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

Diagnosis: Orthopedic/Musculoskeletal/Neck Problem/Pain/Post Neck Surgery
Treatment: Full Hospital Admission
The health plan denied the requested full hospital admission as not medically necessary. The health plan's determination is upheld.

This is a female who underwent an anterior cervical discectomy and fusion (ACDF) of cervical (C5-7). The surgery was without complications. The progress note the morning after surgery states her pre-operative complaints were improved and she was ready for discharge. There are no progress notes explaining the delay of discharge that day. She was discharged home. The appeal letter states her pain was not controlled requiring a longer stay, and that she had tachycardia and hypertension, requiring intravenous (IV) Morphine and Metoprolol.
At issue is the medical necessity for the full hospital admission.

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

The patient could have been discharged the day after surgery. There are no progress notes describing a reason for a prolonged stay, and in fact she was doing well that day after surgery and would be discharged. Patients undergoing anterior cervical fusion procedure done without complications are generally done as an outpatient or in an observational setting with a one night stay. Milliman Care Guidelines (MCG) Guidelines describe the goal of length of stay as "Ambulatory or 1 day postoperative." There is no documentation provided demonstrating a 2 night stay.

A one night stay at an alternate level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell anemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient is a toddler with a history of sickle cell disease (with 6 previous admissions and 3 blood transfusions) who presented to the hospital with cough and fever (maximum temperature 100.3 degrees F). She had no previous shortness of breath, chest pain, other type of pain, excessive crying, lethargy, sore throat, diarrhea or changes in oral input, activity levels, or urine output. She was found to have rhinorrhea, scleral icterus, possible rhonchi, bronchial breath sounds in the right posterior lung base, enlargement of the liver to 4-5 centimeters (cm) below the costal margin, and no splenomegaly. Chest x-ray was negative for any acute disease and no infiltrate was seen. Her hemoglobin was 6.7 (with a baseline of 8 to 9) and she was admitted for treatment of upper respiratory infection in the setting of sickle cell disease with a drop in her hemoglobin. After her admission she was treated with intravenous (IV) antibiotics, placed on cardiorespiratory monitoring, given IV fluids, Tylenol for fever, and had her labs monitored. She had a temperature to 100.6 degrees after admission. Her hemoglobin was 6.0 and she was transfused packed red blood cells. She remained stable and was discharged home. 

This patient was admitted for treatment of low-grade fever and upper respiratory symptoms in the setting of sickle cell anemia. In general, admission is indicated for children with sickle cell disease when there are certain high-risk situations. This patient does not have a history of stroke, seizure, acute chest syndrome (chest x-ray was clear at the time of admission), significant hypoxia or acidosis, need for emergent surgery, splenic or hepatic sequestration, aplastic crisis, vascular complications, traumatic hyphema, severe infection causing hospitalization such as osteomyelitis, or significant finding or clinical condition judged too severe or too persistent to be within the scope of observation care. While the patient had some enlargement of the liver, there was no clear hepatic sequestration. The patient did not have a serious fever (maximum temperature prior to admission 100.3, maximum temperature in the hospital 100.6), there were no chest x-ray changes, no oxygen needs, and no treatment needs that required the acute inpatient level of service. The length of stay and the treatment needs for the patient were more consistent with the observation level of care and not the inpatient level of service.

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: Overturned

Diagnosis: Chronic Urticaria and Psoriasis
Treatment: Otezla
The insurer denied Otezla.
The denial is overturned.

The patient is an adult male. He has a medical history of plaque psoriasis affecting the scalp, eyebrows, elbow, arms, back, abdomen and lower legs with a 5% (percent) total body surface area affected. The patient has previously tried clobetasol 0.05% ointment. This request for coverage of Otezla is under review.

The requested Otezla is medically necessary.

