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

Diagnosis: Heart disease, hypertension and osteoarthritis. 
Treatment: 84 hours per week - consumer directed personal assistant services. 
The insurer denied coverage for 84 hours per week - consumer directed personal assistant services. 
The denial is modified. 

This is an elderly female with chronic medical problems including heart disease, hypertension and osteoarthritis. She lives alone in a private residence. The plan approved 45 consumer directed personal assistant services (CDPAS) hours/week and the request is for 84 CDPAS hours/week. 

In the Uniform Assessment System (UAS) report he patient's cognitive skills are described as "minimally impaired." She is reportedly totally dependent to maximal assistance for completing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires extensive assistance for bathing, lower body dressing, locomotion, toilet transfer/use and ambulation. Limited assistance is reportedly needed for personal hygiene, upper body dressing, bed mobility and eating. The patient is reportedly frequently incontinent of bladder and infrequently incontinent of bowel. Her Activities of Daily Living (ADL) status has reportedly declined over the prior 90 days. Her level of self-sufficiency has reportedly not changed over the prior 90 days. 

The letter from the patient 's treating provider nurse practitioner was reviewed. The patient's cognitive and functional status is rapidly declining. In addition, the Uniform Assessment System (UAS) report demonstrates only modest cognitive and functional decline when compared to the previous report. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested consumer directed personal assistant services 84 hours/week. This physician would agree that the patient may benefit from monitoring for safety; particularly due to his decreased mobility and falls risk. Consumer directed personal assistant services (CDPAS) for companion care or safety supervision without the direct provision of task assistance is not a covered service. However, after reviewing the letter from her treating provider and the prior UAS report, this physician would agree that the patient should have consumer directed personal assistant services increased to 63 hours hours/week. 

From a physical medicine and rehabilitation perspective, the requested increase in Consumer Directed Personal Assistance Services 84 hours per week is not medically necessary. However, 63 CDPAS hours per week are medically necessary. 

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 84 hours per week - consumer directed personal assistant services services is not substantiated. However, 63 CDPAS hours per week are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left thyroid nodule. 
Treatment: Full hospital admit. 
The insurer denied the full hospital admit. 
The determination is upheld. 

This is a male patient with a history of a left thyroid nodule. A fine needle aspiration was performed and was consistent with a goiter. Pre-operatively, the patient denied any radiation exposure, voice changes, dyspnea, dysphagia to solids, or any vocal cord disorders. 
The patient underwent a left hemithyroidectomy. Postoperatively, the patient was admitted for pain control and drain management. Following the surgery, the patient had a "high drain output" of 115 milliliters (ml), 88 ml, 88 ml and then below 30 ml. The concern post operatively was that the patient required close monitoring to be sure that the patient did not require the surgical intervention of reopening of the incision. The surgical team considered sending the patient home on postoperative day (POD) number 2, however, there was concern that the patient was not in proximity to a medical facility. At issue is the medical necessity of an inpatient admission. 

The requested health service did not require a medical stay. The patient had no complications from the surgery and did not have pre-existing criteria requiring admission. The patient had an increased drain output that did not allow removal. However, this could have been assessed initially at a lower level of care. Then, the patient could have discharged. The continued drainage output is not a significant criterion to justify inpatient admission. The inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory distress

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned


This is a male child with a history of asthma who has had 3 prior admissions to the hospital in the past year and one resulted in the need for bilevel positive airway pressure (BIPAP) in the Pediatric Intensive Care Unit (ICU). The child had been sick for 2 days with a cough. The child had been taking twice daily inhaled steroids. When the mother noted increased respiratory rate and an increase in the work of breathing, she administered albuterol in the home. When there was no improvement, she brought the child to the emergency room (ER) for additional treatment.

On presentation he was noted to be in respiratory distress with increased work of breathing, retractions, nasal flaring and wheezing. On physical exam his pulse oximeter was 94% (percent) and the child had diffuse wheezing upon auscultation of the chest, retractions and prolonged expiration.  He was treated with three treatments with duoneb, decadron, and intravenous (IV) magnesium sulfate. Following treatment he continued to have wheezing and increased work of breathing. A chest x-ray was unremarkable. He was started on oxygen at 16 liters per minute.  Since the child continued to have retractions and increased work of breathing the decision was made to admit the child to the hospital for ongoing treatment with albuterol every 2 hours with a diagnosis of status asthmaticus.

