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

Diagnosis: Parkinson's Disease
Treatment: Personal Care Assistance - total of 56 hours a week.
The insurer denied the request for Personal Care Assistance - total of 56 hours a week.
The health plan's determination is overturned.

The patient is a male with a medical history notable for Parkinson's disease, atrial fibrillation, and ambulatory dysfunction. The patient is approved for 35 hours per week of personal care assistance services. The patient and his care team requested an increase to 56 hours per week, and the request was denied by the health plan. This denial is the subject under review.
There were no physician letters or notes provided as part of this review.
The health plan's denial letter states that the patient is being evaluated in a post-hospitalization nursing facility. Therefore, they expect his condition to improve and will not consider increasing his hours. His wife is currently in the hospital and not able to provide informal support at this time.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in person. The patient was alert and oriented and able to make his needs known. For his Instrumental activities of daily living (IADL), he requires maximal assistance for meal preparation, housework, shopping, and transportation. He requires extensive assistance for medications and stairs. For his activities of daily living (ADL), he requires extensive assistance for bathing, hygiene, dressing, walking, locomotion, toilet transfers, and toilet use; notes state that he requires "extensive to maximal assistance" for these tasks. His Parkinson's disease severely limits his ability to participate in ADL (activities of daily living) tasks and they are currently being assisted by nursing home staff. He is occasionally incontinent of urine and continent of bowel. A task tool associated with the UAS (Uniform Assessment System) recommended 35 hours per week to address his personal care needs.

The requested health service of Personal Care Assistance - Total of 56 Hours per Week is medically necessary for this patient. The patient has Parkinson's disease and associated mobility related issues. Although the task tool recommends 35 hours per week, he requires hands-on assistance with nearly all ADL (activities of daily living) tasks which will occur throughout the day on a continuous and unscheduled basis. Therefore, his true level of need cannot be accurately assessed by the task tool. The requested increase in hours is reasonable in light of the patient's functional needs and medically necessary to support personal care functions. Failure to provide for basic needs such as transfers, and toileting could lead to adverse health outcomes.

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

Diagnosis: Diabetes
Treatment: Mounjaro 2.5mg (milligrams)/0.5ml (milliliter) Pen
The insurer denied: Mounjaro 2.5mg (milligrams)/0.5ml (milliliter) Pen
The denial is overturned.

This is an adult female diagnosed with type 2 diabetes mellitus is worsening. This request is for Mounjaro. As reported, she is currently taking Ozempic 0.5 mg (she could not tolerate higher doses in the past due to nausea and vomiting). As per visit note 
from last month, she is on Ozempic; Levemir; Humalog; metformin ER 750; Glimepirides. Her A1C was 7.8 %. 

The health plan should cover the proposed treatment. 

The requested medication Mounjaro (trizepatide) is FDA (Food and Drug Administration) approved for the treatment of adults with type 2 diabetes. It is a GLP-1 (Glucagon-like-1 
peptide) and GIP (dual glucose-dependent insulin tropic polypeptide) receptor agonist. It has been shown in clinical trials to lead to improvement in hemoglobin A1C as well as weight loss [1-3]. There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommends using GLP-1 receptor agonists as a 1st line agent. There is no preference for the requested medication over GLP-1 receptor agonists [4]. The patient has tried a GLP-1 receptor agonist and was unable to titrate upward due to side effects. The patient's hemoglobin A1C is not at goal. The side effects would be expected from the other formulary alternatives in that class. The request is consistent with generally accepted standards of medical practice. The health plan should cover the proposed treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low hemoglobin, right upper extremity and flank pain. 
Treatment: Inpatient Hospital Admission. 

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

The patient in this case is an adult female who presented to the emergency department with right upper extremity and flank pain that had been present for two weeks. She was noted to be wheelchair bound and to have multiple prior medical problems. She also said she was told one week before this visit that her hemoglobin was low. She had pain in her extremities. The patient's physical exam was unremarkable. Her pain was felt due to benign musculoskeletal disease. Evaluation revealed a hemoglobin of 5.3 grams per deciliter (g/dl). She was admitted and transfused packed red blood cells and was discharged the following day. 

The proposed treatment was not medically necessary. 

