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

Diagnosis: Rectal bleeding.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

This is an adult male who presented to the emergency room for bright red blood per rectum for two weeks, abdominal pain, chest pain, and palpitations. The patient was admitted to telemetry. Gastroenterology evaluated the patient and suspected that the ongoing symptoms were likely related to outlet bleeding worsening from hemorrhoids. The patient was discharged the next day.

The proposed treatment was not medically necessary.

An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have active and ongoing rectal bleeding, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  High cholesterol.
Treatment: Repatha.
The insurer denied: Repatha.
The denial is upheld.

The patient is an adult female with history of high cholesterol and intolerance to statins and Zetia. The records include several documented LDL (low-density lipoprotein) values of over 221. 
There is no documented history of CAD (coronary artery disease) or documentation of atherosclerosis, or a family history that meets criteria for Dutch Lipid Clinical Network. The patient did have provocative tests that failed to show atherosclerotic disease. The request for Repatha was denied coverage by health plan as not being medically necessary. The denial is being appealed.

The requested Repatha is not medically necessary.

The letter of appeal was carefully read and considered. Medical necessity criteria for use of PCSK9 (proprotein convertase subtilisin kexin 9) have not been met. The patient does not have evidence of documented atherosclerotic disease. The medical literature has not endorsed the use of PCSK9 (proprotein convertase subtilisin kexin 9) in this clinical situation. PCSK9 (proprotein convertase subtilisin kexin 9) are a new class of medications that are effective in lowering LDL (low-density lipoprotein), often to very low levels. Recent studies have not shown mortality benefit, but a reduction in cardiac events is evidenced to be significant. Community practice and most guidelines use a stepwise progression before this injected drug is used. Standard protocol includes documentation of a familial homozygous state, and presence of ASCVD (atherosclerotic cardiovascular disease), neither of which the patient is documented to have. In this case, the patient has not demonstrated any ASCVD (atherosclerotic cardiovascular disease), nor familial homozygous hyperlipidemia. Thus, the requested Repatha is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: coronary artery disease.
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services: 8.5 Hours per Day, 5 Days per Week - Total of 42.5 Hours per Week.
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 8.5 Hours per Day, 5 Days per Week - Total of 42.5 Hours per Week.
The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, hyperlipidemia, hypertension, mild cognitive impairment, depression, gastroesophageal reflux disease (GERD), osteoarthritis, urinary incontinence, and occasional bowel incontinence who had been assigned CDPAP (consumer directed personal assistant program) services.

Consumer Directed Personal Assistance Program (CDPAP) Services: 8.5 Hours per Day, 5 Days per Week - Total of 42.5 Hours per Week are medically necessary for this patient.
There is documentation from the assessments of increased assistance needs with tasks of transportation, bathing, dressing lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility when comparing the recent assessment to the prior assessment. Furthermore, the plans tasking tool estimated 37.5 hours/week of assistance needs and continued to only approve 27.5 hours/week. The plan assumed the patient had informal help outside of currently assigned CDPAP services. The patient requires at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use all and therefore the patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 8.5 hours/day, 5 days/week, to total 42.5 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 her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease (GERD)/vomiting
Treatment: Surgical Removal of Gastric Band 
The insurer denied Surgical Removal of Gastric Band. The health plan's determination is overturned. 

The patient is a woman with a history of having undergone lap band surgery. She presented with a complaint of symptoms of gastroesophageal reflux disease (GERD) and vomiting when the existing gastric band is tightened. Conversely, when the band is decompressed of fluid, she feels no restriction. Currently, she is 66 inches tall and weighs 253 lbs (pounds) (body mass index (BMI) 40.2). She was evaluated with upper endoscopy that showed eccentric pouch dilatation. A mental health assessment was completed and the patient has been cleared for the proposed revisional operation.

The Surgical Removal of Gastric Band is medically necessary for this patient. This patient has an adjustable gastric band in place for 10 years. She has obstructive symptoms of GERD and vomiting when the band is adjusted with intraluminal fluid. These symptoms required decompression of the gastric band with resultant weight gain.

