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

Diagnosis: Ulcerative Colitis. 
Treatment: Stelara 90 mg/ml Syringe every 4 weeks. 

The insurer denied coverage for Stelara 90 mg/ml Syringe every 4 weeks

The denial is overturned. 

The patient has moderate to severe ulcerative colitis. The patient started Remicade 12 years ago in addition to 6-MP. The patient was then switched to Humira and subsequently to Entyvio. A colonoscopy in middle of last year showed active disease. The patient was then switched to Stelara. The patient had low serum levels of ustekinumab and the dose was escalated to every 6 weeks. The patient's trough levels have remained low, and their physician is advising to increase the dose of Stelara to every 4 weeks. 

Clinical Gastroenterology and Hepatology has published an article titled "Association Between Ustekinumab Trough Concentrations and Clinical, Biomarker, and Endoscopic Outcomes in Patients with Crohn's Disease" the conclusion was that maintaining a maintenance trough concentration of ustekinumab above 4.5 ug/ml was associated with biomarker reductions and an endoscopic response of disease activity. 

The Journal of Clinical Medicine article titled "Update on Therapeutic drug Monitoring with Ustekinumab, Vedolizumab, and Tofacitinib in Inflammatory Bowel Disease" evaluates ustekinumab treatment in ulcerative colitis. Serum concentrations were correlated with clinical, biochemical, and histological remission. A week 8 post induction concentration of 3. 7 ug/ml (micrograms per milliliter) was associated with a response to the drug. A maintenance concentration of 1.3 ug/ml was correlated with increased rates of clinical remission. It was advised that experts agree to target ustekinumab concentrations of at least 3-7 ug/ml at week 8 and 1-3 ug/ml during maintenance for both Crohn's disease and ulcerative colitis. 

The scientific literature supports the use of dose escalation for ustekinumab when there is not an adequate response and trough levels are low. This has been shown to improve health outcomes for IBD (inflammatory bowel disease) patients. The patient has already failed multiple biologic therapies, so it is important to optimize the ustekinumab treatment. The medical literature supports the use of dose escalation and optimization of treatment with Stelara in patients with IBD. The health care plan did not act in the best interest of the patient. 

Based on the above, the insurer's denial must be reversed. The medical necessity for Stelara 90 mg/ml Syringe every 4 weeks is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: functional decline

Treatment: personal care aide (PCA) level 2: 12 hours per day - 7 days per week - 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift)

The insurer denied coverage for personal care aide (PCA) level 2: 12 hours per day - 7 days per week - 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift)

The denial is upheld / overturned


This is an elderly female who has experienced significant functional decline and needs substantial assistance with all daily activities. The patient is currently residing in a skilled nursing facility (SNF), admitted for short term rehabilitation. Prior to admission, the patient received personal care aide (PCA) services 14 hours per week. The patient (via designee) requested PCA services 24 hours per day (split shift), 168 hours per week, which was denied; but PCA services were increased 59.5 hours per week. 

The patient's functional status for Instrumental Activities of Daily Living (IADLs) indicates total dependence for ordinary housework, managing finances and medications, shopping, stairs, transportation; maximal assistance for meal preparation: extensive assistance for phone use. 

The patient has cognitive impairment. Decision making for daily tasks was described as minimally impaired; in specific situations, decisions become poor or unsafe; cues/supervision needed at those times. The patient was oriented to persona and place, with short term and procedural memory problem. Communication ability was described as difficulty finding words or finishing thoughts, but with time, little or no prompting needed; she misses some intent of message but understands most of conversation. The physician's letter indicates patient has poor safety awareness and increased confusion, including episodes of anxiety and confusion at night. 

The Uniform Assessment System (UAS) indicates patient is totally dependent with walking/locomotion in the Skilled Nursing Facility and her mobility is in a wheelchair (wheeled by staff). It is noted that the patient has pressure induced deep tissue damage of heel. It is not clear whether this is a prior diagnosis or an active problem; but either way, it indicates the patient developed (and may still have) a pressure injury on her foot. 

The most recent UAS indicates the patient is totally dependent for toilet transfer (as previously noted, the patient is unable to bear weight during transfer); so, in the absence of a caregiver, the patient is unable to use a commode or toilet. 

