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

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a medical history of asthma. He presented to the emergency department with abdominal pain for three days and constipation, without nausea, vomiting, or diarrhea. The physical examination was notable for periumbilical abdominal tenderness. A computed tomography scan of the abdomen and pelvis showed a normal appendix, lack of bowel obstruction, lack of free air, and slight prominence of the head of the pancreas with questionable pancreatic head focal edema (cannot exclude early acute pancreatitis), difficult to determine since second portion of the duodenum is somewhat collapsed adjacent to the pancreatic head. He was treated with intravenous fluids and oral potassium chloride. He was made nil per os (nothing by mouth).

A gastroenterology consultation noted abdominal pain with intermittent alcohol use; the recommendation was to continue intravenous fluids, continue pain management, start a proton pump inhibitor, and check immunoglobulin (Ig) G4 level. A right upper quadrant ultrasound was normal. He was discharged with a plan for Primary Care and Gastroenterology follow-up. At issue is the medical necessity for the inpatient level of care.

The inpatient level of care was not medically necessary. The care provided could have been provided at a lower level of care.

In this case, the patient presented with abdominal pain consistent with acute pancreatitis, and a possible imaging finding of pancreatitis; the lipase was not sufficiently elevated to meet pancreatitis criteria [1-3]. There were no complications of pancreatitis such as pancreatic necrosis, pseudocyst, or abscess [4-6]. No procedural interventions such as endoscopic ultrasound were necessary during the hospital stay. He was appropriately treated with intravenous fluids, and his symptoms improved; his diet was advanced and discharge was then deemed appropriate. The interventions performed, including labs, monitoring, imaging, empiric antibiotic therapy, and intravenous fluids with gradual advancement of diet, could have been performed without the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) 24 hours/day (split shift), 7 days/week
The insurer denied the requested PCA 24 hours/day (split shift), 7 days/week as not medically necessary. 
The denial is overturned.

This is a case review for a female with a medical history notable for dementia, congestive heart failure, and incontinence. The patient is approved for 24-hour live-in personal care, 7 days/week. The patient and her care team requested an increase to 24-hour split-shift (2-12 hour shifts) and this request was denied by the health plan.

The patient's physician provided a letter of medical necessity for this appeal. The patient has significant night time sleep disturbance for which there are no additional medical options available. She requires oxygen via nasal cannula throughout the day and night and has a history of being entangled in her tubing, requiring assistance to become untangled. She requires hands on assistance for all activities of daily living (ADLs) including bed mobility, and the physician requests turning and repositioning frequently to prevent pressure ulcer formation.

Physical therapy notes were provided and reviewed in detail as part of this case review.
A Uniform Assessment System (UAS) was completed. The patient's cognition was moderately impaired. She is oriented to person only and is not able to make her needs known. For her instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, and shopping. She requires maximal assistance for finances, medications, phone use, stairs, and transportation. For her ADLs, she requires maximal assistance for bathing, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for personal hygiene and dressing. She requires limited assistance for bed mobility and eating. She is frequently incontinent of urine and continent of stool. Functional status was not significantly changed from the prior assessment.

At issue is the medical necessity for Personal Care Aide (PCA) 24 hours/day (split shift), 7 days/week.

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

The requested health service/treatment of PCA 24 hours/day (split shift), 7 days/week is medically necessary for this patient.

The patient is currently approved for 24-hour live-in care. The patient's care team requested an increase to split-shift care. Live-in care is appropriate if the PCA can be reasonably expected to get a minimum of 5 hours of uninterrupted sleep per night. If the patient's personal care needs preclude them being able to get this amount of rest, then split-shift care is appropriate.

There is clear documentation that the PCAs are not able to achieve the minimum required rest period. The patient requires assistance for all ADLs including toileting. She is incontinent of urine and requires assistance with diaper changes. She requires assistance for toileting and other needs overnight. Therefore, it is medically necessary to provide split-shift 24-hour care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate cancer
Treatment: PET scan with CT for Attenuation (Positron Emission Tomography with Computer Tomography - pictures of inside of your body).
The insurer denied PET scan with CT for Attenuation (Positron Emission Tomography with Computer Tomography - pictures of inside of your body).
The health plan's determination is overturned.

