves. Such ADL's Activities of daily living include bathing, showering, management of bodily fluids, toileting, feeding, ambulating, transferring from bed to chair or wheelchair, or in and out of the tub or shower, grooming, taking care of teeth or mouth, housekeeping, or meal preparation. It involves a physician to order the services and then a nursing and/or social work assessment to be done. 

Autism spectrum disorder is a neurodevelopmental disorder that is considered permanent and there are many associated deficits with this disorder so the needs for patients with these disorders and developmental delays can be extensive which was the case with this patient. As a result, the recommendation is to reverse the previous decision and approve the request for an increase in direct personal care assistance services for a total of 30 hours per week. 

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 personal care aide (PCA), consumer directed personal assistance services (CDPAS) 30 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week for a Total Amount of 84 Hours per Week. 
The health plan's determination is overturned. 

The patient is a male with a past medical history of dementia, osteoarthritis, urinary incontinence, glaucoma with vision loss, constipation, benign prostatic hyperplasia (BPH), gastroesophageal reflux disease (GERD), hypertension, coronary artery disease, atrial fibrillation with chronic anticoagulation, depression, neoplasm of the bronchus and lung and chronic obstructive pulmonary disease (COPD) with dependence on supplemental oxygen who had been assigned PCA (personal care aide) services assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, managing finances, phone use, shopping, bathing, and dressing lower body. With tasks of managing medication, stairs, transportation, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating the patient was assessed at extensive assistance. 

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week - Total Amount of 84 Hours per Week is medically necessary for this patient.
There is documentation from the patient's medical provider for the medical necessity of increased PCA services. There is documentation from the plan's own assessment of an increased need in assistance with tasks of managing medication, stairs, shopping, transportation, personal hygiene, dressing upper body, toilet use, and eating without a recommended increase in hours per week.  The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has no informal help to assist him outside of the hours of currently assigned PCA services. The requested increase in PCA 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 services are medically necessary.  Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to the maintenance of the patient's health and safety in his own home.