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

Skin Disorders
Inpatient Hospital

Diagnosis: Cellulitis.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a woman who presented to the hospital. She had a history of recurrent right lower extremity cellulitis, chronic lymphedema, hepatitis C, methadone use, and she presented with cellulitis of the right lower extremity. She reported pain in the right lower extremity and stated that she began feeling sharp pain and tenderness in the right lower extremity along with warmth two days prior to presentation. She also reported fatigue and subjective fevers. Vital signs showed temperature 98.4 Fahrenheit, heart rate 114, and blood pressure 104/63. On physical exam, she was in no distress, heart was regular, abdomen was soft and nontender, and there was edema in the right lower extremity. Labs showed white blood cell (WBC) 15.9, hemoglobin 13.1, platelets 136, sodium 141, potassium 3.7, creatinine 0.9, and glucose 81. The patient was admitted for right lower extremity cellulitis.

The inpatient hospital admission was not medically necessary. The patient was hemodynamically stable and primarily received antibiotics and a diagnostic evaluation, with ultrasound performed and labs monitored, including lactate and white blood cell count. The infectious disease service was not involved. Because of the stability of her presentation and initial diagnostic findings in the emergency department (ED), she could have safely received antibiotics at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular accident 
Treatment: Personal care assistance
The insurer denied Home Care/Personal Care HHC - Level 2 Personal Care Services 24 Hours per Day (Live In). The health plan's determination is overturned.

The patient is a male with past medical history of vascular dementia, glaucoma with blindness, bladder incontinence, history of cerebrovascular accident (CVA), chronic dizziness, benign prostatic hyperplasia (BPH), major depressive disorder, anxiety, insomnia, hyperlipidemia, and gastroesophageal reflux disease (GERD) who had been assigned PCA (personal care assistant) services at 56 hours per week. The patient was assessed at total assistance with ordinary housework while maximum assistance with tasks of meal preparation, managing finances, and shopping. The patient was assessed at extensive assistance with tasks of managing medication, stairs, transportation, and bathing while limited assistance with tasks of phone use, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet and toilet use. 

Home Care/Personal Care HHC - Level 2 Personal Care Services 24 Hours per Day (Live In) is medically necessary for this patient. 

The patient had a documented fall with head injury and subarachnoid hemorrhage with change in functional status. Discharge summary from rehabilitation indicates the patient needs assistance with all of the activities of daily living (ADL)/Instrumental activities of daily living (IADL) tasks that they had assessed for at discharge. The patient's neurologist and primary care physician (PCP) documented medical necessity for increased PCA services. The patient has unscheduled and unpredictable care needs over a continuum of time and the plan failed to document a plan to address these unscheduled and unpredictable care needs when the PCA is not present. The patient's informal helper is not able to provide all care outside of the time the PCA is present. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADL/IADL tasks. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Home Care/Personal Care HHC - Level 2 Personal Care Services 24 Hours per Day (Live In) are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse.
Treatment: Mental Health: Residential.
The health plan denied the ongoing residential mental health stay. 
The health plan's determination is upheld.

This case involves a female who was referred and admitted to residential level services  for treatment of severe poly-substance use disorder with cannabis, sedative-hypnotic-anxiolytic, tobacco and alcohol class substances of abuse, as well as recreational use of other substances including opioids and cocaine. The patient was diagnosed with co-morbid major depressive disorder, obsessive-compulsive related disorders including trichotillomania (hair pulling), attention deficit hyperactivity disorder (ADHD) and generalized anxiety disorder. The patient had multiple stressors that included conflict within the family constellation, including oppositional behavior and school refusal. She was self-harming (cutting) and had expressed suicidal ideation with plans for an overdose or hanging self. Additionally, the patient had a recent sexual assault with a rape with subsequent trauma-related symptoms.

