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

Diagnosis: Status Asthmaticus

Treatment: inpatient hospital

The insurer denied coverage for inpatient hospital.

The denial is overturned.

The patient had a history of asthma. Her last asthma exacerbation requiring an emergency room (ER) visit was one month prior to this illness and she had been hospitalized in the pediatric intensive care unit (PICU). She had been sick with a viral illness for days and had been exposed to her sister who was also sick. When her coughing and shortness of breath developed, she was administered several doses of albuterol and combivent at home. When the wheezing and difficulty breathing did not improve, she was taken to the emergency room for further therapy.

In the ER, she was noted to be in respiratory distress with wheezing retractions and tachypnea noted on physical examination. Her pulse oximetry reading was low at 94% (percent). She was treated with 3 doses of combivent, 2 doses of albuterol, and prednisone. Covid, influenza and respiratory syncytial virus (RSV) testing were normal. A chest x-ray did not demonstrate any infiltrate. Blood testing demonstrated a metabolic acidosis with a bicarbonate (HCO3) of 15. When she was re-evaluated, she was improved but continued to have wheezing and increased work of breathing. She then was treated with a liter of intravenous (IV) normal saline and magnesium sulfate. When her respiratory symptoms did not improve with treatment in the ER, the decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours.  

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. She had been taking albuterol for 2 days at home and following treatment in the ER she continued to have ongoing respiratory distress with persistent wheezing and increased work of breathing. She had a metabolic acidosis with a HCO3 of 15 and was requiring IV fluids and IV magnesium sulfate. 

Based on the medical record it was appropriate and consistent with the standard of care to admit her to the hospital for ongoing treatment with albuterol every 2 hours with a diagnosis of status asthmaticus. She had failed outpatient management of her asthma and there was also concern for ongoing metabolic acidosis. She continued to be in respiratory distress with a diagnosis of status asthmaticus and not stable enough to be sent home.  The admission to the hospital was medically necessary.

The insurer's denial of coverage for the inpatient hospital admission is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hemiparesis in the right dominant side

Treatment: personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift).  

The insurer denied coverage for  the personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift).  

The denial is overturned. 

This female patient has a history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease, osteoarthritis, diabetes mellitus and cerebrovascular accident.


The patient is bedbound, needs high levels of assistance with all functions including bed mobility, transferring and toileting. She is hemiparetic. She has no scheduled informal caregivers. She is incontinent x2 and has repetitive, unscheduled 24-hour needs.  There is no expectation that she can do T&P (turning and positioning) or manage incontinence by herself. She would be at high risk for decubiti/infection if left on her own 12 hours/day. The provision of diapers and durable medical equipment (DME) is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" changing diapers regularly and positioning are also necessary.

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

The carrier's denial of coverage for the personal care aide (PCA) level 2 services of 12 hours per day, 7 days per week; 12 hours per day, 7 days per week (split shift).   is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cognitive and physical impairment.

Treatment: PCW (personal care worker) services of 8 hours per day, 7 days per week for a total of 56 hours per week.

The insurer is denied coverage for PCW services of 8 hours per day, 7 days per week for a total of 56 hours per week.

The denial is overturned. 

This female patient has a history of dementia, cerebrovascular accident (CVA), essential hypertension, incontinence, hyperlipidemia, falls, and wandering.

The functional status report indicates patient is totally dependent or needs maximal assistance for most IADLs; except phone use, stairs (extensive assistance). For activities of daily living (ADLs), the patient needs extensive assistance for bathing and dressing. For all other ADLs, the patient needs limited assistance; except bed mobility (supervision). The patient's level of care (LOC) score from the UAS was 26, which is an increase compared to the previous LOC score of 14 based on the UAS(Uniform Assessment system). Assistance for personal hygiene, toilet transfer, walking, locomotion increased from independent setup help to limited assistance; and assistance for bathing, upper and lower body dressing increased from limited to extensive assistance.
Based on the information provided for review, the patient needs assistance with activities that occur at various routine and unscheduled times during the day, and the care plan needs to accommodate these care needs. It is medically necessary, and in the patient's best interest to have a caregiver present over a longer period of time each day to provide assistance with daily activities in order to prevent adverse health and safety events, such as falls/injury, skin damage and urinary tract infection from inadequate toileting and incontinence care, impaired nutrition, dehydration.