The patient was treated appropriately for an acute episode of wheezing, and difficulty breathing. This child had 3 previous admissions for asthma in the past year. When he did not respond to treatment in the emergency room and he was noted to have persistent wheezing and labored breathing and retractions, it was appropriate and consistent with the standard of care to admit the child to the hospital with a diagnosis of status asthmaticus for ongoing treatment with albuterol every 2 hours. He was not stable enough to be safely discharged. 

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female with a medical history of chronic obstructive pulmonary disease (COPD), emphysema, bronchitis, human immunodeficiency virus (HIV) and seizures who was admitted for a right lower lobe community acquired pneumonia with symptoms of cough, shortness of breath and headache. Her chest x-ray demonstrated a right lower lobe pneumonia but did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia. She was treated with antibiotics (Ceftriaxone & Azithromycin).

Inpatient Hospital Admission was not medically necessary for this patient.
This patient with a medical history of chronic obstructive pulmonary disease (COPD), emphysema, bronchitis, HIV and seizures was admitted for a right lower lobe community acquired pneumonia with symptoms of cough, shortness of breath and headache. As per the clinical documentation, on admission the patient was afebrile, hemodynamically stable, with a respiratory rate of 22 breaths per minute, oxygen saturation 98% on room air, had a normal pulmonary effort, and normal breath sounds on auscultation of the chest. She was treated with antibiotics (Ceftriaxone & Azithromycin). Her chest x-ray demonstrated a right lower lobe pneumonia but did not demonstrate evidence of an empyema/abscess/necrotizing pneumonia. She was alert, awake and oriented throughout her stay, she did not have a documented immunosuppressed state, bacteremia, or dehydration, she was able to take oral medications and feeds and her CURB-65 score was 1 and Pneumonia Severity Index score was a risk class 2. In addition, she did not have any decompensation of her comorbidities and did not require supplemental oxygen for hypoxia/hypoxemia. Therefore, the Inpatient Hospital Admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission

The denial is upheld

 
The patient is an adult male who presented to the emergency room with dizziness. Patient has a history of anemia. Patient had a hemoglobin (Hgb) of 7 and was admitted for intravenous (IV) iron and blood transfusion. Patient has a baseline Hgb of 8-9. 

Iron deficiency anemia can be managed in an alternative level of care such as observation and outpatient. Transfusions can be done in the emergency room (ER) and intravenous (IV) iron does not require 5 days to administer. As this patient was hemodynamically stable, he could have been managed in alternative level of care.

DeLoughery T. G. (2017), "Iron deficiency is one of the most common causes of anemia. The 2 main etiologies of iron deficiency are blood loss due to menstrual periods and blood loss due to gastrointestinal bleeding. Beyond anemia, lack of iron has protean manifestations, including fatigue, hair loss, and restless legs. The most efficient test for the diagnosis of iron deficiency is the serum ferritin. Iron replacement can be done orally, or in patients in whom oral iron is not effective or contraindicated, with intravenous iron."

Warner, MJ., and Kamran, MT. (2021), "The treatment of iron-deficiency anemia includes treating the underlying cause, such as gastrointestinal bleeding and oral iron supplementation. Iron supplementation should be taken without food to increase absorption."                                                         

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

Diagnosis: Ambulatory Dysfunction
Treatment: Personal Care Assistance Services a total of 2/12 hours per week (split shift)
The insurer denied Personal Care Assistance Services a total of 2/12 hours per week (split shift).
The determination is upheld.