Per criteria, the patient must have a history of failure, contraindication or intolerance to a course of therapy with phototherapy or a systemic medication like methotrexate. The provider cites distance from available office-based phototherapy as a contraindication to treatment with the same. Additionally, the clinical chart notes endorse a history of liver disease as a clinical contraindication to treatment with oral systemics like methotrexate. Given valid contraindications to the plan's preferred agents, the request for Otezla is medically necessary for 12 months.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Left hip fracture and replacement, colon cancer, hypertension, muscle weakness, abnormality of gait and chronic pain
Treatment: Personal Care Aide (PCA) services 7 days per week, 24 hours a day live in
The insurer denied coverage for Personal Care Aide (PCA) services 7 days per week, 24 hours a day live in
The denial is modified

 
This is an elderly patient with medical problems that include colon cancer, hypertension and recent hip fracture. She lives alone in a private residence; however, she was in a skilled nursing facility (SNF) at the time the UAS was performed. The insurer approved Personal Care Aide (PCA) 67 hours/week. The request is for PCA service live in, 7 days a week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately impaired- Decisions are consistently poor or unsafe; cues/supervision required at all times." She is totally dependent to maximal assistance for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and managing her medications. She is also totally dependent for bathing, locomotion and ambulation. Maximal assistance is needed for lower body dressing and toilet transfer/use. She is incontinent of bladder and bowel. Extensive assistance is needed for personal hygiene and upper body dressing. Limited assistance is needed for bed mobility and eating.  

However, the physical and occupational therapy notes at the skilled nursing facility (SNF) documented a higher level of functional ability. According to the therapy notes the patient's transfer ability (locomotion) was at the contact guard (limited) assistance level. She was able to ambulate with a rolling walker and contact assistance. Activities of daily living (ADL) including eating, personal hygiene and upper extremity dressing were at the contact guard to set-up level of assistance. Bathing and lower body dressing were at the moderate (extensive) assistance level.    

The patient's medical condition and functional ability are not at the level as to require the requested PCA services 24 hours/day (live-in). This physician would agree the patient may require additional monitoring, particularly due to her cognitive deficits. However, safety monitoring under PCA does not include monitoring an individual (with dementia) when no other Level I or Level II personal care service tasks are being provided. Based on the records reviewed, attention to the patient's functional needs can be appropriately provided and maintained by increasing the approved PCA to 12 hours/day, 7 days/week (total 84 hours/week).

Based on the above, the insurer's denial must be modified. 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 per week, 24 hours a day live in services is not substantiated. However, PCA 7 days/week 12 hours/day (84 hours/week) is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Elevated TG (triglycerides). 
Treatment: Formulary exception for Vascepa. 

The insurer denied: Formulary exception for Vascepa. 
The denial is upheld. 

The patient is an adult female with history of hyperlipidemia and hypertension. Her exam shows BMI (body mass index) of 40 and otherwise normal. She is on fish oil, and Vascepa was requested for elevated TG (triglycerides). No clinical documentation of lipid values was provided. No clinical articles were provided. Vascepa was denied coverage by the health plan as not being on formulary. No documentation of primary treatment recommendations, including weight loss, guidance or results of alcohol reduction and increase physical activity is provided. No documentation of failure of fibrates, niacin or maximum dose statins is provided. 

The health plan should not cover the Formulary exception for Vascepa. 

No documentation of actual TG (triglycerides) levels is provided, so there is no evidence that the formulary drugs would be ineffective. There is no documentation of formulary drug use not having been tolerated. There is no evidence that the non-formulary drug Vascepa is associated with better outcomes in this clinical situation. Randomized controlled trials examining effects of marine omega-3 fatty acids on ASCVD (atherosclerotic cardiovascular disease) outcomes have yielded mixed results. The appeal did not cite any relevant controlled studies. Therefore, given the above, the health plan should not cover the formulary exception for Vascepa.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroid cancer
Treatment: Cytomel 5 microgram (mcg) tablet
The insurer denied coverage for Cytomel 5 microgram (mcg) tablet
The denial is upheld.