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

The carrier's denial of coverage for the PCW(personal care worker) services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.

Treatment: Breo Ellipta 100 micrograms-25 micrograms/inhaler in aerosol powder breath.

The insurer denied coverage for Breo Ellipta 100 micrograms-25 micrograms/inhaler in aerosol powder breath	.

The denial is upheld.

This adolescent patient has a history of moderate persistent asthma and allergic rhinitis. His asthma exacerbations are triggered by weather change, exercise, and exposure to allergens (dust mites, animal dander, pollen, and mold). There is currently some concern for exposure to mold in the home which the mother has been working with the landlord to resolve. He has an elevated IgE [serum immunoglobulin E] and elevated eosinophils on blood testing. The patient's hospitalization was in the pediatric intensive care unit (PICU) and he has been on Breo since with a stable spirometry. He takes albuterol prior to exercise, and he is also on nasal sprays and cetrizine.

The insurer has denied a request for the continuation of Breo Ellipta indicating that the medication is not on their formulary and that there is no documentation in the medical record to indicate that the alternative inhaled steroid/LABA [long-acting beta agonist] medications on the formulary have been tried and failed to control his asthma. The insurer also indicates that Breo Ellipta is not approved for use in children.

The patient has been medically stable with no record of recent need for hospitalization or emergency room (ER) visit for asthma. The insurer is correct in indicating that Breo Ellipta is not approved for use in children and there are several alternative inhaled steroid/LABA combinations that are approved for use in a child with moderate persistent asthma.  There are suitable alternative treatment choices for long term control of this child's asthma.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the medication Breo Ellipta 100 micrograms-25 micrograms/inhaler in aerosol powder breath for the treatment of asthma is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: adenocarcinoma of the prostate and a prostate-specific antigen (PSA).
Treatment: Stereotactic Body Radiation Therapy (SBRT).
The insurer is denied coverage for Stereotactic Body Radiation Therapy (SBRT).
The denial is upheld. 

This male patient has a history of adenocarcinoma of the prostate and a prostate-specific antigen (PSA).


Per NCCN Guidelines Version 2.2021 Prostate Cancer, both proton and photon external beam radiation therapy (EBRT) are effective at achieving highly conformal radiotherapy with acceptable and similar biochemical control and long-term side effect profiles. It is currently felt that there is no clear evidence supporting a benefit or decrement to proton therapy over photon therapy for either treatment efficacy or long-term toxicity. It is understood that the treating provider has the appropriate technology and clinical expertise to deliver proton therapy safely and appropriately. It was also not shown in the records by the patient that there was a clinically significant difference in proton versus photon plans.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the Stereotactic Body Radiation Therapy (SBRT)  is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypothyroidism, glaucoma, breast cancer, vertigo and generalized weakness
Treatment: Increase Level 2 Personal Care Services to 84 hours per week
The insurer denied the Increase Level 2 Personal Care Services to 84 hours per week.
The denial is overturned.

The patient is a female with a history of dementia, hypothyroidism, glaucoma, breast cancer, vertigo and generalized weakness. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 84 hours/week Personal Assistance Services to offer increased ADL support.

Yes, the increase in Level 2 Personal Care Services to 84 hours/week is medically necessary.

Although an assessment of the patient's functionality and ability to perform ADLs was completed and revealed that the currently approved plan of 56 hours/week Personal Assistance Services is sufficient to meet the patient's current needs, the patient relates that this reduced schedule leaves her home alone, completely unassisted for numerous hours/day. Furthermore, the patient's medical providers, including her Rheumatologist and Ophthalmologist, report that due to the patient's progressively worsening arthralgias, myalgias and visual acuity, she is at high risk for worsening fall injuries.

Hence, provision of 84 hours/week Personal Assistance Services can reasonably be expected to be beneficial for the patient, and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment 84 hours/week Personal Assistance Services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse/Addiction
Treatment: Inpatient hospital stay
The health plan denied the inpatient hospital stay as not medically necessary. The reviewer has upheld in whole the health plan's determination.

The patient has a past medical history significant for type II diabetes mellitus and alcohol dependence and presented for detoxification from alcohol. Apparently, the patient had not been taking his home medications for diabetes for a long time. He reported drinking approximately one pint of vodka daily. The admitting physician stated that the patient had no complaints at the time of admission and just requested detoxification from alcohol. The Clinical Institute Withdrawal Assessment (CIWA) score was 15. This was treated with oral Valium.