The patient is dependent on caregivers for meal preparation/service, and she needs extensive assistance with eating.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for personal care aide (PCA) level 2: 12 hours per day - 7 days per week - 12 hours per day - 7 days per week - for a total of 168 hours per week (split shift) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pancreatitis
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is overturned. 

The patient is a male who was admitted to the hospital for abdominal pain. He had a history of chronic pancreatitis, fatty liver, alcohol use disorder, and pancreatic surgery. On presentation, the patient had vomiting and diarrhea. He was not able to tolerate anything by mouth. He was drinking a pint of vodka per patient and goes through periods of drinking every day. The patient's Clinical Institute Withdrawal Assessment (CIWA) score was 9.
A computed tomography (CT) scan noted hepatomegaly with hepatic steatosis. The patient was treated for pancreatitis with intravenous (IV) fluids and pain control. The patient was treated for alcohol withdrawal symptoms with Ativan and Librium and given Morphine IV for pain. His sodium was 151 and lipase was 3. The patient's diet was advanced, and the patient signed out against medical advice (AMA).
At issue is the medical necessity of inpatient admission.

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

The requested health service/treatment of inpatient admission was medically necessary for this patient.
The patient in question does meet medical necessity for the acute inpatient level of care per current literature and standard of care. According to Singh et al., (2011), van Santvoort et al., (2011), and Tenner et al., (2013), the patient had signs of pancreatitis and most notably alcohol abuse causing severe gastrointestinal (GI) symptoms in the setting of a history of alcohol withdrawal seizures. Due to the patient's high-risk nature and severe comorbid conditions and history of seizures from withdrawal, the patient was most appropriate for acute inpatient care following the generally accepted standard of care.
Therefore, the requested health service/treatment of inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
The patient had a history of alcoholic pancreatitis and presented with abdominal pain. He had a recent hospital admission for alcohol withdrawal. He was afebrile and the vital signs were stable. He had abdominal tenderness but did not have peritoneal signs. There was no leukocytosis. The liver and pancreatic enzymes were elevated. The lipase was 194 (normal to 83). He was on pancreatic enzymes for chronic pancreatitis. A computed tomography scan (CT) scan was read as no acute findings and no evidence of pancreatitis. The ethanol level was elevated. He was diagnosed with pancreatitis and alcoholic liver disease. The liver and pancreatic enzymes improved. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) M-250 for Pancreatitis. Clinical indications for admission include having acute pancreatitis as manifested by 2 of the following: abdominal pain, serum lipase greater than 3 times the upper limit of normal, and imaging studies indicative of acute pancreatitis. In this case, the pancreatic enzymes were not 3 times above the upper limit of normal and the imaging study was negative for acute pancreatitis. Indications for admission for chronic pancreatitis include inability to maintain oral hydration after observation care, evidence of infection, hemodynamic instability, severe vomiting, stage 3 acute renal failure, altered mental status, and severe electrolyte abnormalities. The patient did not have these conditions. 

This patient has liver and pancreatic disease related to alcohol use. He required IV hydration and monitoring of his liver and pancreatic chemistries and Clinical Institute Withdrawal Assessment (CIWA) status. This could have been done with observation status. He did not have evidence of severe pancreatitis and did not have acute liver failure. He did not meet MCG criteria for admission for Pancreatitis. 

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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Jugular thrombosis; Cushing's syndrome
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient in this case is an adult male with a history of Cushing's syndrome. The patient presented to the emergency department with shortness of breath, chest pain and right arm pain. Thyroid ultrasound two months before this had revealed a jugular thrombosis and the patient never followed up. This was never treated. Evaluation in the emergency department revealed a large filling defect in the right jugular vein obstructing more than 90% of blood flow. Vital signs and laboratory findings were unremarkable. Physical examination did not reveal any significant abnormalities. The patient was admitted to the hospital and started on anticoagulation. He was seen by vascular surgery in the emergency department and no acute surgical intervention was recommended. The patient remained hemodynamically stable and was transitioned from intravenous heparin to Eliquis. He was discharged on day #2.

The proposed treatment was not medically necessary.