This patient is a man with a rise in prostate-specific antigen (PSA) to 22.4. He had prostate biopsies that revealed a Gleason 8 adenocarcinoma. He had PSMA (Prostate-specific membrane antigen) positron emission tomography (PET) scan preoperatively and was found to have no evidence of distant disease. He then went on to prostatectomy and pathology showed Gleason 8 disease with positive pelvic lymph nodes for metastases as well as extra nodal extension and seminal vesicle invasion. His PSA never became undetectable. Due to his high-risk disease and entry to a phase III trial comparing standard of care to possible better with additional hormonal manipulation, a PSMA positron emission tomography (PET) with computed tomography (CT) is recommended.

The PET scan with CT for attenuation is considered medically necessary for this patient.
The recommended PET scan with CT attenuation is considered medically appropriate and necessary for this patient and his clinical scenario of prostatectomy with high risk disease with positive nodes for metastases and a PSA postoperatively that never reach undetectable. This PET will be very important to assist in determining further therapy for this patient and his clinical scenario. This is also supported by National Comprehensive Cancer Network (NCCN) Guidelines with category 2a support as follows:
Because of the increased sensitivity and specificity of PSMA- PET tracers for detecting micro metastatic disease compared to conventional imaging (computed tomography (CT), magnetic resonance imaging (MRI)) at both initial staging and biochemical recurrence, the panel does not feel that conventional imaging is a necessary prerequisite to PSMA-PET and that PSMA- PET/CT or PSMA-PET/MRI can serve as an equally effective, if not more effective front-line imaging tool for these patients.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive multifocal leukoencephalopathy with hemiplegia, right side joint contractures, seizures and bipolar disorder
Treatment: Personal care aide (PCA) services 7 days x 12 hours x 2 shifts, for a total of 168 hours per week
The insurer denied coverage for PCA services 7 days x 12 hours x 2 shifts, for a total of 168 hours per week
The denial is overturned.
 
This is a young adult with medical problems that include progressive multifocal leukoencephalopathy with hemiplegia, right side joint contractures, seizures and bipolar disorder. She lives with her disabled father in a private residence. The insurer approved PCA services 10 hours/day, 7 days/week and the request is for PCA services 7 days x 12 hours x 2 shifts, for a total of 168 hours per week.

According to the Uniform Assessment System (UAS) report the patient's cognition is described independent. However, she is totally dependent for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also totally dependent for lower body dressing, bed mobility and toilet use. Maximal assistance is needed for bathing and upper body dressing. She is essentially bed bound with right upper and lower extremity hemiplegia as well as joint contractures. The patient is also bowel and bladder incontinent. The patient's functional ability has declined when compared to the prior UAS report. She requires a Hoyer lift for transferring out of the bed and unable to use a bed pan or bedside commode due to hemiplegia and contractures.  

The patient's clinical condition, functional deficits and poor prognosis are at a level and unpredictable as to require the requested PCA 7 days per week, 24 hours per day split shift. Of particular concern is her bed bound status, risk of pressure ulcers and progression of her joint contractures. She requires routine repositioning in bed at least every 2-3 hours.  Based on the clinical records, a live-in PCA is unlikely capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift. Attention to the patient's functional needs are more appropriately provided and maintained by the requested PCA services 7 days x 12 hours x 2 shifts, for a total of 168 hours per week.

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) services 7 days x 12 hours x 2 shifts, for a total of 168 hours per week is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gender Dysphoria
Treatment: Estradiol Valerate 40mg/ml (milligrams/milliliter) Injection
The insurer denied Estradiol Valerate 40mg/ml injection.
The health plan's determination is overturned. 

This patient is diagnosed with gender dysphoria male to female. This request is for Estradiol Valerate. As per a recent visit note, the patient was advised to switch from oral pills to estradiol injections due to lower risk of side effects. The patient reported stomach upset with oral pills and nausea. 

A formulary exception is indicated in this case.

