Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld


Diagnosis: paroxysmal supraventricular tachycardia
Treatment: Cardizem CD (diltiazem SR)
The insurer denied Cardizem CD (diltiazem SR). 

The health plan's determination is upheld.

The patient is a man with a history of paroxysmal supraventricular tachycardia. He was treated with brand name Cardizem CD (long acting) previously. At that time his health plan no longer covered Cardizem CD as a formulary agent. He has since been treated with both short-acting and long-acting generic diltiazem. Per the physician's appeal letter, while taking these agents, the patient developed an allergic reaction as well as an increase in the frequency of his palpitations. 

A formulary exception is not indicated in this case. The physician's appeal letter indicates that, in this case, treatment with generic brands of diltiazem have caused an allergic reaction as well as an increase in the patient's palpitations.
Multiple manufacturers supply long-acting diltiazem and it is unclear if the patient has tried a single generic formulation or multiple formulations. As far as comparable efficacy between brand name and generic drugs, the Food and Drug Administration (FDA) standards for bioequivalence for generic drugs are rigorous and multiple reports confirm the bioequivalence of the various generic formulations of commonly used drugs. In the study by Kesselheim, et al, all 4 of the previously published randomized controlled trials comparing generic to brand name calcium blockers demonstrated clinical equivalence.
It is unclear how many of the formulary alternatives long-acting calcium channel blockers this patient has tried but, given these results, it is likely that if he were to try at least three, at least one of them would be similarly effective.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The determination is upheld.

This is a patient with a past medical history (PMH) of previous pyelonephritis who was admitted with complaints of (c/o) a two-day history of dysuria and pelvic pain after outpatient treatment for a urinary tract infection (UTI). The patient's vital signs were unremarkable. The physical exam was notable for suprapubic and left lower quadrant (LLQ) tenderness to palpation (TTP). Lab work was notable for a creatinine of 1.22, urinalysis (UA) with large leukocyte esterase (LE), a urine culture grew less than (<) 100,000 colony forming unit (CFU) of Escherichia (e) coli. Imaging studies included a computed tomography (CT) scan of the abdomen/pelvis (A/P) which showed left kidney hydroureteronephrosis. The patient was diagnosed with pyelonephritis and treated with intravenous fluids (IVF), pain control, and intravenous (IV) antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with c/o a two-day history of dysuria and pelvic pain after outpatient treatment for a UTI. The patient was hemodynamically stable, did not meet systemic inflammatory response syndrome (SIRS) criteria, did not have an acute severe kidney injury, toxic appearance, unstable vital signs, immunosuppression, urinary obstruction, coexisting urolithiasis, failure of outpatient treatment, residing in long-term care facility, diabetes mellitus type 2 (DM2), abnormal anatomy, abscess formation, single kidney, or kidney transplant. In addition, the patient did not have the inability to tolerate oral therapy, intractable nausea/vomiting, pregnancy, indwelling urinary catheter, or extremes of age. Overall, this patient was found to have a UTI/pyelonephritis without sepsis and treated with IV antibiotics, with resolution of the patient's symptoms, and these interventions could have been safely and appropriately provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple Cavities.
Treatment:  Ambulatory surgery (outpatient procedure 41899x32).

The insurer denied Ambulatory surgery (outpatient procedure 41899x32).  The denial is overturned.

The patient is a preschool female requesting general anesthesia for dental procedures in the operating room (OR). The prior denial was due to reportedly being no physical, mental or medical reason that prevents dental treatment being done with standard pain control.

The proposed treatment (i.e., general anesthesia) is medically necessary.

This patient was examined by the provider and was reported to be uncooperative just for the exam. Based upon her age and mental issues (attention deficit hyperactivity disorder, anxiety, Autism, acute reaction to stress-these all have associated medical codes), the provider deemed it necessary to have general anesthesia used to allow for proper treatment of this young child. There are already 12 procedures needed with the possibility of more, and to complete these on an uncooperative child is impossible. Even if the patient was cooperative, it would require multiple appointments to complete, and that is not possible on a child with mental issues that won't allow these procedures to be done. Standard pain control medication will not stop the mental and behavioral issues from surfacing, and therefore no treatment, or very little will be accomplished; all while traumatizing this patient. The need for general anesthesia to properly and thoroughly treat this patient is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Class I occlusion 
Treatment: Braces
The insurer denied braces. The health plan's determination is upheld. 

The patient in question is a female with a Class I occlusion with 5 millimeter (mm) overbite and 5 mm overjet. She has moderate maxillary and mandibular crowing. She is treatment planned for 24-30 months of braces to correct her malocclusion. 

