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

Diagnosis: Impulsive Behavior, Depression
Treatment: Residential Behavioral Health Level of Care, Child or Adolescent
The insurer denied Residential Behavioral Health Level of Care, Child or Adolescent.
The determination is upheld.

This is a female patient with a past psychiatric history of attention deficit hyperactivity disorder, body dysmorphic disorder, self-injurious behavior, obsessive compulsive disorder and mood disorder She was admitted to the residential level of care for impulsive behavior, depression, anxiety and body image. Prior to her admission at the residential level of care, she was admitted to the inpatient hospitalization level of care for a manic episode. She also had a prior history of residential treatment. On arrival to the residential level of care, she settled into the unit well and denied any harm to self or others. She was guarded and anxious. She did well with treatment and participated in therapy groups. Her medications were changed, and she was placed on a different antipsychotic/mood stabilizer. At issue is the medical necessity of the residential level of care.
The requested residential behavioral health level of care was not medically necessary for the patient. She was not manic, psychotic, agitated or failing to complete activities of daily living. She was not threatening to harm herself or others. Medication changes/adjustments could have been performed at a lower level of care. She was attending groups and adequately participating in treatment. She did not need constant monitoring for medication side effects. She was willing to participate in treatment at a lower level of care. Guidelines suggest using the least restrictive level of care to provide the most generalizable treatment effects in adolescents and as such residential level of care was not medically necessary (1,2,3).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache and vision problem. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is an adult male who was admitted for progressive diplopia that became severe and headaches. Computed tomographic angiography (CTA) showed right supraclinoid internal carotid artery (ICA) aneurysm. Admission was done on basis of concern for mass, stroke, or multiple sclerosis. The inpatient admission was denied due to not meeting inpatient level of care. 

The requested health service was medically necessary. 

Inpatient admission was medically necessary as the patient had severe neurologic findings with a differential diagnosis that was not amenable for outpatient evaluation per the Milliman Care Guidelines (MCG) criteria 26th edition neurology. Furthermore, stroke and mass causing severe neurologic deficits can lead to significant morbidity and mortality. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The decision was upheld. 

The patient underwent elective cardiac catheterization due to an abnormal stress test prior to umbilical hernia repair surgery. The patient had complained of exertional chest pain, relieved by rest. The patient had a history of hyperlipidemia. Cardiac Catheterization showed normal left main, 80% mid LAD [left anterior descending] artery stenosis, circumflex 100%, and RCA [right coronary artery] 100% with collaterals from the left coronary and LV [left ventricular] ejection fraction was 40%. Based on the catheterization findings, Cardiac Surgery consultation was requested. After surgery, the patient complained of chest pain which worsened with deep breathing. Electrocardiogram showed no changes. The patient was admitted for observation pending transfer to a tertiary care hospital for consultation for bypass surgery. The patient was transferred around midnight to the receiving hospital. 

The patient had an elective cardiac catheterization which is typically an outpatient procedure. However, in this case, the patient developed atypical but persistent chest pain after the cardiac catheterization which showed critical CAD [coronary artery disease]. Thus, it was appropriate to continue to observe the patient and transfer to a Cardiac Surgery center. Until the transfer was made, it was appropriate to place patient on observation status. As such, observation status is considered medically necessary but full admission is considered not medically necessary. 

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 hospital services is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld



Diagnosis: obesity.
Treatment: Contrave Tablets.
The insurer denied Contrave Tablets.
The health plan's determination is upheld.

This is a case review for a female being prescribed Contrave 8 mg-90 milligrams (mg) tablet extended release (ER) for the diagnosis of morbid obesity. The patient's current body mass index (BMI) is above 40. The health plan denied coverage for this medication, and this denial is the subject under review.
The request states that the patient will use the medication in addition to diet and exercise to promote weight loss. Further detail was not provided. There were no letters or office visit notes provided for review.

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

There was no formulary alternative drug provided for the patient. There were also no clinical details or office visit notes provided. There is insufficient clinical documentation to determine the effectiveness of the requested medication.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Functional deficits

Treatment: Home Care

The insurer denied coverage for an increase in Personal Care Services to 7 hours a day, 5 days a week.