The patient has a current BMI of 40. Alternative bariatric operations such as sleeve gastrectomy and roux en Y gastric bypass are associated with greater sustained weight loss than that associated with the gastric band procedure. Removal of the ineffective gastric band is medically necessary and consistent with standards of medical care. This will alleviate her obstructive symptoms of GERD and vomiting and will allow conversion to a more efficacious bariatric surgical procedure.
Appeal type: Medical necessity
Decision: Upheld

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

This is a patient with relapsing multiple sclerosis who presented to the emergency room following a brief seizure. The patient was admitted to the hospital. A computed tomography (CT) scan of the patient's head was negative for an acute abnormality. The patient had recent magnetic resonance imaging (MRI) of the brain showing chronic white matter lesions. The patient may have had a mild urinary tract infection. Following the seizure, the patient returned to baseline mental status and no further seizures were identified. The patient did not have new neurologic deficits and mild generalized weakness with increased tone was noted. The patient was discharged with outpatient follow-up. At issue is the medical necessity of an inpatient stay.

An acute inpatient admission following a seizure at home is not medically necessary. Inpatient care of seizure is not medically necessary unless the patient has multiple seizures without return to baseline mental status, status epileptics, new neurologic deficits, or acute findings on imaging of the brain. In this instance, the patient returned to baseline mental status within an observation period. The patient had stable imaging of the brain, and the patient did not have any new neurologic deficits. The seizure was attributed to medication or a mild urinary tract infection. The patient was not discharged on anticonvulsant medication. The patient did not require rehabilitation due to a seizure. The patient did not require complex nursing services. The patient did not have any other significant medical comorbid conditions. Therefore, an inpatient stay was not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic kidney disease
Treatment: Acthar Gel
The insurer denied Acthar Gel.
The health plan's determination is overturned. 

The patient is a male with a history of obesity, hypertension (HTN), and chronic kidney disease (CKD) stage 4 secondary to PLA2R (phospholipase A2 receptor) (-) membranous nephropathy. He was started on the Ponticelli protocol (cytoxan and corticosteroids), then rituximab x (times) 2 without significant improvement in his proteinuria. He was later transitioned to tacrolimus but continued with nephrotic range proteinuria after > (greater than) 6 months of therapy.

A formulary exception is indicated in this case.

The health plan states that Acthar Gel is only approved for the treatment of Infantile Spasms and Multiple Sclerosis. Per the health care plan, the use of Achtar Gel for the treatment of all other Food and Drug Administration (FDA) approved indications has not been proven to be superior to conventional therapies and as a higher cost. One of these FDA approved indications is to induce a diuresis or remission of proteinuria in nephrotic syndrome without uremia of the idiopathic type or due to lupus erythematosus.

The health plan will provide an exception if the patient has had a documented inadequate response, intolerable adverse reaction or contraindication to at least three formulary alternative or all alternatives if there are less than three. The patient in this case has been treated with the cytocan, corticosteroids, rituximab and tacrolimus. He has failed to have a response to all four of these alternatives. Given his failed response to three or greater alternatives, a formulary exception is indicated in this case. The use of Acthar gel to treat this patient's persistent nephrotic range proteinuria is indicated in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep Apnea
Treatment: Continuous airway pressure (CPAP) device, 3 units
The insurer denied Continuous airway pressure (CPAP) device, 3 units.
The health plan's determination is upheld.

The patient is a female who suffers from severe sleep apnea with an apnea hypopnea index (AHI) of 33.2. The provider is requesting the coverage of continuous positive airway pressure (CPAP). The patient has history of obesity, anemia, pulmonary hypertension, atrial fibrillation and congenital pulmonic stenosis.