This patient was hemodynamically stable. There was no indication that she was bleeding or that she had acute coronary ischemia or any other organ dysfunction. She did not require acute care inpatient admission for transfusion, which could have been done in the observation setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rectal pain and bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

According to the documentation submitted, this is a patient with a history of hypertension (HTN), hyperlipidemia (HLD) and chronic rectal pain. As per the triage the patient complained of rectal pain with some bleeding. The patient was afebrile with stable vital signs. In the emergency department (ED) the patient was noted to have more recent worsening rectal pain and possible fistula as per the outpatient colon rectal surgeon. The patient began having rectal pain approximately 7 months ago and had been treated for hemorrhoids and for possible perianal abscess/proctitis. More recently the patient had been on antibiotics for possible early anal infection which finished on the day of admission. On exam the patient had no external abnormalities including no hemorrhoids, erythema, fluctuance, or cellulitis. No fissures or hemorrhoids were palpated. Labs were unremarkable including a white blood cell count (WBC) of 3.85. The patient's body mass index (BMI) was 26.9. The principal diagnosis was recto cutaneous fistula. The patient had a computed tomography (CT) which showed no abscess but did show a fistula.

At issue the insurer has denied coverage for inpatient hospital admission. In their Final Adverse Determination letter they stated that they are upholding their denial decision. They noted to approve this service, the following criteria must be met: the health data sent did not meet the guide they use called Milliman Care Guidelines (MCG) criteria. There was no hemodynamic, pulmonary, neurological, or metabolic reason for acute level of care. 

According to MCG Health General Recovery Guidelines 27th edition General Surgery or Procedure GRG: SG-GS (ISC GRG), Operative Status Criteria is ambulatory for many procedures. Examples include: Endoscopic procedures; Embolization procedures; Most biopsy procedures; Many elective operations; including Stoma repair, Fistula repair.  He did not have a high white blood cell (WBC) count or fever that necessitated inpatient care but rather observation. The fact that he had rectal pain was not an indication for an acute admission (1). 

Finally, MCG Health noted in General recovery care 27th edition General admission criteria GRG: CG-GAC (ISC GRG) that admission is indicated for 1 or more criteria (2).  Based upon these guidelines this patient should have been observed rather than placed in an acute admission as he did not have any indication as noted above for inpatient stay.

Based upon these findings the health care plan did act reasonably and with sound medical judgment. The criteria utilized included MCG guidelines as to what constitutes good acceptable standard of care with references below.

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: Medical necessity
Decision: Upheld

Diagnosis: adrenal hemorrhage

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is the case of a young adult who presented to triage with complaint of left sided pain radiating to the abdomen. Vital signs included Blood Pressure of 107/87, Pulse 77 and she was afebrile. As per the nursing note the patient gave birth and had a cholecystectomy recently. As per the emergency department (ED) provider note the patient was post-partum and post cholecystectomy and presented to the ED with left sided flank pain radiating to the left upper abdomen that began suddenly and worsened. She had dirty urine that resolved a few days ago. She denied chills, dysuria, vomiting, or diarrhea. Exam revealed the abdomen to be soft, non-distended, with left sided abdomen tender to palpation without guarding or rebound. Labs included normal amylase, White blood cells (WBC) of 14.5, lactate level of 3.55, Hemoglobin (HgB) 13.2 and platelet count of 481. Computed tomography (CT) of the abdomen at 23:52 revealed diffuse left adrenal gland enlargement measuring 3.5 x 1.7 centimeters (cm) with trace fluid around the upper pole of the left kidney compatible with adrenal hemorrhage. Surgery and Obstetrics / Gynecology (OB/Gyn) were consulted. The patient was admitted to surgical service. 

Based upon the records, the full inpatient admission was not justified at the acute inpatient level as this patient could have been managed in an ambulatory/observation setting. She presented for abdominal pain and the finding on CT was adrenal hemorrhage. She was medically stable with stable vital signs and stable hemoglobin. Her pain was well controlled. All that was needed was observation in a controlled setting. She did not need any inpatient admission but rather 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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Glioblastoma.
Treatment:  Xpovio 80 milligrams (mg) / week (40 mg x 2).

The insurer denied coverage for Xpovio 80 milligrams (mg) / week (40 mg x 2).  The denial is overturned.

The insurer has denied coverage for Xpovio 80 milligrams (mg) / week (40 mg x 2), as not medically necessary. In a Final Adverse Determination letter, they stated that the medication was prescribed to treat glioblastoma. The medication can be approved to treat certain types of cancer and when other criteria are met. The patient did not meet criteria for approval. 