The patient has had adverse side effects with the formulary alternative Estradiol tablet. The only formulary alternative has been ineffective. Furthermore, oral estradiol is associated with higher risk of thrombosis. Therefore, the use of Estradiol Valerate 40mg/ml (milligrams/milliliter) injection is indicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, stroke, pressure ulcers.

Treatment: Consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.

The insurer denied coverage for consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.

The denial is overturned.

This is a patient with heart disease, stroke and pressure ulcers. The patient lives with daughter and son-in-law in a private residence. The insurer approved Consumer Directed Personal Assistance Services (CDPAS) 98 hours per week and the request is for CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient is totally dependent for much of the Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also totally dependent for lower body dressing and toilet transfer/use. The patient is frequently incontinent of bowel and bladder. Maximal assistance is needed for bathing, personal hygiene and upper body dressing. The patient is essentially bedbound; being totally dependent for bed mobility and locomotion. The patient is non-ambulatory.  

The patient's medical condition and functional ability are at a level or unpredictable as to require the requested CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week. The option of a live-in CDPAS is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. Of particular concern is the patient developing pressure ulcers and the need for repositioning while in bed at a frequency of at least every 3-4 hours. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home with CDPAS 24 hours a day, 7 days a week (split shift), totaling 168 hours per week.

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 consumer directed personal assistance services (CDPAS) 24 hours a day, 7 days a week (split shift), totaling 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heroin overdose
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The health plan's determination is overturned. 

The patient is a female with history of human immunodeficiency virus (HIV), substance abuse, chronic opioid use, methadone treatment, depression/anxiety, and asthma who was evaluated in the emergency department (ED) status/post (s/p) using 1 bag on heroin. Emergency Medical Services (EMS) administered naloxone 4 milligrams (mg) due to AMS (altered mental status). On admission, the patient (pt) had a temperature of 39-39.3oC, blood pressure (BP) 96/61, heart rate (HR) 90's and pulse oximetry 88-99%. She was intermittently arousable and would answer some questions. She had a negative review of symptoms (ROS) except 5/10 frontal H/A (headache) and nausea. The pt weighted 54 kg (kilograms) and was 5'4" (5 foot 4 inches) with a body mass index (BMI) 20. Physical exam noted lethargy and bilateral basilar crackles but was o/w (otherwise) normal. 

The inpatient admission was medically necessary.

This case is complex in the sense that the patient had several comorbid conditions and findings consistent with pneumonia on chest x-ray (CXR). Her comorbid conditions made determining the cause of her fever more difficult and concerning. Specifically, her h/o (history of) HIV and noncompliance with her highly active antiretroviral therapy (HAART) widen the DDX (differential diagnosis) to include atypical or opportunistic organisms which can be non-responsive to conventional antibacterial and also potentially include the requirement for anti-fungal/anti-viral agents. Additionally, with her altered mental status, the pt was at risk of an aspiration event or other non-infectious etiologies including pulmonary edema from naloxone, Castlemans disease, Kaposi Sarcoma, etc. The patient also is likely cachectic and may have normally had low systolic BP which may have confounded assessment, although a MAP (mean arterial pressure) of less than 55 is clearly abnormal. Not only was there a concern for sepsis and subsequently septic shock, the pt had polysubstance abuse and her neurologic improvement is not congruent with just a heroin overdose. Given the high fever and MS (mental status) change, the concern for meningitis seems reasonable. When the pt had hypotension in addition to her MS changes she was transferred to the Intensive Care Unit (ICU). She improved with observation and conservative therapy. There were clearly some signs that were reassuring such as her respiratory rate (RR), and heart rate (HR) but her MS, hypotension, and oxygen saturation which was in the high 80s was concerning. She responded to oxygen therapy and her hypoxia was likely due to concomitant respiratory acidosis since her A-a gradient was normal, but one could not also rule out sepsis as a cause of these findings. As a result, the inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Cellulitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history significant for benign prostatic hyperplasia (BPH) and sciatica. He was brought to the emergency department due to leg pain that woke him up from sleep. The patient stated that the pain was severe and excruciating. It was associated with redness, swelling, and local warmth in the area. The patient denied any trauma but stated that he was not able to walk.
There was left lower extremity redness noted. The rest of the physical exam was unremarkable.
The patient was admitted to the hospital with leg pain. At the time of admission, the patient was suspected to have cellulitis and was started on intravenous antibiotics, with significant improvement in his symptoms in 24 to 48 hours. He also underwent an echocardiogram, which demonstrated no intercardial masses, thrombi, or vegetation. The patient refused blood cultures or any other laboratory testing during the hospital stay. Since his clinical condition continued to improve, he was transitioned to outpatient care. At issue is the medical necessity of an inpatient stay.