The patient has a history of outpatient and partial hospital program (PHP) mental health treatment with therapy and medication, and counseling for the substance use disorders. She had no history of psychiatric hospitalization or suicide attempts or inadvertent overdose of drugs or alcohol. The substance use escalated with progression of the disease.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service/treatment of Residential Treatment Facility-Mental Health Level is not medically necessary for this patient. The patient no longer requires the continued structure and monitoring of a residential level service. Effective treatment of the co-occurring disorders can be effectively provided at a lower level of care. The health plan's determination is reasonable in this case scenario.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied: Inpatient Stay. 
The denial is upheld in whole.

The patient is a male with a history of metastatic prostate cancer with bilateral nephrostomy tube placement, who presented on the advice of his nephrologist for a non-functioning right nephrostomy tube. The patient had noticed no drainage from the right nephrostomy tube but denied fevers, chills, abdominal pain, nausea, vomiting, chest pain or shortness of breath. Vital signs showed that he was afebrile with a blood pressure of 104/66, a pulse of 66, a respiratory rate of 20 and a room air pulse oximetry of 98%. Labs showed a creatinine of 0.60, a blood urea nitrogen (BUN) of 17, a potassium of 4.6, a white blood cell (WBC) count of 6.3, and a hemoglobin of 11.3. Nephrology, urology and infectious disease were consulted. He underwent a nephrostomy tube change. He was placed on intravenous (IV) Zosyn, but there were no documented signs or symptoms of infection. There was no documentation of positive urine or blood cultures. He was discharged home the following day in stable condition.

The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld in whole.

The inpatient stay was not medically necessary for this patient based on the documentation provided. The patient presented with a non-functioning right nephrostomy tube and was otherwise asymptomatic. He was hemodynamically stable. There was no documentation of acute renal failure or urinary tract infection. He did not have any hematuria that required inpatient management. He did not require an inpatient procedure or require inpatient monitoring after a procedure. There was no other documented clinical condition that required inpatient monitoring or treatment. The patient could have been safely and effectively managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hematochezia. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with a past medical history of hypertension, diabetes mellitus, and a history of DVT (deep venous thrombosis) of the right leg. The patient who presented to the facility filing the appeal from the rehabilitation unit due to hematochezia with a positive fecal occult blood test. The laboratory values demonstrated anemia with a hemoglobin of 10.1, a Hematocrit of 29.9%, an increased Red Cell Distribution Width, and a decreased red blood cell count. 

The patient's admitting diagnosis was hematochezia secondary to gastrointestinal bleeding. The plan was a gastroenterology consultation and a colonoscopy which demonstrated internal hemorrhoids, and a esophagogastroduodenoscopy, which demonstrated Barrett's esophagus with mucosal changes of approximately 2cm (centimeters), which was biopsied with cold forceps for histology and pathology as well as inflammatory changes denoted within the entirety of the stomach with biopsies taken as well as visualization of multiple gastric ulcerations and a small hiatal hernia, consistent with duodenitis and gastritis, and close monitoring of the patient's signs and symptoms.

The Gastroenterology consultant concluded that the patient's gastrointestinal bleeding was multifactorial in nature due to anticoagulation, gastritis, duodenitis, diverticulosis, and the internal hemorrhoids. The patient was medically cleared and was transferred back to the Rehabilitation Unit to undergo the completion of his rehabilitation program with prescriptions and instructions to follow-up in accordance with their aftercare plan. 

No, the Inpatient admission was not medically necessary. 

While the treatment as received was medically appropriate, the care was rendered at a level which was not medically necessary. 

Despite the patient's presentation, the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring, need for blood products or blood transfusion, severe electrolyte dyscrasias or any other indication for an acute admission.  As such the care, including the endoscopy and colonoscopy, could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems (skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, deep bite, excessive overjet, incisor protrusion and anterior crossbite with gingival attachment loss). 

Treatment: Orthodontic treatment (braces and monthly treatment visits) (codes D8080 and D8670). 

