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

Diagnosis: Fractured right hip
Treatment: Ambulance Service (HCPCS-0A0428) Ambulance Transport From Hospital to Skilled Nursing Facility (HCPCS-A0425) Ground Mileage
The insurer denied: Ambulance Service (HCPCS-0A0428) 
Ambulance Transport From Hospital to Skilled Nursing Facility (HCPCS-A0425) Ground Mileage
The denial is overturned.

The patient is an adult female that she sustained a fractured right hip. She subsequently had ORIF (open reduction internal fixation), and she was placed on non-weight-bearing (NWB) status right lower extremity. The patient was transferred from the acute inpatient facility to the Skilled Nursing Facility (SNF) by ground ambulance transportation because of weakness, deconditioning, fall risk, and unsteady gait with her non-weight-bearing on the right lower extremity. The health plan denied coverage of the ground ambulance transportation, because her case was a non-emergent case. They note that the transport was not medically necessary, as transportation could have been provided by Ambulette, and also because she was not bed-confined with no documentation of whether she was ambulatory. The denial is being appealed.

The ambulance transport was medically necessary.

The ground ambulance transportation in this instance is medically necessary, based on standard guidelines under generally accepted standards of medical practice for transportation of that type of patient with such type of condition. The patient was status post right hip fracture ORIF (open reduction internal fixation) and NWB (non-weight bearing), making her limited in ambulation. Furthermore, transportation was within six days of the ORIF (open reduction internal fixation).
Any alternative mode of transportation would have required difficulty in maintaining NWB (non-weight bearing) status, with danger of falls, and difficulty with safety and efficiency. Therefore, ground ambulance transportation is medically necessary to meet the patient's basic health needs. It was rendered in the least intensive and most appropriate setting. It was consistent in type, frequency and duration with general medical guidelines for ambulance transportation. It was consistent medical guidelines for a patient who is NWB (non-weight bearing) status post hip ORIF (open reduction internal fixation). The ambulance transport was not for the comfort or convenience of the patient or her treating physician, and it was done safely and effectively.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: chronic low back and sacroiliac joint pain

Treatment: pain injection (27096 x 1)

The insurer denied coverage for pain injection (27096 x 1)

The denial is overturned


This is an adult female with chronic low back and sacroiliac (SI) joint pain.  The progress note  states: 

"Sharp pain on palpation of sacroiliac joint with trigger points over gluteus muscle and radiating to the buttock and posterior thigh and shin is triggered by palpation of sacroiliac joint. Parker's test positive on the left side. Gaenslens positive. Positive SIJ compression test."

Thawrani et al (1) reviewed the diagnosis of sacroiliac (SI) joint pain:

"No pathognomonic clinical history, physical examination finding, or imaging study exists that aids clinicians in making a reliable diagnosis. However, imaging combined with clinical provocative tests might help to identify patients for further investigation. Although provocative physical examination tests have not received reliable consensus, if three or more provocative tests are positive, pursuing a diagnostic SIJ injection is considered reasonable. Notable pain relief with intra-articular anesthetic injection under radiographic guidance has been shown to provide reliable evidence in the diagnosis of SIJ pain."

Schneider et al (2) similarly found that 3 or more physical exam provocative maneuvers are needed:

"Accurate diagnosis of sacroiliac joint (SIJ) pain is challenging. Diagnosis can be aided by pain referral patterns, historical features, physical examination maneuvers, and imaging. However, all of these diagnostic tools have limitations. The most reliable clinical tools may be a combination of three or more positive physical exam maneuvers, although the evidence is inconsistent even for this strategy."

Three provocative maneuvers are documented here, and the request is deemed medically reasonable and necessary.

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 pain injection (27096 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot wound
Treatment: Inpatient admission
The insurer denied Inpatient admission.
The denial is overturned.

The patient is an adult male diabetic. He presented to the emergency room with tachycardia and a sub metatarsal ulceration with foul smelling sero-sanguineous drainage. He had failed outpatient antibiotic therapy, and he was admitted for IV (intravenous) antibiotics. He was evaluated by the Podiatry team, and he underwent debridement. He would need further wound care however he lives in a shelter and was screened for short-term rehabilitation for his wound care needs.

The Inpatient admission was medically necessary.