This is an adult patient with the diagnosis of glioblastoma whose treating provider would like to use Xpovio. The request is for Xpovio 80 milligrams (mg) / week (40 mg x two (2)). 

The medication was previously denied, as the patient did not have the type of cancer for which the plan covered the requested medication.

This is a patient with extensively treated glioblastoma whose treating provider would like to use Xpovio. While there are no phase III data, there are phase II data that suggest this drug could be effective. Given the lack of other possible therapies available for this patient and the positive phase II data, the drug is medically necessary for this patient. 

Per Lassman et al., (2022) "Selinexor is an oral selective inhibitor of exportin-1 (XPO1) with efficacy in various solid and hematologic tumors... At 80 mg weekly, single agent Selinexor induced responses and clinically relevant PFS6 with manageable side effects requiring dose reductions. Ongoing trials are evaluating safety and efficacy of Selinexor in combination with other therapies for newly diagnosed or recurrent glioblastoma."

Per Syed (2019) "Selinexor (XPOVIO) is a first-in-class, oral, small molecule Exportin-1 (XPO1) inhibitor that is being developed by Karyopharm Therapeutics for the treatment of cancer. Selinexor (in combination with dexamethasone) received accelerated approval in the United States of America (USA) in July 2019 for the treatment of adult patients with relapsed or refractory multiple myeloma (RRMM). Selinexor is also undergoing clinical development in a wide range of haematological and solid cancers."

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

The medical necessity for Xpovio 80 milligrams (mg) / week (40 mg x 2) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocarditis.
Treatment: Long Term Acute Care.

The insurer denied Long Term Acute Care.  The denial is upheld.

The patient is an adult male with infective endocarditis. He was referred to a long-term acute care hospital (LTAC) for six weeks of IV (intravenous) antibiotic therapy. Twenty-six (26) skilled nursing facilities denied the patient service due to his drug history. He was currently receiving the same treatment at the hospital, and so the requested coverage was denied by the health plan as not medically necessary. The denial is being appealed.

The requested Long Term Acute Care is not medically necessary. 

Based on the peer-reviewed medical literature, there is not a medical need for the requested LTAC (long term acute care). The patient is receiving the same treatment at the current facility. Transfers to another facility are not considered medically necessary when the care can be provided at the current facility or at a lower level of care, such as a SNF (skilled nursing facility). The transfer to long term acute care would not meet generally accepted national standards of medical practice, as it 
would not be the least intensive and/or most appropriate alternatives among treatment options. Therefore, based on the submitted information and the current published medical literature, the requested health service is not medically necessary. The patient is receiving the same treatment at the current facility. Transfers to another LTAC (long term acute care) is not considered medically necessary, since the care can be provided at the current facility or at a lower level of care, such as a SNF (skilled nursing facility). The facility can continue to search for a skilled nursing facility to accept the patient. Patient or physician preference for a LTAC (long term acute care) for patient, physician or hospital convenience does not establish medical necessity. Therefore, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke, hypertension, diabetes, leg edema, kidney disease, osteoarthritis, cervicalgia, and congestive heart failure
Treatment: Personal care assistance services 24 hours/day, 7 days/week (split shift)
The insurer denied personal care assistance services 24 hours/day, 7 days/week (split shift).
The denial is upheld.

This elderly female patient has medical conditions that include stroke, hypertension, diabetes, leg edema, kidney disease, osteoarthritis, cervicalgia, and congestive heart failure. Denial of personal care assistance (PCA) services 24 hours/day, 7 days/week (split shift) is being appealed. Uniform Assessment System (UAS) performed last month shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; extensive assistance with managing finances and medications, bathing, dressing, and toileting; limited assistance with phone use, personal hygiene walking, locomotion, and eating; and supervision with bed mobility. She has frequent bladder incontinence. Compared to UAS evaluation completed last year, there has been a decline with bathing, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and eating.

The proposed treatment is not medically necessary.

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of PCA services 24 hours/day, 7 days/week (split shift) is being appealed. UAS evaluation completed last month shows the patient needs assistance with all activities of daily living (ADLs), except bed mobility. She has bladder incontinence. Compared to UAS evaluation completed last year, there has been a decline with bathing, personal hygiene, dressing, walking, locomotion, toileting, bed mobility, and eating. This patient has significant limitations with ADLs that has progressed between UAS evaluations. However, the information does not support that the patient has continuous needs with frequent assistance with toileting, transfers, and turning/repositioning that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. Therefore, the proposed increase of PCA services to 24 hours/day, 7 days/week (split shift) is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer
Treatment: Proton Beam Radiation (lymph nodes)
The insurer denied proton beam radiation (lymph nodes).
The denial is overturned.