The denial is upheld.

This is an elderly patient with chronic medical problems including hypertension, diabetes, and kidney disease. The patient lives with their daughter who is involved with their care. The request is for an increase in Personal Care Services (PCS) from 5 hours/day, 5 days/week for a total of 25 hours/week to 7 hours/day, 5 days/week, for a total of 35 hours/week that was denied by the insurer; leading to an external review. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired. The patient can activate their Personal Emergency Response System (PERS). The patient reportedly requires extensive assistance to total dependence for performing much of their Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient requires limited assistance for toilet transfer. However, the patient is otherwise at the supervision level or independent for bathing, personal hygiene, dressing, eating, bed mobility, locomotion, toilet use and ambulation. The patient is frequently incontinent of bladder and continent of bowel. There have been no reported falls over the prior 90 days.  

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require the requested increase in PCS to 7 hours/day, 5 days/week. The office visit notes from the patient's treating physician describing the patient's clinical condition was reviewed.  The patient is described as fully alert and oriented with "motor and sensory intact."  The doctor opined the patient "remains at high risk of fall given stairs at home, during afternoon hours and requires additional supervision."  

While the patient may benefit from additional monitoring for safety; particularly due to the reported vision impairment and falls risk, PCS 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 are appropriately provided and maintained by the approved PCS 25 hours/week, shared household responsibilities of the other adult living in the home, informal care from family and Personal Emergency Response System (PERS). Given that the patient is at the supervision level or independent for performing most of their ADLs, the 25 hours per week (which can be flexibly used), is sufficient to maintain and meet the patient's functional needs.

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 an increase in Personal Care Services to 7 hours a day, 5 days a week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain
Treatment: Gelsyn injections
The insurer denied Gelsyn injections.
The determination is upheld.

The patient is a female with bilateral knee pain. The records document that an initial office visit was completed. Plain radiographs revealed moderate bilateral knee osteoarthritis for this patient. The provider recommended bilateral Gelsyn injections. The injections were initially denied by the patient's insurance plan. The patient was evaluated in the office again, and the Gelsyn injections were recommended again as treatment for this patient's knee osteoarthritis. At issue in this case is the medical necessity of the requested Gelsyn knee injections.

The requested Gelsyn-3 16.8 milligrams (mg)/2 milliliter (mL) injections for this patient's knees are not medically necessary. The peer-reviewed orthopedic literature has not proven their efficacy for the treatment of knee osteoarthritis. More specifically, a peer-reviewed article published by Tammachote and colleagues in the Journal of Bone and Joint Surgery was a randomized and prospective, double blinded study that compared an injection of Hylan viscosupplementation to a corticosteroid injection in patients with knee osteoarthritis. The authors concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second study published by Jevsevar and associates in the Journal of Bone and Joint Surgery was a meta-analysis and systematic review of the evidence for viscosupplementation in the knee. These authors found that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid treatment over placebo." Lastly, the recent clinical practice guideline published by the American Academy of Orthopedic Surgeons in 2022 did not endorse viscosupplementation injections as an effective treatment for patient s with knee osteoarthritis. Therefore, based upon this peer-reviewed research and the American Academy of Orthopedic Surgeons (AAOS) clinical practice guideline, the requested injections in this case are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left flank pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is an adult male with a past medical history of nephrolithiasis who presented to the hospital complaining of sharp colicky left flank pain lasting one day. Urinalysis (UA) was positive for hematuria (blood in the urine) but not urinary tract infection (UTI). Computed tomography (CT) scan showed left ureteral obstructing stone. The patient was admitted, seen by urology and given intravenous (IV) fluids, IV antibiotics, and oral Flomax. The patient taken to the operating room (OR) for Cystoscopy, left retrograde, and left stent placement. The patient recovered uneventfully and was stable for discharge later that day without urology follow-up. 

Per Milliman Care Guidelines (MCG) Health (27th Edition): Renal Colic + Kidney Stones criteria: the patient fails to meet indications for admission to in patient care; Urologic Surgery or Procedure criteria: the patient meets the discharge parameters within 24 hours past procedure. As per the guidelines, this procedure is performed in an ambulatory surgery setting.