This is a female patient with a medical history notable for ambulatory dysfunction. The patient and her care team requested an increase in personal care assistance services to 2/12 hours per week split shift.
The request for additional hours came after the patient had an inpatient hospitalization  due to pneumonia. The patient lives alone and has numerous medical needs. There were no medical records or letters of medical necessity provided as part of this appeal.
The health plan denied the request. They state that they have put in place skilled nursing services and physical and occupational therapy services to help promote the patient's recovery. There is no indication for an increase in personal care services. Personal care services are not approvable for safety monitoring and security.
A Uniform Assessment System (UAS) was completed. The assessment was conducted via teleconference. The patient lives alone. She was alert and oriented, but with periods of forgetfulness and confusion. She is able to direct her own care and make her needs known. For her instrumental activities of daily living, she requires maximal assistance for meal preparation, housework, shopping, and transportation. She requires extensive assistance for stairs and finances. For her activities of daily living, she requires extensive assistance for bathing, hygiene, dressing, walking, locomotion, toilet transfer, and toilet use. She is independent for bed mobility and eating. She is frequently incontinent of urine and uses Pull-Ups for incontinence care. A task tool associated with the assessment recommended 24.24 hours per week to address her personal care needs. Compared to a prior assessment, the patient showed a similar level of functional need. At issue is the medical necessity of Personal Care Assistance Services a total of 2/12 hours per week (split shift).

The requested health service of Personal Care Assistance Services a total of 2/12 hours per week (split shift) has not been demonstrated to be medically necessary for this patient.
The patient had a recent hospitalization for pneumonia. This is not typically an indication to increase personal care services, as a short-term need for recovery can be addressed by increasing skilled care services or through placement in a subacute rehabilitation facility. There are no letters of medical necessity or notes detailing why the increase in personal care services would be permanently necessary. Therefore, the requested increase has not been demonstrated to be medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with medical history of acute pancreatitis complicated by pseudocyst, alcohol use disorder, and asthma. He presented to the emergency department with abdominal pain radiating to the back, nausea, and vomiting. He had been using marijuana; he had discontinued alcohol. Vital signs were unremarkable. Physical examination was notable for soft, nondistended, nontender abdomen. Labs showed low hemoglobin of 12.6 and hematocrit of 37.1% (percent), low potassium of 3.3, and elevated lipase of 545. Chest x-ray showed no focal consolidation to suggest pneumonia. Computed tomography scan of the abdomen and pelvis showed marked ascites, findings suggestive of acute pancreatitis with stable 2.2 centimeter (cm) pancreatic pseudocyst in the head of the pancreas, mildly enlarged para-aortic lymph nodes, and mild diffuse increased hazy density and nodular changes within the omentum. 

The inpatient hospital admission was not medically necessary. The patient had abdominal pain, imaging, and elevated lipase consistent with acute pancreatitis, and he had a stable pancreatic pseudocyst. However, there was no reported pancreatic necrosis or impingement of the pseudocyst on other structures. The patient was appropriately treated, with intravenous fluid administration and nil per os status with a plan for gradual advancement of diet, and outpatient follow-up for pancreatic pseudocyst drainage. There was a lack of hemodynamic instability, organ failure, pleural effusion, or other sequelae to justify acute inpatient level of care, and the treatment provided during the brief stay could have been provided at a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines.
Treatment: Aimovig.
The insurer denied Aimovig.
The determination is upheld.

This is a female patient with chronic migraine who is requesting treatment with Aimovig. The patient had previously tried and failed oral medication such as propranolol, amitriptyline, and riboflavin. The Aimovig was denied because the patient has not used the available formulary alternatives of Emgality, Ajovy, and Qulipta. At issue is whether the formulary drugs will be ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

There is no documentation to show that the patient has tried and failed the available formulary alternatives of Ajovy, Emgality, or Qulipta. There is no reason to believe that these drugs would not be as effective as the non-formulary drug Aimovig. Although there are no head-to-head comparisons of these medications available, all of the formulary alternatives are Food and Drug Administration (FDA) approved and literature and compendious supported for preventative treatment of migraine. There are no data to show that Aimovig is superior to these drugs. As such, it cannot be said that the formulary alternatives would not be as effective.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes
Treatment: Ozempic 0.25 - 0.5 MG/DOSE (milligrams per dose) Pen (C9399)
The insurer denied: Ozempic 0.25 - 0.5 MG/DOSE (milligrams per dose) Pen (C9399).
The denial is overturned.