The patient is an adult male with prostate cancer. His Gleason score is 4+5=9, and PSA (prostate specific antigen) level is 6.3. The prostate is metastatic to external iliac node. The patient is status post external RT (radiation therapy) of 56.25 Gy (Gray) pelvic nodes followed by brachytherapy 2 years ago. He then developed rising PSA, and PSMA-PET (prostate-specific membrane antigen positron emission tomography) scan showed enlarged retroperitoneal nodes and common iliac nodes. Proton beam therapy (PBT) is being requested for salvage RT of recurrent prostate cancer in the retroperitoneal nodes and common iliac nodes.

The requested PBT is medically necessary.

This patient has an unresectable recurrence in the retroperitoneal nodes and common iliac nodes in close proximity to prior RT fields of 56.25 Gy, completed 2 years ago.

Continued local progression of this recurrent tumor in this area will cause severe pain, rectal obstruction, sacroiliac nerve damage and bleeding. Therefore, it is critical to control this isolated recurrent perirectal node.

However, in this patient who has been previously treated with RT of 56.25 Gy to pelvic nodes, re-irradiation with photon RT (IMRT [intensity-modulated radiation therapy] or conformal RT) is limited due to tolerance of small bowel, bladder and rectum. Proton beam has the advantage of being able to deposit high dose of radiation to the tumor with sharp dose fall off from normal tissues. It can enable delivery of higher dose to the tumor without exceeding normal tissue tolerance and can improve local control and reduce risks of radiation complications.

Thus, the requested PBT is medically necessary to deliver RT dose to control metastatic retroperitoneal/common iliac nodes and spare adjacent normal tissues. 

The 2022 ASTRO (American Society for Radiation Oncology) Model Policy on PBT notes that PBT is considered reasonable in instances where sparing the surrounding normal tissue is of added clinical benefit to the patient and cannot be adequately achieved with photon-based radiation therapy. The requested PBT for re-irradiation of common iliac node in close proximity to prior pelvic RT 56.25 Gy 2 years ago is consistent with the 2022 ASTRO Model Policy on PBT.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose Veins. 
Treatment: Outpatient procedures (phlebectomy - 37765 x1 and 37766 x1). 

The insurer denied: Outpatient procedures (phlebectomy - 37765 x1 and 37766 x1). 
The denial is overturned. 

This patient is an adult female who presents with symptomatic varicose veins. Symptoms are severe enough to affect her normal activities, and she has failed a recent trial of compression stockings. Physical examination and duplex study demonstrate the varicose veins. No axial reflux is seen on the duplex study. The provider has recommended phlebectomy, which has been denied on the basis that (1) the target veins are not 3 millimeters or more; and (2) the patient does not have axial reflux.

The proposed treatment is medically necessary. 

The key issue in this case is the medical necessity for phlebectomy in the absence of axial reflux. Most patients with symptomatic varicose veins have both enlarged varicosities and axial reflux, in which case treatment of the axial reflux (with or without phlebectomy) is medically indicated. However, when patients present with isolated branch varicosities (i.e., varicose veins without axial reflux), phlebectomy is well accepted as the appropriate treatment strategy [1-2]. Clinical results of phlebectomy in this patient group are excellent [1-2]. The veins to be removed are documented by the office notes to be "very large" and "ropey". It can be inferred that they are 3 millimeters or larger, because these terms would not be applied to veins smaller than 3 millimeters. Codes 37765 and 37766 are alternative codes; the provider bills for one or the other depending on the number of phlebectomy incisions. Therefore, phlebectomy (CPT 37765 or 37766) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck and arm pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female with neck pain and left arm pain. The patient was seen and noted to have carotid stenosis and diagnostic angiogram was recommended. The patient was admitted and discharged the next day. Diagnostic angiogram showed left internal carotid artery (ICA) dissection.

The proposed inpatient hospitalization was medically necessary.

The patient had acute onset of severe pain that was concerning for vascular pathology. The patient underwent diagnostic angiogram during the hospitalization which showed dissection. 
This was the appropriate management course and was performed as an acute inpatient which was the most appropriate option for this patient. This could not be performed in a lower level of care and therefore this was medically necessary, and the dates of admission were medically necessary.