This patient presented with symptoms related to chronic occlusion of the right jugular vein. He had no hemodynamic instability and no signs of acute ischemia. There was no coronary ischemia or respiratory insufficiency. No acute surgical intervention was recommended. The patient could have been treated with anticoagulation at a lower level of care. This was not a high-risk thrombosis, especially since it has been present for two months and since this patient did not have severe symptoms or complications related to his jugular venous thrombosis. The patient did not have any high-risk medical co-morbid conditions. He did not require acute care inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, heart disease, hypertension, weakness, history of stroke, memory loss, hearing loss, diabetes, and syncope
Treatment: Increase Consumer Directed Personal Assistance Services (CDPAS) to 56 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance Services (CDPAS) to 56 Hours per Week
The denial is overturned.

This elderly male patient has medical conditions that include arthritis, heart disease, hypertension, weakness, history of stroke, memory loss, hearing loss, diabetes, and syncope. 
The denial of an increase in consumer directed personal assistance services (CDPAS) to 56 hours per week is being appealed. The health plan approved 24.5 hours per week. Uniform Assessment System evaluation completed ten months ago shows modified independent cognition and functional status; he is independent with personal hygiene, walking, locomotion, bed mobility, and eating. 
A statement from New York State notes the patient needs more assistance due to left side pain, limited range of motion, muscle weakness, instead gait and mobility, incontinence, memory loss, 
and fatigue. He cannot perform activities of daily living without full assistance. The statement is remarkable for noting that the patient needs assistance with toileting throughout the day. He 
requires assistance with turning/positioning in the bed. This is supported by the daily log. 
A letter from his Provider notes there has been a decline in the patient's state. He cannot perform activities of daily living without full assistance. He is a safety hazard due to an unsteady gait. He has incontinence and gets up numerous times during the night.

The proposed treatment 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 patient has multiple chronic conditions. The denial of an increase in consumer directed personal assistance services (CDPAS) to 56 hours per week is being appealed. The health plan approved 24.5 hours per week. Uniform Assessment System evaluation completed ten months ago shows modified independent cognition and functional status he is independent with personal hygiene, walking, locomotion, bed mobility, and eating. The appeal statements indicate the patient's functional status has declined and he now requires full assistance with activities of daily living. He has urinary incontinence and needs assistance with transfers and toileting throughout the day and night. He is at risk for falls. The information provided shows that this patient has significant limitations in functioning that have declined. The approved personal care services 24.5 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 56 hours per week is medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Pelvic congestion syndrome
Treatment: Pelvic Embolization
The insurer denied: Pelvic Embolization
The denial is upheld.

The patient is an adult with pelvic congestion syndrome. She was recommended to undergo pelvic embolization for treatment. The procedure was denied coverage by the health plan as experimental/investigational. The denial is being appealed.

The health plan should not cover the Pelvic Embolization.

Use of this procedure lacks data from well-conducted prospective and long-term studies to show efficacy and safety. It is not supported by peer-reviewed data, and it is not supported by professional organizations. The requested Pelvic Embolization is not more beneficial. There is no high-quality evidence to show that use of this procedure improves health outcomes or that it is more beneficial than standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer antigen (BRCA) 2 mutation
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient with a deleterious breast cancer antigen (BRCA) 2 mutation as well as chronic hidradenitis suppurativa involving her bilateral axillary regions, inframammary folds and inguinal regions. She was admitted to the hospital and underwent bilateral risk-reducing mastectomies, bilateral sentinel lymph node biopsies and resection of the inframammary skin with complex wound closures. Her operation was uncomplicated. Postoperatively, she was transferred to the general medical/surgical nursing floor where she received standard postoperative care including administration of intravenous (IV) fluids, IV (intravenous) antibiotics, oral pain medications, and drain care. On postoperative day number (#)1, she was examined and found to be without any signs of bleeding, infection or other postoperative complication. She was tolerating by mouth (PO) liquids and was ambulating without difficulty. She was deemed stable for discharge to home. At issue is the medical necessity of an inpatient stay.