The patient is an adult male with type 2 diabetes. The request for Ozempic is under review. The prior request was denied coverage by the health plan, because approval on criteria requires a diagnosis of type 2 diabetes mellitus by history of one of the following: A1C (glycated hemoglobin) greater than or equal to 6.5% (percent), fasting plasma glucose greater than or equal to 126 mg/dL (milligrams per deciliter), two hour plasma glucose greater than or equal to 200 mg/dL as part of an oral glucose tolerance test, or symptoms of hyperglycemia and a random plasma glucose greater than or equal to 200 mg/dL. The denial is being appealed.

The patient's A1C was 7.5% three years ago. The patient's most recent A1C was normalized by medication, but he no longer tolerates it. The request is to switch to Ozempic.

The requested Ozempic is medically necessary.

This request is for Ozempic for the treatment of type 2 diabetes. The prior request was denied due to lack of documentation confirming a diagnosis of type 2 diabetes. The appeal documentation includes an A1C of 7.5%, which is consistent with a diagnosis of type 2 diabetes. This patient's more recent A1C levels improved on treatment, but he is no longer tolerating that treatment, and Ozempic is being requested. The use of Ozempic for the treatment of type 2 diabetes is consistent with the Ozempic prescribing information and the American Diabetes Association clinical guidelines. Without Ozempic, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the requested Ozempic is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Stroke, diabetes type 2, congestive heart failure (CHF), hypertension, and osteoarthritis.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 8 hours per day: 56 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 8 hours per day: 56 hours per week.  The denial is upheld.
 
This is an adult with chronic medical problems, including a previous stroke, diabetes type 2, congestive heart failure (CHF), hypertension, and osteoarthritis. The patient lives with his daughter, who assists him with some instrumental activities of daily living (IADL) and activities of daily living (ADL). He has had no falls or hospitalizations in the last 90 days and has had no seizure activity for several months.
  
The New York State Comprehensive Assessment form was reviewed. The patient's cognitive function is described as independent with no memory loss.   He can ambulate with a cane up to 299 feet.  He needs limited assistance for dressing and manages with some assistance for shopping, meal preparation and housework.  He can call for emergency assistance independently and is independent in toileting and eating. Groceries can be delivered. The hours approved assist him with the tasks listed above and for personal hygiene. Consumer Directed Personal Assistance Services (CDPAS) hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no one else is available to provide assistance. 

Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained with 31.5 CDPAS hours/week. He has the means for emergency assistance and can use the emergency devices reliably. 

The carrier's denial of 56 hours per week of CDPAS services is medically appropriate.  The patient can be safely managed with 31.5 hours of CDPAS weekly. 

The carrier's decision to deny 56 hours of CDPAS services per week and approve 31.5 hours per week should be 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 Consumer Directed Personal Assistance Services (CDPAS) 7 days per week, 8 hours per day; 56 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral gastroenteritis.
Treatment: Inpatient Hospital Stay.

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

This is a male patient who presented to the emergency room for abdominal pain, vomiting and diarrhea. He was found to have evidence of dehydration. His laboratory studies were significant for an elevated creatinine, concerning for mild renal dysfunction. He was diagnosed with viral gastroenteritis and dehydration. He was given intravenous fluids, antiemetics and admitted for further management. At issue is the medical necessity of an inpatient stay.

An inpatient hospital stay was not medically necessary.
Most gastroenteritis cases do not require inpatient care. However, a small percent of patients develop severe dehydration and require intravenous rehydration and hospital care. Per Banyai, K., et al. (2018) "For treatment of dehydration caused by gastroenteritis viruses, the administration of reduced-osmolality oral-rehydration solutions (50-60 millimoles per liter (mmol/L) sodium) is the first line of therapy. Profuse vomiting, worsening dehydration with altered consciousness, or severe acidosis, hypovolaemic shock, abdominal distension, and ileus are indications for intravenous rehydration".
This patient presented to the emergency room for diarrhea and vomiting and developed signs of dehydration. He was unable to maintain oral hydration however, he was hemodynamically stable and did not have mental status changes or severe electrolyte abnormalities. No evidence of bowel obstruction or ileus. He did not have evidence of severe renal injury or other organ damage. The provided care included intravenous fluids, antiemetics and monitoring. The patient did not require invasive procedures or surgical interventions. He did not require a complex treatment regimen or respiratory support. Therefore, the patient's condition and his care were manageable at a lower level of care. An acute level of care was not medically necessary.