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

The requested health service/treatment of continuous airway pressure (CPAP) device, 3 units, is not medically necessary for this patient. Obstructive sleep apnea (OSA, a disorder characterized by obstructive apnea and hypopnea) is associated with serious comorbidities. Continuous positive airway pressure is a highly effective therapy for OSA.
Continuous positive airway pressure therapy reduces apneas and hypopneas, decreases daytime sleepiness, and improves sleep architecture, daily activity, quality of life, neurobehavioral performance, and hypertension. Evidence suggests that, to maintain treatment effects, nasal CPAP therapy for OSA needs to be used every night. One night without therapy can return the patient to pretreatment physiological status and disability.  
According to Medicare and national guidelines, continuous CPAP coverage requires objective evidence of adherence to use of the CPAP device. Adherence to therapy is defined as use of positive airway pressure (PAP) greater than or equal to (>=)4 hours per night on 70 percent (%) of nights during a consecutive thirty (30) day period anytime during the first three months of initial usage.
This patient suffers from severe sleep apnea and was placed on CPAP. There is no evidence in the submitted documents that the patient is using the CPAP adequately. The documents submitted did not include any objective evidence that the patient is compliant with CPAP therapy. There is no evidence that the patient is using the CPAP more than 4 hours at least 70% of the time. Therefore, the patient does not meet medical necessity of the requested service. The CPAP cannot be considered as medically necessary unless there is an objective and convincing evidence that the patient is using effectively the CPAP machine.

The health plan's determination of medical necessity is upheld in whole.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes.
Treatment: Formulary exception for Mounjaro.
The health plan should deny the Formulary exception for Mounjaro.
The denial is overturned.

The patient is an adult male with type 2 diabetes. The request for continuation of Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient has not had a trial and failure or inability to use Ozempic, Rybelsus, Victoza, and Trulicity. He has tried and failed Trulicity and Victoza. He was intolerant to Ozempic and metformin. He was switched to Mounjaro with well-controlled glucose levels and improvement in liver fibrosis and elevated liver enzymes. The patient's A1C (glycated hemoglobin) is 5.5%.

The patient has tried and failed Trulicity and Victoza. He was intolerant to Ozempic. The remaining formulary alternative is Rybelsus. Both Ozempic and Rybelsus are forms of semaglutide. Given this patient was intolerant to Ozempic, he is at high risk of also being intolerant to Rybelsus. This patient is currently stable on Mounjaro. The formulary alternatives are less potent glucose lowering agents. It is not clinically appropriate to switch this patient from Mounjaro, on which he is stable, to a formulary alternative to which he is likely to be intolerant. Therefore, yes, the health plan should cover the formulary exception for Mounjaro.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis
Treatment: Home health care/ Consumer Directed Personal Assistance, Total of 56 Hours per Week. 

The insurer denied Consumer Directed Personal Assistance, Total of 56 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of osteoporosis, hypertension, hypothyroidism, hyperlipidemia, right eye blindness, osteoarthritis, hearing loss, and urinary incontinence, who had been assigned Consumer Directed Personal Assistance (CDPA) services.

The patient required at least extensive assistance with tasks of walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs that span a continuum of time, and the insurer has failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has no informal help. The requested increase in CDPA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs (activities of daily living) and IADLs (instrumental activities of daily living). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, CDPA services 56 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 her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara 90 milligrams (mg) every 4 weeks
The insurer denied coverage for Stelara 90 milligrams (mg) every 4 weeks
The denial is overturned
 
The patient has Crohn's disease and was started on Stelara with doses every 8 weeks. A magnetic resonance imaging (MRI) done showed an active fistula, stricture, and small bowel inflammation. His physician is now recommending increasing the Stelara to every 4 weeks. 

Clinical Gastroenterology and Hepatology 2021 Jan 19 (1 ): 104-110 has an article titled "Effectiveness of Ustekinumab Dose Escalation in Patients with Crohn's Disease." Data was studied from patients who initially received ustekinumab every 8 weeks and then had their interval shortened to every 4 weeks. The conclusion was that shortening the ustekinumab dose to every 4 weeks, in patients who did not respond to dosing every 8 weeks, improved clinical and biological indices of disease activity. It was noted that dose interval shortening was effective and safe. 

This patient has active Crohn's disease and now requires an increased dose of the Stelara. He is having active symptoms and the imaging study confirms that he has active disease. Dose escalation of Stelara is well supported in the medical literature. 

