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

Diagnosis: Type 2 Diabetes
Treatment: Tresiba FlexTouch
The insurer denied Tresiba FlexTouch.
The determination is overturned.

This is a patient with type 2 diabetes. A request for continuation of Tresiba is under review. The patient has had hives and itchiness with Basaglar, Lantus, Toujeo, Levemir and Semglee. At issue is the medical necessity of Tresiba FlexTouch.

The requested Tresiba is medically necessary.

This request is for the continuation of Tresiba for the treatment of type 2 diabetes. This patient has had hives related to multiple forms of glargine insulin: Basaglar, Lantus, Toujeo, and Semglee. The formulary alternatives are insulin glargine and insulin glargine-YFGN. This patient is at high risk of also having an allergic reaction to the formulary alternatives as they are also forms of glargine insulin. Without Tresiba, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, the requested Tresiba FlexTouch pen is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Upper Respiratory Infection
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a male brought to the emergency room with upper respiratory infection (URI), cough, retractions, and post tussle emesis. There was no history of recent fever. At triage, the oxygen saturation was 95% (percent) on room air and he was afebrile with a normal blood pressure. On exam, he is described as being in no acute distress with bilateral wheezing and transmitted breath sounds. There is no comment about the presence or absence of tachypnea or retractions. He was given intravenous (IV) fluid, systemic steroids, three DuoNeb inhalation treatments, and magnesium. Complete blood count (CBC) and metabolic panel were normal. Coronavirus (COVID) was negative. Chest x-ray (CXR) was normal. There is a comment in the emergency department (ED) notes that "patient unable to maintain saturations without support, saturations 88-92," but in the records provided, there is no documented saturation measurements confirming this statement or any evidence of the patient being put on oxygen. The saturation on presentation at triage was 95%, at recheck it was 96%, at recheck it was 97%. The later documentation shows vital signs given for height and weight, but not saturation. The admission history and physical (H&P) describes the ED course but does not mention any low saturations or use of oxygen. The physical exam describes a well appearing patient with "mild" wheeze and "mild" subcostal retractions without other signs of distress or hypoxemia. He was treated with further albuterol overnight; the next day, he continued to have intermittent wheezing and was noted to be active and playful so was sent home on albuterol. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

The inpatient hospital admission is not medically necessary for this patient. This patient did not have a history of asthma or any chronic respiratory condition. He presented with wheezing, cough, and post-tussive emesis. The records document no more than mild wheezing or subcostal retractions at any time, and there is no documentation of significant tachypnea or any hypoxemia requiring oxygen treatment. He received a number of standard treatments for the wheezing as if he were having an asthma exacerbation (steroids, albuterol, magnesium), but there is no documentation that these treatments improved his mild symptoms and signs. In fact, on discharge, he is described quite similarly to how he presented - a well appearing patient without hypoxemia with mild/intermittent wheeze and retractions. He did not require admission for IV treatments or oxygen and did not meet medical necessity criteria for acute inpatient hospitalization. The patient could have been managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blood Disorder/Anemia
Treatment: Inpatient Admission
The health plan denied the requested inpatient admission as not medically necessary.
The health plan's determination is overturned.

The patient is a female who presented for care with severe anemia. She had a history of progressively worsening fatigue, constipation, and picky eating. On presentation to the emergency department (ED), she had a heart rate of 130 beats per minute (bpm), and appeared tired with pallor. Lab studies showed a hemoglobin of 2.6 grams/deciliter (g/dL), with a mean corpuscular volume (MCV) of 52, and iron level of 10, a ferritin level of less than 1, and a total iron binding capacity (TIBC) of 510. She was admitted to the pediatric intensive care unit (PICU) for further management of her iron deficiency anemia. She was given packed red blood cell transfusions, iron supplementation, serial blood counts, and hematology was consulted. The initial transfusion consisted of 15 cubic centimeters/kilograms (cc/kg), and the second transfusion consists of 10 cc/kg of packed red blood cells. Over time, she stabilized, her hemoglobin improved to 10.1, and she was considered safe for discharge.
The acute inpatient stay is under review for medical necessity.

The recommendation is to overturn, in whole, the health plan's determination of medical necessity.