There is no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. This patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. The patient has a 5mm overjet but this amount of overjet does not affect oral health related quality of life. If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. Braces are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, hypothyroidism and iron deficiency anemia
Treatment: Home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 50 hours per week
The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 50 hours per week
The denial is upheld

This is an adult with chronic medical problems including diabetes, hypothyroidism and iron deficiency anemia. She lives with her husband, daughter and son-in-law.  

In the  recent Uniform Assessment System (UAS) report the patient's cognition is described as moderately impaired.  She reportedly requires extensive assistance to total dependence for much of her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping.  She reportedly requires extensive assistance for bathing, personal hygiene, dressing, locomotion, ambulation and toilet transfer/use.  The patient is frequently incontinent of bowel and bladder.  She is independent with bed mobility and limited assistance is needed for eating. The patient's functional ability is much the same; if not slightly improved compared to the prior UAS report.

The patient's condition and functional deficits are not at a level or unpredictable as to require an increase in personal care services from 45 to 50 hours/week.   This physician would agree the patient may require additional monitoring, particularly due to her reported cognitive deficits.  However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care service task is being provided.   Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the currently approved  home care / personal care HHC - level 2 personal care services, per 15 minutes 45 hours per week.   

From a physical medicine and rehabilitation perspective, the requested home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 50 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 50 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.

This is an adult male who presented to the hospital complaining of shortness of breath and weight gain for several days duration.  Past medical history was significant for heart failure with reduced ejection fraction, coronary artery disease, diabetes mellitus, mechanical aortic valve replacement, and subcutaneous implantable cardiac defibrillator. On physical examination blood pressure 156/80 and pulse was 60. Mechanical heart sounds were noted along with minimal pedal edema.  12 lead electrocardiogram (EKG) demonstrated sinus rhythm at 60 without acute ischemic changes. Serum blood testing revealed elevated troponin at 0.03 and B-type natriuretic peptide (BNP) 1210.  The patient was treated with intravenous furosemide and admitted to the hospital for treatment with guideline directed medical therapy.

This patient presented with complaints of dyspnea and weight gain.  Upon presentation, physical exam and laboratory testing confirmed fluid overload due to systolic congestive heart failure.  He required treatment with intravenous diuretic therapy and was ultimately discharged on oral guideline directed medical therapy.  Failure to admit and treat this patient would have resulted in excess morbidity or even mortality.  Patients with chronic congestive heart failure have a high risk of adverse outcomes warranting a higher level of care. (Reference 1) In one study, patients presenting with congestive heart failure and an elevated BNP level were found to have an increased morbidity and mortality in the subsequent 90 days. (Reference 2)  In conclusion this patient had decompensated congestive heart failure and an elevated BNP level. Inpatient hospital admission was medically necessary.

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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fluctuant Mass on buttock
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a male with human immunodeficiency virus (HIV) who presented to the emergency room (ER) with 1 week history of rectal pain. The patient noted painful lesion on his right gluteal cleft near the rectum. The pain was noted to be 8/10. The patient's vitals were unremarkable. Exam noted a 4-5 centimeter (cm) fluctuant mass adjacent to the anus on his right buttock with tenderness on rectal exam. The patient's white blood cell (WBC) was 15.8. Computed tomography (CT) scan demonstrated 4.6x4.8x3.2cm abscess. Surgery consult was obtained. This was drained at the bedside. The patient was hospitalized overnight. The patient did well overnight and was discharged home. The subject under review is the medical necessity for the inpatient hospital admission.

The inpatient hospital admission was not medically necessary. The patient was identified to have a rectal abscess which was drained surgically and the patient did well after the procedure. There is no evidence that additional complex testing or therapy other than the surgery was performed. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased Oral Intake
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Overturned

The patient is male who presented with lethargy and decreased oral intake. He was well until the night prior to presentation when he developed decreased oral intake. He also had difficulty passing stools and decreased urine output. His mother noted that he also looked pale and had an episode where he was tense and was arching his back and was unresponsive. His sibling was ill with rhinovirus infection.
In the emergency department his temperature was 99.9 Fahrenheit (F). On physical examination he was described as pale and somnolent with mottled skin in the lower extremities. Laboratory values revealed a white blood count of 4.7 with 82% neutrophils and 4% bands, and a hematocrit of 27. A chest x-ray and abdominal x-ray were obtained. He was given a bolus of normal saline and started on intravenous fluids. He was subsequently admitted due to concerns from his initial presentation.
In the hospital he received intravenous fluids and his vital signs were monitored. By the following day his lethargy had improved, he was afebrile and was drinking well, and was felt to be stable for discharge to home with follow up as an outpatient. The subject under review is the medical necessity for the full hospital admission.