The patient was admitted to the hospital and started on CIWA protocol. For the treatment of diabetes mellitus, he was started on a combination of long-acting and short-acting insulins. The low serum sodium level was attributed to pseudohyponatremia because of hyperglycemia.

During the hospital stay, the patient's clinical condition significantly improved. For instance, according to the progress notes the patient looked comfortable with no tremor. He was able to speak in full sentences and requested a double diet. There were no signs of excessive sweating, his CIWA score was zero. The acute renal failure, hyponatremia, and hyperglycemia resolved. According to the same note, the patient demonstrated a steady gait and had no signs of acute alcohol withdrawal. Subsequently, the patient continued to remain in stable condition without symptoms of active alcohol withdrawal, tongue fasciculations, or diaphoresis. At the end of the hospitalization, the patient was discharged home.

The review of the medical records clearly demonstrated that the patient had no active signs of alcohol withdrawal after the initial evaluation in the emergency department. His tachycardia resolved, and the patient had no nausea or vomiting, tremors, or increased perspiration that was visible to his physician. There were no signs of delirium, seizures, or any other unstable clinical conditions that would require admission at the acute inpatient level of care.

Taking into consideration these facts, the admission for a lower level of care was justified, to watch the patient for severe alcohol withdrawal symptoms as well as to determine the safest disposition. However, considering the overall stability of the patient's condition, there was no overwhelming evidence that the patient required admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Loss 
Treatment: Replacement of cochlear implant 
The insurer denied replacement of the cochlear implant. 
The determination is overturned. 

The patient has bilateral hearing loss. She has bilateral cochlear implants. Her current external processor is not functioning and is out of warranty. 

At issue is the medical necessity of replacement of the cochlear implant. 

The request is for an external processor, which is a necessary component used to transmit sound to the actual implant. Without a consistently functioning external processor, the cochlear implant is nonfunctional and the patient does not have hearing. 
The patient has hearing loss and requires a cochlear implant. Her current external processor is not working consistently, thus her cochlear implant does not work and she is left with no hearing. The request is not being made for the sole purpose a technology upgrade. 

The request is medically necessary because without a replacement, the patient cannot hear. There are no reasonable options available to the patient. The request is considered standard of care and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alopecia Areata. 
Treatment: Compounded Tofacitinib Solution (Pre-service). 

The insurer denied the Compounded Tofacitinib Solution. 
The denial is overturned. 

The patient is a woman with alopecia areata. She has failed topical Elidel, fluocinolone, and intralesional Kenalog. The request is for compounded topical tofacitinib. 

Yes, the requested Compounded Tofacitinib Solution is medically necessary. 
The patient has failed multiple first-line treatments. Therefore, she has refractory disease, and JAK (janus kinase) inhibitors are considered appropriate for treatment of refractory alopecia areata. 

There are limited data suggesting that topical formulations of ruxolitinib and tofacitinib may be beneficial, although these are not yet commercially available. A 28-week phase 1 trial in which 16 adults with alopecia universalis applied tofacitinib 2% ointment, ruxolitinib 1% ointment, clobetasol dipropionate 0.05% ointment, or vehicle to one of four randomly assigned areas of the scalp and eyebrows twice daily found hair regrowth in the treated area in 6, 5, 10, and 0 patients, respectively. In addition, in a 24-week, open-label study, hair regrowth occurred in 3 of 10 adults with alopecia areata or alopecia totalis during use of tofacitinib 2% ointment. 

Case series also support potential benefit of topical JAK (janus kinase) inhibitors in children. In the larger series, tofacitinib 2% ointment therapy in 11 children with alopecia areata, alopecia totalis, or alopecia universalis refractory to oral and topical corticosteroids was associated with improvement in the SALT (Severity of Alopecia Tool) score in 8 children, including 3 children who had sufficient hair regrowth to cover the scalp or conceal residual areas of hair loss. 

Current published literature supports the use of topical tofacitinib in refractory alopecia areata that has failed multiple first-line therapies.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Bronchial Asthma. 
Treatment: Dulera, Pre-service. 
The insurer denied the Dulera. 
The denial is overturned. 

The patient is a female with moderate persistent asthma and is being prescribed Dulera.  The patient has tried and failed Symbicort as well as Breo and Advair (she was unable to tolerate Symbicort and disease was not controlled on Breo). The patient has been doing well on Dulera. 