The insurer denied coverage for orthodontic treatment (braces and monthly treatment visits) (codes D8080 and D8670). 

The denial is overturned. 

This patient is a female who presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to skeletal Class I, vertical growth pattern, maxillary and mandibular crowding, deep bite, excessive overjet, incisor protrusion and anterior crossbite with gingival attachment loss. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, an HLD index is utilized. This index provides 6 specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care. 

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

The orthodontic treatment (braces and monthly visits) (codes D8080 and D8670) is considered medically necessary for this patient. 

The carrier's denial of coverage for orthodontic treatment (braces and monthly treatment visits) (codes D8080 and D8670) should be overturned. The medical necessity is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Central Nervous System
Pharmacy/prescription drugs

Diagnosis: Epilepsy
Treatment: Keppra
The insurer denied Keppra. The health plan's determination is upheld. 

The patient is a male with a history of epilepsy. According to correspondence from his treating provider, the patient has been treated with Keppra (brand) 750 milligrams (mg) two tabs twice a day.

In this case, the patient has a history of epilepsy. He is said to have been treated with Keppra (brand) for over 7 years. His health plan has indicated that Keppra (brand) is not a formulary agent. The plan requires that the patient have had a trial of the generic equivalent agent.

According to the current position statement from the American Epilepsy Society (Vossler et al 2016):

"The American Epilepsy Society (AES) recognizes that well-designed, prospective studies of generic antiepileptic drug (AED) substitution have been completed. Two studies demonstrated bioequivalence of generic products in patients with epilepsy taking concomitant AEDs. Additionally, an analysis of Abbreviated New Drug Application data suggests that generic products of branded modified-release products (e.g., extended release, delayed release) are bioequivalent and safely interchangeable. Results from these studies have shown no difference in bioequivalence when switching from a brand product to a generic product or between multiple generic products. These studies confirm that the U.S. Food and Drug Administration (FDA) standards for bioequivalence are appropriate for patients with epilepsy.

In an editorial in Neurology, Vossler (2016) noted that switching from a brand formulation anti-convulsant to a generic equivalent "to US patients appear to be safe choices."

This conclusion was based on studies (Kesselheim et al, Ting et al, Privitera et al) and has been further validated in subsequent research (Gha and Dae).

As such, it cannot be stated that the non-formulary drug would be more effective than the plan's formulary medication. A formulary exception is not indicated in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Digestive System/Gastrointestinal/Crohn's Disease
Treatment: Pharmacy/Prescription Drugs
The health plan denied the requested prescription drug, Pentasa. 
The health plan's determination is overturned.

The patient is a female under evaluation and management for Crohn's Disease. The patient has small bowel Crohn's. The patient has tried and failed previous therapies including Cimzia, Imuran, Entocort and Prednisone. A recent colonoscopy confirmed ulceration of the small bowel. A small bowel follow through demonstrated 2 areas of ileal narrowing.
The patient's provider has requested approval for treatment with Pentasa. This request for a non-formulary drug was denied because the patient was not tried previously on other Mesalamine products such as Delzicol, Apriso, and Colazal and Sulfasalazine.

I recommend overturning the denial, in whole and approving Pentasa.

The formulary drugs would not be as effective as Pentasa. The provider is correct that only Pentasa, via its unique delivery system, would deliver adequate medication to the ileum. The drugs on formulary only work for colonic inflammatory bowel disease (IBD).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Skilled Nursing Facility. 
The insurer denied skilled nursing facility services. 
The denial is overturned.

The patient is a male with human immunodeficiency virus (HIV), depression and anxiety who initially presented to outside hospital (OSH) with bilateral upper and lower extremity weakness. He was diagnosed with rhabdomyolysis in the setting of paraneoplastic myositis secondary to new diagnosis of large cell neuroendocrine lung cancer with hospital course complicated by COVID-19. The plan denied skilled nursing, stating that to approve this service the patient must "require at least minimum assistance with mobility requiring physical, occupational, speech or require improved brain functional therapy with the ability for significant, sustainable functional improvement." 