Yes, the requested health service/treatment of an inpatient admission was medically necessary for this patient.
This patient presented with severe iron deficiency anemia, of unclear etiology. At the time of presentation, she was tachycardic and hypotensive, and placed in the pediatric intensive care unit for close monitoring and treatment. Her blood volume had to be slowly replaced, with close laboratory monitoring, and vital sign monitoring. In general, transfusion therapy is indicated for those children with severe iron deficiency anemia, with hemoglobin levels of less than 5 g/dL. These children are considered to be at risk for serious short-term morbidity and mortality, such as cardiac failure, or stroke, which can be prevented by stabilization with transfusion. Transfusions must be administered with caution to avoid fluid overload and heart failure, with transfusions given in small aliquot volumes. Given the degree of this patient's anemia, with a hemoglobin well below 5, the need for blood transfusions, and close monitoring, the care was not appropriate to be given outside of the intensive care unit setting. While it was suspected that her anemia was solely due to iron deficiency, active hemolysis, and active bleeding cannot be ruled out, especially given her history of hemorrhoids.
Therefore, this request for acute inpatient stay was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diplegic Cerebral Palsy
Treatment: Durable medical equipment (L1970x2, L2820x2, L2275x4, L2780x4, L2250x2, L2270x2, L4205x4, L2755x4)
The insurer denied coverage for durable medical equipment (L1970x2, L2820x2, L2275x4, L2780x4, L2250x2, L2270x2, L4205x4, L2755x4).
The denial is overturned.

This is a child with a diagnosis of diplegic cerebral palsy and associated weakness, spasticity and abnormal gait. The child was seen by a rehabilitation Center. The patient's musculoskeletal assessment showed contracture in the left hip, bilateral increased tone, generalized weakness, and a diplegic gait.

The patient is a child who has outgrown the current lower extremity braces, which are also in disrepair. The current braces also cause pressure irritations at the calves and ankles, consistent with poor fit and dysfunction. The requested properly fitted braces will provide support and stability for the patient's foot and ankle, reduce stress on the hip and knee joints, improve balance and alignment throughout the lower extremities providing a more stable gait and decreased energy expenditure for ambulation, decrease the risk of injury due to falls as well as improve development of upright and gross motor skills.

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.
 
Medical necessity of the requested durable medical equipment (L1970x2, L2820x2, L2275x4, L2780x4, L2250x2, L2270x2, L4205x4, L2755x4) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male with past medical history significant for attention deficit hyperactivity disorder (ADHD) on Adderall, headaches, and seizures (two prior seizures, work-up done, no medications) that had his third episode of seizure with eyes rolling and generalized tonic-colonic activity. He was postictal when brought in by Emergency Medical Services (EMS) but was able to open eyes and respond to commands. Patient's mother reported the episode lasted for about ten minutes.

He had had two seizures that occurred during sleep. Electroencephalogram (EEG) and 24-hour EEG were reportedly normal, he was on no medications. He had been diagnosed with benign Rolandic epilepsy. Mom also reported that he talked to himself and had auditory hallucinations. There was no history of trauma. He was diagnosed with ADHD at age five by a neurologist and took Adderall intermittently as needed. Neurology examination was unremarkable. Keppra was recommended but declined by the mother. Ophthalmology was consulted for the headaches. After a dilated fundal examination, no ophthalmologic explanation was found for his headaches. He was referred back to neurology for management. EEG result was pending at the time of discharge. He was discharged to follow-up with neurology and obtain an outpatient MRI (magnetic resonance imaging).

The health plan's determination is upheld.

The requested acute inpatient admission was not medically necessary for this male patient admitted for seizure activity. He could have been safely and appropriately managed at a lower level of care with appropriate testing and outpatient follow-up. This patient with reported history of benign Rolandic epilepsy presented to the emergency department (ED) with his third life-time seizure accompanied by severe headache and vomiting. Neurology recommended hospital observation. EEG was obtained and anticonvulsant therapy was recommended which the mother subsequently refused. While it was reasonable to monitor this patient for a period of time, he was overall hemodynamically stable, afebrile, with no further seizure activity. He did not require acute hospital admission and could have been safely managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Causalgia of right lower limb
Treatment: Percutaneous Implantation of Neurostimulator Electrode Array (pre-service)
The health plan denied the requested Percutaneous Implantation of Neurostimulator Electrode Array (pre-service) as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a lower extremity injury that resulted in chronic pain in her right leg. Medications include Amitriptyline as well as multiple other agents. Her pain is located in the right lower extremity on medial side of her leg from the knee to the medial malleolus. The pain is noted to be 9 out of 10 at baseline. Physical therapy as well as injections have been trialed in the past. A physical exam demonstrated allodynia on the medial aspect of the right leg. A psychological consultation has been performed.
At issue is the medical necessity for the requested Percutaneous Implantation of Neurostimulator Electrode Array.