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

Diagnosis: Urinary tract infection.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient is an adult with a benign past medical history other than urinary tract infection (UTI). The patient presented to the emergency room (ER) with complaints of abdominal pain, dysuria, and urinary frequency.

Vitals on presentation included a temperature of 98.3 Fahrenheit (F), blood pressure (BP) of 126/76, a heart rate (HR) of 84, a respiratory was of 15, and an oxygen (O2) saturation of 99%.

Laboratory results included a white blood cell count (WBC) of 6.14, hemoglobin (Hgb) 12.4, hematocrit (Hct) 38.9, creatinine 0.7, glucose 76, and lactate 0.8. The urinalysis was negative x 2.

The patient was started on intravenous (IV) fluids and empiric antibiotics (ceftriaxone) for a possible UTI. Urine cultures grew Enterococcus faecium susceptible to vancomycin. Infectious Diseases recommended oral (PO) Linezolid. The patient remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient follow-up on PO antibiotics. 

According to documentation, the patient was referred by the Gynecologist for urine cultures that grew less than(<)50,000 Enterococcus faecium. Otherwise, the patient was afebrile and hemodynamically stable. There were unremarkable laboratory findings including a normal WBC. Additionally, the urinalysis was negative x 2. Based on above findings, the patient did not fulfill criteria for acute inpatient admission.   

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased mobility. 
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 18 Hours per Day: 126 Hours per Week, Continuous Care. 
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 18 Hours per Day: 126 Hours per Week, Continuous Care. 
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for frontotemporal dementia, mobility issues, incontinence, and pressure ulcer. The patient's hospice social worker provided a letter of support for this appeal. The letter states that the patient is terminally ill with an estimated prognosis of 6 months or less. She has advanced frontotemporal neurocognitive disorder. She is weak, nonverbal, and bed-bound. 

The requested Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 18 Hours per Day: 126 Hours per Week, Continuous Care by More than One Person is medically necessary for this patient. 
The patient is bed bound, nonverbal, and duly incontinent. She requires around the clock care to allow for adequate turning and repositioning to prevent bed sore recurrence as well as for incontinence care. As described in the notes, her family is not able to provide informal support for all of the hours of the day that she requires assistance. Therefore, the requested increase is medically necessary and reasonable for the patient. Failure to provide for the patient's personal care needs could result in skin breakdown and or infection.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Psoriasis Vulgaris
Treatment: Formulary exception for Ilumya
The insurer denied: Formulary exception for Ilumya
The denial is upheld.

The patient is an adult male with psoriasis. He has been treated with topical steroids and Ilumya. His provider requesting continuation of Ilumya, with which he has been well controlled since earlier this year. The health plan denied coverage of the request, as it requires a trial and failure to Otezla, Humira, Stelara, Tremfya, Skyrizi, and Taltz. The denial is being appealed.

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

The formulary requires a trial and failure to Otezla, Humira, Stelara, Tremfya, Skyrizi, and Taltz. The formulary drugs would not be expected to ineffective for this patient. They are likely be as effective as the requested non-formulary drug and would not be expected to have greater adverse effects for this patient than the requested non-formulary agent. In the meta-analysis by Bai et al, ixekizumab 80 milligrams every 2 weeks ranked the highest in short-term achievement of PASI 75 (75 percent [%] reduction in Psoriasis Area and Severity Index score). Brodalumab 210 milligrams ranked the highest in short-term achievement of PASI 100 (100% reduction in Psoriasis Area and Severity Index score). Secukinumab 300 milligrams ranked the highest in short-term achievement of sPGA (Static Physicians Global Assessment) 0/1 or IGA (Investigator's Global Assessment) 0/1 or PGA (Physician Global Assessment) 0/1. In terms of having a risk of adverse events, the rates were higher in brodalumab, secukinumab, ixekizumab, and ustekinumab 45 milligrams compared with placebo. Ixekizumab 80 milligrams every 4 weeks ranked the highest in the risk of adverse events during short-term treatment. Guselkumab 50 milligrams ranked the highest in the risk of serious adverse events during short-term treatment. Ixekizumab 80 milligrams every 4 weeks ranked the highest in the risk of discontinuations due to adverse events during short-term treatment. Therefore, the health plan should not cover the formulary exception for Ilumya.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Brachial Plexus Schwannoma