The requested inpatient hospital admission was not medically necessary for this patient.
The care provided to the patient was entirely appropriate, including her postoperative care in the hospital, intravenous (IV) medications and IV (intravenous) fluids. However, the identical services could have been provided at a lower level of care rather than an acute inpatient level of care.
There are a number of factors that would justify inpatient services, such as a high severity of illness, comorbid medical conditions that would be likely to increase the patient's need for medical services and the medical probability of a complication (1). The patient is a generally healthy female who underwent an uncomplicated procedure. Thus, the records do not support the need for an acute inpatient hospitalization.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cirrhosis
Treatment: MRI (magnetic resonance imaging) of the Abdomen
The insurer denied MRI of the Abdomen.
The determination is overturned.

This is a male patient with cirrhosis secondary to nonalcoholic steatohepatitis. An ultrasound showed diffusely heterogenous hepatic echotexture consistent with hepatocellular disease; although no focal masses were seen, given the patient's history and diffusely heterogenous ultrasound appearance of the liver which may obscure small masses, magnetic resonance imaging was recommended for further evaluation; a 9-millimeter (mm) gallbladder polyp; splenomegaly; and small right renal cyst. Magnetic resonance imaging showed stable cirrhotic liver with mild interval increase in size without hepatoma and marked splenomegaly. An ultrasound showed cirrhotic liver morphology, without sonographic evidence of liver mass, splenomegaly, and trace perihepatic ascites. An esophagogastroduodenoscopy showed grade 2 esophageal varices, portal hypertensive gastropathy, and duodenitis. The medical necessity of magnetic resonance imaging of the abdomen is under review.

The requested magnetic resonance imaging is medically necessary in this case. Liver disease, including hepatic steatosis and cirrhosis, can limit the ability of ultrasound to screen for hepatocellular carcinoma, as documented in the ultrasound reading in this case (which therefore recommended magnetic resonance imaging for hepatocellular carcinoma screening) [1,2]. Guidelines from the American Association for the Study of Liver Diseases state that "if ultrasound is attempted but inadequate, computed tomography (CT) or magnetic resonance imaging (MRI) may be utilized" [3,4]. Magnetic resonance imaging has a significantly higher detection rate for hepatocellular carcinoma than ultrasound in patients with cirrhosis [5].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Human immunodeficiency virus (HIV), arthritis, chronic anemia, hypertension, vitamin D deficiency, and cognitive decline.
Treatment: Consumer Directed Personal Assistance Services (CDPAS) for a Total of 56 Hours per Week
The insurer denied: Consumer Directed Personal Assistance Services (CDPAS) for a Total of 56 Hours per Week
The denial is upheld.

This adult male patient has medical conditions that include human immunodeficiency virus (HIV), arthritis, chronic anemia, hypertension, vitamin D deficiency, and cognitive decline. He is in a methadone program. The denial of consumer directed personal assistance services (CDPAS) for a total of 56 hours per week is being appealed. The health plan approved 31 hours per week. The patient lives with his brother and sister-in-law.
Uniform Assessment System evaluation completed three months ago shows minimally impaired cognition and functional status: maximal assistance with meal preparation housework, and 
shopping; extensive assistance with managing finances and medications, phone use, stairs, transportation, bathing, and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and supervision with bed mobility and eating. He has bowel and bladder incontinence. Compared to Uniform Assessment System evaluation completed last year, there has been an improvement with cognition, meal preparation, housework, stairs, shopping, transportation, personal hygiene, upper body dressing, walking, 
locomotion, toileting, bed mobility and eating. A letter from the Provider notes the member is human immunodeficiency virus positive and needs a nutrition consultation.

The proposed treatment is not 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. The denial of consumer directed personal assistance services (CDPAS) for a total of 56 hours per week is being appealed. The health plan approved 31 hours per week. Uniform 
Assessment System evaluation completed three months ago shows the patient needs assistance with all activities of daily living (ADLs), except bed mobility and eating. Compared to Uniform Assessment System evaluation completed last year, there has been an improvement with cognition, meal preparation, housework, stairs, shopping, transportation, personal hygiene, upper body dressing, walking, locomotion, toileting, bed mobility and eating. The patient has bowel and bladder incontinence. The information provided does not support that the patient has functional needs requiring consumer directed personal assistance program services 56 hours per day. The approved consumer directed personal assistance program services 31 hours per week is appropriate to meet this patient's needs for assistance with activities of daily living. The proposed consumer directed personal assistance program services 56 hours per week is not medically necessary.