The patient is a diabetic who had failed outpatient care and was showing systemic signs of infection, including tachycardia with an open draining wound and leukocytosis. He required parenteral antibiotics, surgical evaluation and inpatient monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Strokes, heart disease and hypertension

Treatment: Home Care/Personal Care Level 2 Personal Care Services increase to 24 hours per day (split shift)

The insurer denied coverage for Home Care/Personal Care Level 2 Personal Care Services increase to 24 hours per day (split shift)

The denial is upheld 


This is an elderly male with chronic medical problems including strokes, heart disease and hypertension.  He lives with his spouse in a 2-bedroom apartment.  Family and friends are supportive of his care.  The insurer increased Personal Care Aide (PCA) services from 84 hours/week to 24 hours/day- 7 days/week- (live-in).  The insurer denied the request for Home Care/Personal Care Level 2 Personal Care Services (PCS) increase to 24 hours per day (split shift). 

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as minimally impaired.  He is reportedly total dependent for performing much of his Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires maximal assistance for bathing, personal hygiene, dressing, locomotion, toilet transfer/use and ambulation.  However, he ambulates with a walker with contact guard assistance.  Extensive and limited assistance is reportedly needed for bed mobility and eating, respectively.  He is frequently incontinent of bladder and occasionally incontinent of bowel.  There has been no reported change in the patient's ability to perform activities of daily living, self-sufficiency or reported falls over the prior 90 days.   His cognitive and functional ability are much the same; if not modestly (functional) deceased when compared to the earlier Uniform Assessment System (UAS) report.

The patient's clinical condition and functional deficits are not at a level and unpredictable as to require Personal Care Aide (PCA) services 7 days per week, 24 hours per day (split shift).  The letter dated 10/18/23, from the patient's treating physician, Dr. McWilliams describing his clinical condition and recommended "24 hour of home health aide to support his ADLs/IADLs" was reviewed.  Dr. McWilliams did not include his associated treatment notes to support the claim of the patient's reported functional incapacity.  

Based on the clinical records, a live-in PCA is clinically appropriate and likely capable of consistently obtaining approximately 5 hours of uninterrupted sleep during the aide's 8-hour period of sleep.  There are also shared household responsibilities of the other adult living in the home and informal care from family.  Attention to the patient's functional needs is appropriately provided and maintained via the approved PCA services 7 days/week, 24 hours/day (live-in).  

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 Home Care/Personal Care Level 2 Personal Care Services increase to 24 hours per day (split shift) services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The determination is overturned.

This is a male patient with atopic dermatitis. The body surface area affected is 8 percent (%), including the periorbital skin. He has tried halobetasol, topical tacrolimus, and Opzelura. The medication under review for medical necessity is Dupixent.

The requested health treatment of Dupixent is medically necessary for this patient,
While it is noted the plan denied the Dupixent previously, given that "we ask that you are not receiving Dupixent in combination with Opzelura," the patient has failed monotherapy with Opzelura, therefore, requires the addition of Dupixent.  There are many patients in dermatology practice who are on both therapies, needing both treatments for optimal control of their atopic dermatitis. It is within the standard of care and medical practice to prescribe both medications concomitantly.
The requested health treatment of Dupixent is medically necessary for this patient,
The request for Dupixent is supported by the medical literature and specialty society guidelines.  Dupixent is approved by the Food and Drug Administration (FDA) for the management of atopic dermatitis.  In early 2017, the FDA approved Dupixent for adults with moderate-to-severe AD who are inadequately controlled with topical treatments  (1-3).  According to consensus guidelines "Dupilumab has shown strong efficacy and safety for treatment of moderate-to-severe atopic dermatitis (AD) .... Considering the safety profiles of conventional systemic therapies, which are not FDA-approved for AD treatment, it is recommended that dupilumab be used as a first-line systemic treatment ... with moderate-to-severe AD who are uncontrolled with topical therapies" (1).  Given that the patient has tried topical treatments and continues to have atopic dermatitis affecting 8 percent (%) of his body surface area, Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: lower extremity weakness

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

 
The patient was seen in the Emergency Department (ED) and complained of having suffered a fall due to lower extremity weakness, no associated injury, no headache, paresthesia, neck, or back pain. The patient stated that he can walk despite the weakness. X-ray lumbar spine was done and showed no acute pathology, Computed tomography (CT) head was done and showed no acute intracranial abnormalities, x-ray chest was normal. 

Neurology consulted, sensation to pain and light touch is intact bilaterally, symmetric muscle bulk with no fasciculation seen and there were no focal deficits. 

A rehab consult was done to determine functional deficit. The patient is positive for malaise/fatigue and weight loss. He is also positive for shortness of breath, flank pain, and back pain and weakness. 