The hospital stay was not medically necessary for this patient at the acute inpatient level of care. There was no compelling clinical reason why the patient could not have safely and appropriately received evaluation and treatment at a lower level of care with subsequent transition to outpatient care, rather than admission to an inpatient level of care.
In general, admission at the acute inpatient level of care is indicated for patients with cellulitis who fail outpatient therapy, in cases of a limb-threatening infection, or rapid progression of the infection that necessitates high-intensity monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus or liver cirrhosis.
Admission at the acute inpatient level of care is also indicated for patients with cellulitis and bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection, or oral cellulitis, or when patients need a surgical procedure not amenable to outpatient or emergency department care, cases of cutaneous gangrene, or when patients have severe pain requiring acute inpatient management, inability to maintain oral hydration, in cases of compartment syndrome, or some other conditions that were not relevant to this clinical case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: amyotrophic lateral sclerosis (ALS)
Treatment: Home Care / Personal Care - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift).
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift).
The health plan's determination is upheld.

This is a case review for a male with medical history notable for amyotrophic lateral sclerosis (ALS). The patient and his care team requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift).

The requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hours per Day (Split Shift) is not medically necessary for this patient.
The patient requires hands-on assistance for all activities of daily living (ADL) and Instrumental activities of daily living (IADL). He does require 24 hour personal care. The final adverse determination states that he is approved for 24-hour live-in care. The patient requested an increase to 24 hour split-shift care. Live-in aides are expected to be able to receive adequate rest including a minimum of 5 hours of uninterrupted rest. There is no documentation regarding why a live-in aide would not be able to receive the required amount of rest, which would be required to approve an increase to split-shift care. There were no night-logs of care required overnight and no documentation of pressure ulcer that would require frequent repositioning. Therefore, there is insufficient evidence of medical necessity for the requested increase.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders-atopic dermatitis
Treatment: Prescription/Pharmacy Drugs-Rinvoq
The health plan denied the requested Rinvoq as the patient did not have evidence of inadequate treatment with other drugs or the drug is not advisable. The reviewer has upheld in whole the health plan's determination. 

The patient is a female with moderate to severe atopic dermatitis (25% (per cent) body surface area involvement) that includes the scalp and face. The patient has used topical fluocinonide solution and tacrolimus, 0.1% ointment to the face and body for over 6 months at a time.  The patient was unable to tolerate spironolactone due to side effects and has no plans for pregnancy. Pimecrolimus has helped her facial seborrheic dermatitis. The patient was prescribed but never started Dupixent.  The patient was started on Rinvoq, 15 milligrams per day (mg/day).

The patient has no documented treatment failure with, or true medical contraindication to, either of the standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Methotrexate, Azathioprine, or Mycophenolate Mofetil), or to biologic agents more newly approved for this condition (Dupixent or Adbry). Rinvoq is not proven to be superior to all other formulary alternatives as per comparative, controlled studies, and is only Food and Drug Administration (FDA) -approved for second-line systemic therapy behind the other, aforementioned systemic therapies. Therefore, as per current medical literature, the requested Rinvoq would not be considered more effective than the formulary drug(s).
Modern dermatology literature supports use of the health plan formulary and preferred medications as similarly efficacious to the requested Rinvoq, particularly for a patient with no history of systemic atopic therapy previously utilized, and this literature recommends use of these preferred agents as appropriate for this patient's clinical scenario. Rinvoq is the only FDA-approved for moderate to severe atopic dermatitis in patients who previously tried and failed other systemic therapies. The provider is prescribing and requesting Rinvoq out of convenience and/or preference of the provider and/or patient. Therefore, as per current medical standards of care, Rinvoq is not considered more effective.