The subject under review is the medical necessity for the skilled nursing facility services.

The requested health service of skilled nursing facility services is medically necessary for this patient.

The patient is a male who was described as previously independent and was diagnosed with paraneoplastic myositis secondary to new diagnosis of large cell neuroendocrine lung cancer with hospital course complicated by COVID-19. The plan denial letter stated that the patient must be minimum assistance (MINA) for mobility. Physical therapy clearly documented that the patient required moderate assistance (MODA) for sit to stand transfers and MODA for ambulating 3 steps forwards and backwards. Therapy noted that the patient was MODA for rolling, but subsequently he had already progressed to MINA. Also, he previously required maximum assistance (MAXA) for transfers and subsequently he had progressed to MODA. The patient continues to be deconditioned but is making functional progress. Lastly, documentation reviewed stated that the patient was requiring straight catheterization secondary and had missed several days of Flomax for unclear reasons, supporting the need for skilled nursing and medical oversight. Therefore, skilled nursing facility services are medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Central Nervous System
Home Health Services

Diagnosis: Spinal Muscular Atrophy
Treatment: Personal Care Assistance
The insurer denied Personal Care Services: 24 hours per day, 7 days per week (split-shift) for a total of 168 hours per week. The health plan's determination is overturned. 

The patient is a male with past medical history of spinal muscular atrophy, quadriplegia, wheelchair bound, and tracheostomy status who had been assigned PCA (Personal Care Assistant) services. The patient's mother provided care for the patient during the day, but she was hospitalized with cellulitis requiring surgery with change in her functional status and the patient's sister was not able to care for patient as she has spinal muscular atrophy as well. There was a request to increase PCA services to 24 hours/day, split-shift, 7 days/week, to total 168 hours/week. The patient underwent a telephonic assessment tool, assessing the patient at total assistance with task of stairs, while maximum assistance with tasks of shopping, transportation, dressing lower body, and locomotion. The patient was assessed at extensive assistance with meal preparation, ordinary housework, managing finances, managing medication, phone use, equipment management, bathing, personal hygiene, dressing upper body, walking, transfer toilet, toilet use, bed mobility, and eating. Notes from the assessment stated the patient needs to be turned and repositioned every 45 minutes due to discomfort, needs assistance around the clock, and has no informal helper.

Personal Care Services: 24 hours per day, 7 days per week (split-shift) for a total of 168 hours per week is medically necessary for this patient.

The patient has the diagnosis of spinal muscular atrophy and requires assistance with all activities of daily living (ADLs)/Instrumental activities of daily living (IADLs). The patient has quadriplegia. The patient does not have an informal helper. The patient requires turning and positioning overnight every hour to prevent pain. An aide would not be able to obtain five hours of uninterrupted sleep due to the patient's care needs. The increase in PCA hours is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/IADLs. 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, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Physical Therapy. 
The insurer denied: Physical Therapy. 
The denial is overturned. 

The patient is a female with diagnosis of knee pain, who underwent knee arthroscopy with meniscectomy. The subject under review is the medical necessity for physical therapy for this patient.

The health plan's determination is overturned.

Yes, physical therapy is medically necessary.  The patient underwent knee arthroscopy with meniscectomy. Physical therapy (PT) initial examination noted impaired right knee range of motion with flexion 100 degrees and extension -10 degrees. Exam also significant for "Poor quad activation in extension, straight leg raise (SLR) with 10 degree lag.  Right (R) quad 3/5, hamstring 3+/5." In addition, patellar mobility on the right was described as hypo mobile.  The patient continued to have post-operative stiffness and poor quad tone, but active and passive range of motion was described as improved. Right knee flexion had improved to 125 degrees active. Exercises were advanced during session.  Documentation shows that the patient is making progress but as noted gait is still "mildly antalgic" and range of motion and strength were not yet described as normal.