In this case, an adult male with a history of anemia, pancreatitis, and alcohol abuse presented for an emergency evaluation due to fall and lower extremity weakness. The patient reported weakness in his legs, which was worse after the fall. On examination, he had lower extremity weakness, laboratory studies were remarkable for hemoglobin of 10.8. Electrocardiogram (ECG) demonstrated normal sinus rhythm. Chest radiograph demonstrated normal chest x-ray, CT scan of the lumbar spine showed degenerative lumbar spondylosis and diffuse disc bulging. 

Although the patient has lower extremity weakness, decreased balance and decreased functional endurance, CT scan of the lumbar spine showed degenerative lumbar spondylosis and diffuse disc bulging. There were no acute findings on imaging to support admission. In addition, the ECG demonstrated normal sinus rhythm. Chest radiograph demonstrated normal chest x-ray. The care given to the patient is more appropriate in a lower level of care such as Outpatient care in the emergency department, observation care or a Recovery facility. 

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

Diagnosis:  Hydronephrosis with ureteral calculus.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

This is a case of a male admitted for diagnosis of hydronephrosis with ureteral calculus. The patient presented with chief complaint a right upper quadrant pain that radiated to the flank. Vital signs demonstrated temperature 36.6C (degrees Celsius), pulse 99, respiratory rate 12, blood pressure 118/93 and O2 (oxygen) saturation 100% (percent). Physical exam showed no altered mental status with moderate distress because of the right flank pain. White blood cell count was 11.4 with hemoglobin 13.7. A computed tomography (CT) of the abdomen and pelvis showed right mild to moderate hydronephrosis and perinephric edema. There were two calculi measuring 4 to 5 millimeter (mm). He was treated with intravenous fluids, Flomax and morphine as needed. 

The inpatient hospital admission was not medically necessary.

The patient in this case had hydronephrosis on the right side, but there was no bilateral hydronephrosis. The patient had normal kidney function and no concerning electrolyte abnormality. The potassium on admission was normal at 4.6. He was given a dose of Rocephin initially, but then it was noted that there was no evidence of urinary tract infection. Antibiotics were then able to be discontinued. He simply underwent stent placement and was then able to be discharged. There was no hemodynamic instability or hypoxia. He was then recommended to follow up for stent removal on an outpatient basis.

Although the patient required services in the hospital setting, the monitoring, diagnostic testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Head Injury, Weakness, Dizziness
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male child with a medical history significant for sickle cell trait who presented to the emergency department (ED) with difficulty walking due to weakness, headache, and dizziness. He had sustained head trauma during a basketball game, was hit by the ball on the parietal area, with no loss of consciousness or altered mentation at that time. He developed a fever to 104 degrees Fahrenheit with associated nausea and decreased appetite. The examination was significant for no acute distress, non-toxic appearance, no congestion, moist mucous membranes, clear oropharynx, regular heart rate and rhythm, clear lungs, benign abdomen, narrow-based and unsteady gait, decreased deep tendon reflexes, down-going toes, no obvious evidence of skull fracture, and no bruising. The differential diagnosis included viral myositis versus traumatic brain injury with ataxia.
 He was treated with ibuprofen and admitted for further management. Admission orders included maintenance intravenous (IV) fluids, regular pediatric diet, and anti-pyretics. A head computed tomography (CT) scan was obtained because of the head injury history and was unremarkable. The following day, his gait was intact, with no reported weakness or muscle pain. He was able to jump and hop without difficulty. He was deemed stable for discharge to follow-up with his primary care practitioner for clearance prior to returning to sports. At issue is the medical necessity of an inpatient stay.

This patient presented to the ED with a history of mild head trauma without loss of consciousness or altered mentation several days prior, and a two-day history of fevers, dizziness, and weakness causing difficulty with ambulation. His laboratory evaluation was unremarkable. His symptoms were considered most consistent with viral syndrome. Acute viral syndrome is a diagnostic term for viral infection with no clear etiology. Symptoms include fever, sore throat, headache, injected sclera, nasal congestion, rhinorrhea, diffuse body aches, nausea and vomiting, diarrhea, abdominal pain, and rash. The onset is rapid, with the illness lasting several days. Treatment is typically symptomatic, including antipyretics, fluids, and rest. There is some risk for secondary bacterial infection, but typically affected individuals recover without sequelae. While it was not unreasonable to monitor this child in the hospital for resolution versus progression of symptoms, he was overall hemodynamically stable with no evidence of rhabdomyolysis or severe infection, no significant dehydration, and no altered mentation. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and a history of multiple cerebral vascular accidents (CVAs)
Treatment: Increase Home/Personal Care, Level 2, to 84 Hours per Week
The insurer denied Increase Home/Personal Care, Level 2, to 84 Hours per Week.
The denial is overturned.