Based on the above, the insurer's denial must be reversed. 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 a quantity exception for Stelara 90 milligrams (mg) every 4 weeks is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Central nervous system
home health care

Diagnosis: Alzheimer's disease
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Level 2: 12 Hours per Day - 7 Days per Week; 12 Hours per Day - 7 Days per Week (Split Shift) - for a Total Amount of 168 Hours per Week. The health plan's determination is overturned. 

This is a case review for a male with medical history notable for Alzheimer's disease, mobility issues, and incontinence of bowel and bladder. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient requires help with toileting, hygiene, dressing, and several other tasks. He requires frequent assistance at night with activities of daily living (ADL) including transfers for toileting, cleaning up, frequent changes of pullups to prevent bedsores, and turning/repositioning in bed every 2 hours. The patient has a history of pressure ulcers. He also frequently gets up at night to urinate and is at a fall risk; he does not remember that he cannot do this without assistance. 

The Personal Care Aide (PCA) Level 2: 12 Hours per Day - 7 Days per Week; 12 Hours per Day - 7 Days per Week (Split Shift) - for a Total Amount of 168 Hours per Week is medically necessary for this patient.
The patient has advanced dementia, incontinence of stool and urine, and requires maximal assistance or more for almost all activities of daily living (ADL) and Instrumental activities of daily living (IADL). He is not able to direct his own care. He has a history of pressure ulcers and requires turning and repositioning overnight as well as frequent toileting to address soiled diapers. His personal care needs have been demonstrated to be continuous and unscheduled throughout the day and night. His niece is unable to provide continuous support while working full time. The requested increase in personal care hours is medically necessary and reasonable for this patient. Failure to increase his personal care hours could result in skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, hypertension, osteoarthritis, depression, and anxiety
Treatment: Personal Care Aide (PCA) services 12 hours/day, 7 days/week
The insurer denied the PCA services 12 hours/day, 7 days/week.
The denial has been overturned.

The patient is an elderly female. Her medical conditions include dementia, hypertension, osteoarthritis, depression, and anxiety, and history of spinal fracture. Denial of personal care aide (PCA) services 12 hours/day, 7 days/week is being appealed. The health plan approved PCA services 7 hours/day, 7 days/week.

Uniform Assessment System (UAS) evaluation completed a few months prior shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, and shopping; maximal assistance with managing finances; extensive assistance with managing medications, bathing personal hygiene, lower body dressing, walking, locomotion, and toileting; limited assistance with phone use and upper body dressing; an independent with bed mobility and eating. The patient has frequent bladder incontinence. Compared to UAS evaluation completed a year ago, there has been a decline with personal hygiene, upper body dressing, walking, locomotion, and toilet transfer.

A letter from the patient's provider notes the patient has multiple chronic conditions. She has progressive confusion. She is unable to independently perform ADLs (activities of daily living).

A letter from another provider notes the patient has deteriorating mental and physical functioning. She is unable to walk independently and is mostly confined to bed. She requires continuous supervision and assistance. She requires turning and repositioning as well as daily and nightly assistance with diaper changes.

The patient's child notes that the patient cannot get out of bed on her own. The patient requires a walker and assistance for ambulation. She has constant pain, which limits her ADLs. She had a spinal fracture a few months prior. She is a fall risk. She has urinary incontinence and is unable to change her own diapers.

This patient has multiple chronic conditions. UAS evaluation completed a few months ago shows the patient needs assistance with all ADLs, except bed mobility and eating. Compared to UAS evaluation completed last year, there has been a decline with personal hygiene, upper body dressing, walking, locomotion, and toilet transfer. She has frequent bladder incontinence. Appeal statements indicate the patient's mental and physical functioning are deteriorating. She is unable to independently transfer and ambulate. She requires turning and repositioning as well as daily and nightly assistance with diaper changes due to urinary incontinence. The information provide show that this patient has significant limitations in functioning. The approved PCA 49 hours/week is insufficient to meet this patient's needs for assistance with ADLs. The requested increase to PCA 84 hours/week is medically necessary.