This patient is an adult who has a history of thyroid cancer and status post right thyroid lobectomy. The patient continues to struggle with persistent tightness in muscles and pain in the low back in a large area that happens predominantly at night. The patient has had extensive evaluations with multiple specialists with no specific finding. The patient felt that increasing Cytomel is somewhat helpful. The patient will continue on current dose of Cytomel five micrograms and decrease the Tirosint (levothyroxine) to five pills weekly. 

To approve this service, the following criteria must be met: The doctor must show that the patient has tried and failed three preferred, generic drug(s) for the condition. The preferred options include liothyronine 5mcg tablets [multiple generic manufacturers available].

Per providers appeal information, the requested medication Cytomel is a medical necessity. The patient underwent a right thyroid lobectomy for a tall cell variant of papillary thyroid carcinoma and subsequently required levothyroxine therapy. That therapy started and the dose was raised up, but she maintained hypothyroid symptoms that were profound and dramatically affecting her quality of life. The addition of Cytomel to her regimen made a dramatic impact in her being able to maintain her activities of daily living, her energy level, her thought processes, and her overall sense of well-being.

The patient is requesting brand name Cytomel, but the generic version is covered under the plan. There are no head-to-head studies showing that the generic is inferior to the brand name version.

Cytomel five microgram (mcg) tablet is not considered medically necessary for this patient.   

Although Cytomel has benefitted the patient, there is no reason that the patient cannot take the generic version of the medication. There is no documentation of trial and failure, intolerance or adverse effect of the generic of Cytomel, which is liothyronine. As such, the denial is upheld.

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 Cytomel 5 microgram (mcg) tablet services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Brain injury
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 168 Hours per Week.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 168 Hours per Week. 
The health plan's determination is overturned. 

The patient is a male with past medical history of traumatic brain injury following motor vehicle accident, paraplegia, constipation, G-tube status, tracheostomy status, suprapubic catheter, anxiety, depression, urinary incontinence, and bowel incontinence who had been assigned CDPAS (Consumer Directed Personal Assistance Services).

Consumer Directed Personal Assistance Services (CDPAS): 168 Hours per Week are medically necessary for this patient.
The patient has documented 24-hour care needs that span a continuum of time. Therefore, the patient has unpredictable and unscheduled care needs and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has bowel incontinence which would require prompt changing of incontinence supplies to prevent infection and skin breakdown. The patient also has a tracheostomy requiring prompt treatment if there were any mechanical issues or obstruction requiring suctioning. The plan's own assessment stated the patient should be turned and repositioned every 2 hours as to prevent skin breakdown. The patient requires oxygen when needed and is unable to administer to himself. The patient's medical provider documented the requirement of 24-hour support. The patient's care needs are such that an aide would not be able to obtain at least 5 hours of uninterrupted sleep. 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, CDPAS services 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: Formulary Exception
Decision: Upheld

Diagnosis: Crohn's Disease. 
Treatment: Pentasa 500 mg (milligrams) controlled release (CR) capsules. 

The insurer denied coverage for Pentasa 500 mg CR capsules. 

The denial is upheld. 

The patient has Crohn's Disease. A computed tomography (CT) enterography report was submitted which showed mild active inflammation involving a 12 cm (centimeters) segment of distal and terminal ileum. The physician is requesting Pentasa 500 mg CR capsules. The insurance company is offering mesalamine 500 mg capsules, mesalamine 800 mg delayed release, and mesalamine delayed release 1.2 gram tablets. 

The American College of Gastroenterology has published a guideline on Management of Crohn's Disease in Adults (American Journal of Gastroenterology, Volume 113, pages 481-517). The article discusses treatment of mild to moderately severe disease. It advises that Sulfasalazine is effective in treating symptoms of Crohn's Disease. Oral mesalamine has not been consistently shown to be of benefit in active Crohn's Disease. 

Mesalamine has been shown to be useful for ulcerative colitis but less so for Crohn's Disease. However, there is no recommendation that Pentasa is more effective compared to the other mesalamine formulary alternatives. The insurance company has offered several formulary alternatives to Pentasa. The formulary alternatives of mesalamine delayed release capsules are not likely to cause the patient an adverse reaction. There is no documentation that mesalamine has been ineffective. Giving Pentasa is not likely to be more beneficial than mesalamine. Since the insurance company has offered formulary alternatives to the Pentasa and the scientific literature does not show that Pentasa is more beneficial than other forms of mesalamine for Crohn's Disease, the denial is upheld. 