The patient is an elderly female with a history of general debility due to dementia and a history of multiple cerebral vascular accidents (CVAs). The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 59 hours per week to 84 hours per week based on Uniform Assessment System (UAS) of 3 months ago. The health plan denied the request because the patient has good memory and the authorized 59 hours are adequate in amount, duration, and scope necessary to meet the patient's personal care needs; any more hours would be for safety monitoring which is not a covered benefit under the personal care aide (PCA) program. The additional hours requested are because of the patient's chronic medical conditions, and to help with her activities of daily living (ADLs) as she requires extensive assistance with bathing, personal hygiene, upper/lower body dressings, walking, locomotion, and toilet use/transfer. A review of the records showed that the patient has multiple chronic medical conditions including dementia, diabetes mellitus with diabetic neuropathy, hypertension, hypercholesterolemia, gastroesophageal reflux disease (GERD), bilateral carotid artery stenosis, history of multiple cerebral vascular accident, generalized osteoarthritis, unstable gait and increased tendency to fall. The Uniform Assessment System - New York (UAS-NY) evaluation of 3 months ago showed that the patient is moderately cognitively impaired with decisions consistently poor or unsafe and requiring cues, independent with eating, requires limited assistance with bed mobility, extensive assistance with bathing, personal hygiene, upper/lower body dressings, walking, locomotion, toilet use/transfer, maximal assistance with managing finances, managing medications, and totally dependent for meal preparation, housework, and shopping. The patient's family support is very good as she lives with her daughter.

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 59 hours per week to 84 hours per week is medically necessary.

The requested hours are medically necessary because the patient is moderately cognitively impaired with decisions consistently poor or unsafe and requiring cues, independent with eating, requires limited assistance with bed mobility, extensive assistance with bathing, personal hygiene, upper/lower body dressings, walking, locomotion, toilet use/transfer, maximal assistance with managing finances, managing medications, and totally dependent for meal preparation, housework, and shopping. The reason for denial by the health plan as stated in the clinical information above, does not align with the patient's disability features as stated in the recent Uniform Assessment System. Therefore, the 84 hours per week requested should be approved.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention deficit hyperactivity disorder (ADHD)-Inattentive presentation.  
Treatment: Adderall 20 mg (milligram) Tablets. 
The insurer denied coverage for Adderall 20mg Tablets. 
The denial is overturned. 

This adult female reportedly had a diagnosis of attention deficit hyperactivity disorder (ADHD)-Inattentive presentation. It was reported that she was taking brand name Adderall 20 mg and that it was effective without side effects. It was reported that she tried other generic Adderall, amphetamine/dextroamphetamine and had intolerable side effects such as nausea, dry throat and mouth, dizziness/lightheadedness, fatigue, dehydration, bowel issues, and nervousness and also had less efficacy as it reportedly did not last and wore off faster. It was reported that she also took Ritalin and Vyvanse in the past and had lack of efficacy and side effects also. It was reported that she had been taking brand name Adderall for about one year with reported efficacy and therapeutic effect and with tolerability and lack of side effects. 
  
If she were to stop this her ADHD symptoms would worsen as evidenced by this occurring when stopping this and her anxiety also increased. She reportedly also tried Ritalin which is an Food and Drug Administration (FDA) approved methylphenidate product for ADHD treatment and had lack of efficacy and side effects so it was not likely that another methylphenidate product on formulary such as dexmethylphenidate would have more efficacy or tolerability without side effects than brand name Adderall. Also, she tried Vyvanse with lack of efficacy and with reported side effects. It also was not more likely that Atomoxetine would be more effective than the psychostimulant, brand name Adderall, as it is not a psychostimulant with immediate onset effectiveness as it is a nonstimulant blocking the Atomoxetine neurons and is also used to treat ADHD and typically takes weeks for its therapeutic effect. Brand name Adderall at 20 mg tablets per day appeared to be the most effective treatment for this patient as evidenced by its efficacy and tolerability for about one year so it was considered medically necessary treatment. 

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 Adderall 20mg Tablets is substantiated.