The requested full hospital admission was medically necessary for this patient. This patient presented with lethargy following an episode of arching with unresponsiveness. He continued to have somnolence and pallor at the time of presentation and had a low white blood count with predominantly neutrophils and 4% bands. He therefore required admission to the hospital for ongoing fluid hydration along with close monitoring with additional treatments as needed.

Therefore, the decision making for this patient at the time of admission was consistent with his age, the presence of a brief unexplained event and lethargy at the time of presentation along with concerning laboratory values, and the need for intravenous hydration along with close monitoring for potential deterioration of clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
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 chest pain and exertional dyspnea. Her medical history was remarkable for hypertension, hyperlipidemia, paroxysmal atrial fibrillation, stroke, gastroesophageal reflux disease and chronic back pain. Coronary computed tomography (CT) angiography performed previously, showed normal coronary arteries. Her electrocardiogram showed sinus rhythm without acute changes. Her serum troponin level was normal and remained normal when re-measured. A lower extremity venous ultrasound showed no evidence of deep vein thrombosis. The patient was treated with aspirin and was admitted to the hospital. She was seen by a cardiologist who opined that her chest pain was atypical for angina and, given her recent normal coronary CT angiogram and a normal echocardiogram, no further cardiac workup was recommended. She was discharged. The medical necessity of an inpatient admission is at issue. 

Based on the documentation provided an inpatient level of care was not medically necessary. 

This patient presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until acute coronary syndrome (ACS) could be ruled out was a reasonable approach. However, she was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. Coronary CT angiography performed several months prior showed normal coronary arteries. She did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided at a lower level of care. This approach has been shown to be safe and is in accordance with current guidelines including the 2021 American Heart Association (AHA)/American College of Cardiology (ACC)/American Society of Echocardiography (ASE) /American College of Chest Physicians (CHEST)/ Society for Academic Emergency Medicine (SAEM)/Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Personal Care Aide Level 2: 12 hours per day - 7 days/weeks - for a total of 84 hours/week
The insurer denied: Personal Care Aide Level 2: 12 hours per day - 7 days/weeks - for a total of 84 hours/week
The denial is overturned

The patient is an elderly female. She has osteoarthritis. This is an appeal for denial of personal care services at 12 hours per day, 7 days per week for a total of 84 hours per week. The health plan approved 6.5 hours per day, 7 days per week for a total of 45.5 hours per week. The patient's Uniform Assessment System Evaluation completed 2 months ago shows minimally impaired cognition and function status: total dependence with housework and managing finances; maximal assistance with meal preparation, managing medication, shopping, bathing, and toilet transfer; extensive assistance with personal hygiene, dressing, walking, locomotion, toilet use, and bed mobility; limited assistance with phone use; and independent with eating. The patient has bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been a decline with upper body dressing, personal hygiene, toilet transfer, bathing, walking, and locomotion.

The requested Personal Care Aide Level 2: 12 hours per day - 7 days/weeks - for a total of 84 hours/week is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This is an appeal for denial of personal care services at 12 hours per day, 7 days per week for a total of 84 hours per week. The health plan approved 6.5 hours per day, 7 days per week for a total of 45.5 hours per week. Uniform Assessment System Evaluation completed 2 months ago shows the patient requires assistance with all ADLs (activities of daily living), except eating. Compared to UAS (uniform assessment system) evaluation completed last year, there has been a decline with upper body dressing, personal hygiene, toilet transfer, bathing, walking, and locomotion. She is incontinent of bowel and bladder. This patient has significant impairments that require assistance with ADLs (activities of daily living) and have progressed between UAS (Uniform Assessment System) 
evaluations. The approved personal care services of 6.5 hours per day, 7 days per week for a total of 45.5 hours per week is insufficient to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The requested 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary to meet this patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: abdominal pain.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

This case involves a woman with end-stage renal disease on dialysis who was admitted to the hospital with nausea, vomiting, and feeling unwell. The symptoms were present for four days before arrival, with associated nonspecific abdominal pain, constipation, nausea, and vomiting. There were no other associated symptoms. She had missed dialysis during the preceding week. The medical team notes the patient has had multiple prior admissions with similar presentations.

The Inpatient hospital admission was medically necessary for this patient. There are multiple qualifying factors to indicate inpatient admission status. Ischemic colitis was a suspected diagnosis in this patient, based on a CT scan, severe abdominal pain, and an episode of hematochezia with acute blood loss anemia. Furthermore, the patient was having episodes of diarrhea, with concern for C. difficile (Clostridium difficile) infection. The patient has had multiple admissions to the hospital and receives dialysis; therefore, exposure to healthcare-acquired pathogens is high. With a history of diabetic gastroparesis and persistent severe vomiting, it was reasonable to admit this patient under inpatient status for several days.