The carrier's denial of Request for Formulary Exception for Pentasa 500 mg CR capsules to treat Crohn's Disease is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancytopenia. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

The patient was sent by their primary care physician to the emergency room with pancytopenia including severe thrombocytopenia. The patient has been seeing hematology as an outpatient, but evaluation was delayed due to severe pain from an anal fissure. The patient was admitted to the hospital. The patient was seen by hematology and interventional radiology was consulted for a bone marrow examination, but this was not performed. The patient was discharged without any intervention. At issue is the medical necessity of the inpatient stay. 

The requested health service/treatment of the inpatient stay was not medically necessary for this patient. The patient was admitted to inpatient care for a known diagnosis of pancytopenia, for which the patient had previously seen outpatient hematology. A bone marrow examination was recommended but it was decided this should be done as an outpatient procedure. While hospitalized, the patient underwent no diagnostic procedures and no therapeutic interventions. The patient was afebrile with normal vital signs and did not require intensive nursing care, surgery, or other care. In this setting, support for inpatient care is not available in the literature and medical necessity cannot be established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Sided Weakness. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a patient with a past medical history (PMH) of breast cancer, asthma, and prior transient ischemic attack (TIA) who was admitted with complaints of (c/o) left-sided weakness. Her vital signs were unremarkable. The physical exam documented 0/5 in the left extremities, but she was documented to have normal movement "contrary to previous exams documented as 0/5," in addition to a concern for narcotic shopping. Lab work was unremarkable. Imaging studies, including a computed tomography (CT) scan of the head and computed tomography angiography (CTA) of the head/neck showed no acute pathology, a chest x-ray (CXR) showed no acute pathology. An electrocardiogram (EKG) showed normal sinus rhythm (NSR). The patient was diagnosed with a possible cerebrovascular accident (CVA) and treated with acetylsalicylic acid (ASA), physical therapy (PT) / occupational therapy (OT), Speech Language Pathology (SLP) and neurology consultations, and a statin. The patient was discharged against medical advice (AMA). At issue is the medical necessity of an inpatient level of care.

No, the hospital stay was not medically necessary at an acute inpatient level of care.
This patient presented to the emergency department (ED) with c/o left-sided weakness. The patient was found to have two negative CT scans, CT head and CTA head/neck, for acute findings. Further suggestion that this patient was appropriate for a lower level of care is that the patient did not have a crescendo transient ischemic attack (TIA), a head CT scan was negative, there was no known extracranial embolic source or artificial heart valve, known carotid stenosis, disabling stroke, altered mental status, or hypertensive encephalopathy. In addition, there was documentation suggesting that the patient had full strength in her extremities, despite the documentation of 0/5 strength (suspected confabulation of exam for secondary gain), there was no radiological evidence of cerebral infarction, and the patient's plan was to receive statin, anti-platelet, telemetry, radiology diagnostic work-up, neurological checks, and neurology work-up, all of which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic hepatitis C
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult female with chronic hepatitis C status post treatment and sustained virological response, decompensated cirrhosis, and ascites. She presented with abdominal pain and distention. She also was noted to have chronic dysphagia to solids. The platelet count was 19,000. She underwent paracentesis with removal of 6 liters of fluids. She was treated with IV (intravenous) albumin, IV (intravenous) Toradol, Pepcid, Lactulose, Spironolactone, Lasix, Zinc sulfate, folic acid, Nadolol, Tylenol, MVI (multiple vitamins injection).

The Inpatient Hospital Admission was medically necessary.

The patient had ascites causing abdominal distention which was treated with paracentesis. However, inpatient level of care was medically necessary due to thrombocytopenia, need for fluid post-paracentesis (required albumin), and need for titration of diuretics.