Yes, the health plan should cover the proposed treatment. 
The patient has moderate persistent asthma and is being prescribed Dulera. The patient has tried and failed Symbicort as well as Breo and Advair. The patient has been doing well on Dulera. 

The continued use of dulera is medically necessary.  The patient has tried and failed multiple inhaled corticosteroids and has had positive outcomes with Dulera. Thus, continued treatment is medically necessary. Not continuing it likely to cause worsening quality of life, more asthma exacerbations and frequent doctor's visit.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum Disorder. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay for medical necessity. 
The denial was overturned. 

The patient is a male with severe autism who is non-verbal. He presented to the emergency room (ER) with refusal of by mouth (PO) for 6 days. Per his father he stopped eating suddenly without apparent inciting factors. Since then, he had only taken water PO, no solids, or additional liquids. He had associated weight loss on day of presentation (10.4% loss). Per his father, the patient has had similar episodes of PO refusal in the past. He was hospitalized. At baseline he is a picky eater with a restricted diet. He had some increased fatigue, taking 1-2 naps per day (patient does not nap at baseline). He was not complaining of abdominal pain, throat pain, or mouth pain. Per his father, the patient is usually able to communicate when he has pain or physical complaints. He had no vomiting, diarrhea, or upper respiratory infection (URI) symptoms. He had a tooth extraction 10 days ago and had not been complaining of pain. He had no recent illnesses, and no known sick or coronavirus positive (COVID+) contacts.
The physical exam in the ER was documented as lips dry, and tacky mucous membranes. His labs were notable for a potassium (K) at 5.1, Bicarbonate was 16, Creatinine was 0.62, and complete blood count (CBC) was not concerning. He was admitted to the pediatric floor with a diagnosis of PO refusal, weight loss and dehydration. There was concern for failure to thrive in the ER due to his 5 pounds (lbs.) weight loss in the past month.
The nutritionist cautioned to monitor for refeeding syndrome if he continued with food refusal for greater than or equal to (>/=) 7 days. The patient continued to have decreased PO intake; however, he had improved urine output on fluids. With improving lab results and physical exam he was deemed stable for discharge with follow up and with strict return precautions.
At issue is the medical necessity of the inpatient stay.

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

The requested health service/treatment of inpatient stay was medically necessary for this patient.
This patient, presented with physical signs of dehydration as documented by the ER physician. He was found to have low carbon dioxide (CO2), an indicator for metabolic acidosis, as well as PO refusal. The child also has a diagnosis of autism and chronic issues with feeding, intermittently failing to thrive and anorexic behaviors. Multidisciplinary care which would address his nutritional concerns, feeding concerns, developmental barriers, as well as the presenting diagnosis would be necessary. Of concern are complications that may arise such as refeeding syndrome if he continued to refuse PO and eventually required nasogastric (NG) feedings. Given his chronic state of poor feeding, intermittent failure to thrive and the acute PO refusal and dehydration, the inpatient level of care was necessary to care for this patient.
Therefore, the inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Upper Gastrointestinal (GI) Bleed

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient had a history of a bleeding duodenal ulcer and an infection with clostridium difficile. Both endoscopy and colonoscopy were performed. He was found to have a duodenal ulcer with an adherent clot. A hemostatic clip was placed. He then presented with blood in the bowel movements. The initial blood pressure was 88/59. The hemoglobin dropped from 9.4 to 7.9. He was diagnosed with an upper gastrointestinal (GI) bleed. An endoscopy revealed a duodenal ulcer with a visible vessel. It was treated with both an epinephrine injection and bipolar coagulation.

Clinical indications for admission for Upper GI Bleeding (M-180) include ongoing active bleeding as manifest by a decreasing hematocrit. A peptic ulcer with high-risk endoscopic features such as a non-bleeding visible vessel is also an indication for admission.

This patient had a drop of the hemoglobin from 9.4 to 7.9 after receiving one unit of packed red blood cells (PRBC). In addition, he had a high-risk endoscopic feature with an ulcer containing a visible vessel which needed to be both injected and cauterized. This met the Milliman Care Guideline (MCG) criteria for admission for upper GI bleeding. The healthcare plan did not act with sound medical judgement. An inpatient admission was medically necessary.

The insurer's denial of coverage for the inpatient admission is reversed. Medical Necessity is substantiated.