Treatment: Assistant surgeon utilized during the excision neurofibroma/neurolemmoma; extensive (w/ malignant type) - code 64792

The insurer denied coverage for assistant surgeon utilized during the excision neurofibroma/neurolemmoma; extensive (w/ malignant type) - code 64792

The denial is overturned

This is case of a patient with right brachial plexus schwannoma.  The patient had excision of the tumor by an Ear, Nose and Throat (ENT) surgeon and plastic surgery for neural repair.  The otolaryngologist performed access to the tumor and removal of the tumor.  Plastic surgery, performed repair of the nerves to the brachial plexus.

This patient had excision of a neurofibroma/schwannoma that resulted in lysis of a nerve in the brachial plexus.  The surgical team appropriately planned for repair of the nerve with an assistant microvascular plastic surgeon.

It is standard of care for head and neck schwannomas to be excised by otolaryngologists.  In this case, there is need for neural repair. Then a microvascular trained surgeon such a plastic surgeon is recruited to repair the nerve.

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 assistant surgeon utilized during the excision neurofibroma/neurolemmoma; extensive (w/ malignant type) - code 64792 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left fibular fracture and lower right tibial fracture with some mild displacements
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Overturned
This patient was an emergent admission to the hospital with a left ankle injury. The patient heard a pop, and upon getting up the ankle was very deformed, the foot flopped and the patient was in immediate pain. Imaging including a Computed tomography (CT) scan of the left leg showed acute fractures of the left distal tibia and proximal fibula. Left ankle radiographic image (x-ray) showed upper left fibular fracture and lower right tibial fracture with some mild displacements. An Orthopedic Surgery evaluation was performed and orthopedic surgery was required after medical clearance. Intervention in the Emergency Department (ED) included administration of Acetaminophen and Oxycodone. The inpatient plan of care included: Admission to Orthopedics, intravenous (IV) hydration infusing, neurovascular monitoring, preoperative clearance, neurovascular monitoring and pain control.

The records show the necessity of acute medical care. The patient had several underlying comorbidities which could cause complications after surgery. There were respiratory problems. The patient had an elevated body mass index (BMI). The first post-surgical visit showed hypoxia and tachycardia. The patient required intravenous (IV) narcotics for pain relief and oxygen.

Due to ongoing complaints and poor vital signs additional imaging studies were ordered. They showed a pulmonary embolism (PE). It is important to note the patient's condition was unstable. The patient required several additional studies and subspecialty consultations for anticoagulation and respiratory support. These services could not be obtained at a lower level of care. 

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible Drug Overdose. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is an adult female who was treated at an inpatient level of care with a diagnosis of possible drug overdose. The patient was admitted to the hospital for suspected opioid overdose. The patient reportedly received methadone from a methadone clinic and then used a bag of heroin received from a friend that had been laced with fentanyl. The patient reported then waking up in an ambulance. The patient had a history of multiple medical problems including hypertension, asthma, iron deficiency anemia, syphilis, opioid use disorder on methadone, morbid obesity, and chronic back pain. The patient was admitted to the hospital and started on cephalexin for bilateral ankle cellulitis, although there was no subsequent evidence of infection. Urine drug test had been positive for fentanyl, methadone, opiates, and benzodiazepines. The patient was suspected of using substances during the admission and unknown pills were found in a Xanax bottle. 

The requested health service was not medically necessary. 

This was not an intentional overdose although the patient was using opioids regularly. Records indicate suspicion that the heroin was laced with fentanyl, causing the overdose reaction. The patient did not have life-threatening medical conditions once initially stabilized. The patient could have been safely evaluated and treated at the observation level of care. Therefore, the requested health service was not medically necessary.