I uphold the health plan's determination of medical necessity, in full.

In this case, the patient is noted to have causalgia of the right lower limb, and this is a request for a peripheral nerve stimulator. Peripheral nerve stimulation involves placing a small electrical device (a wire-like electrode) next to one of the peripheral nerves. These are the nerves that are located beyond the brain or spinal cord. The electrode delivers rapid electrical pulses that are felt like mild tingles/paresthesias. This modality is not recommended until there is higher quality research, including research on adverse events. The supporting evidence is limited to case reports, retrospective reviews, and small case series, mostly focusing on migraine treatment.

The request is not medically necessary. There is lack of support in the medical literature for the use of this modality. Hence, the requested health service/treatment of Percutaneous Implantation of Neurostimulator Electrode Array is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Genitourinary
surgical services

Diagnosis: uterine bleeding and dysmenorrhea 
Treatment: Hysterectomy
The insurer denied Hysterectomy. The health plan's determination is upheld. 

The patient is a female with abnormal uterine bleeding and dysmenorrhea for which she misses work. Physical exam including pelvic exam was normal. Pelvic ultrasound was normal. There is a past medical history of laparoscopy for ovarian cyst, no endometriosis was documented. A laparoscopic hysterectomy was recommended for treatment. There is a question of the medical necessity of the hysterectomy.

The requested Outpatient Hysterectomy Surgery is not medically necessary for this patient.
The American College of Obstetricians and Gynecologists (ACOG) recommends that a physical exam exclude etiologies of abnormal bleeding including evaluation of a polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, and endometrial. There are no vaginal cultures nor urine cultures for evaluation. ACOG also recommends medical management for the initial treatment of patients. There is no documentation that the patient has tried conservative measures for her bleeding. There is no hormonal treatment, conservative analgesics, hormonal therapy, tranexamic acid nor endometrial ablation documented. Therefore, the hysterectomy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Home health care

Diagnosis: osteoarthritis
Treatment: Home health care
The insurer denied Personal Care Assistance Services: 5 Hours per Day, 5 Days per Week (Monday through Sunday) - Total of 25 Hours per Week. The health plan's determination is overturned.

The patient is a female with past medical history of hyperlipidemia, diabetes mellitus type 2, hypertension, colon cancer, osteoarthritis, anemia, chronic kidney disease, cerebrovascular accident (CVA), osteoporosis, and urinary incontinence who had been assigned PCA (personal care assistant) services following a telephonic assessment assessing the patient at maximum assistance with tasks of ordinary housework and shopping while extensive assistance with tasks of meal preparation, stairs, transportation, and equipment management. With tasks of managing finances, managing medication, bathing, dressing upper/lower body patient was assessed at limited assistance while set up with task of phone use. 

Personal Care Assistance Services: 5 Hours per Day, 5 Days per Week (Monday through Sunday) - Total of 25 Hours per Week are medically necessary for this patient.
There is documentation from the patient's PCP (primary care provider) and geriatrician of worsening physical functioning due to increasing pain. There is documentation from the patient's geriatrician of medical necessity of increased PCA (personal care assistant) services. The assessment showed improvement in patient's ability to perform task of shopping and equipment management when compared to previous assessment. There is documentation of worsening physical functioning and therefore the recent assessment underestimated the patient's care needs for these tasks. The plan's own assessment documented a decline in activities of daily living (ADL) status and deterioration of overall self-sufficiency in the last 90 days. The requested increase in PCA services could not 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, PCA services 5 hours/day, 5 days/week, to total 25 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: Atopic dermatitis. 
Treatment: Opzelura 1.5% EX (external) CREA (cream. 

The insurer denied coverage for Opzelura 1.5% EX CREAM. 

The denial is overturned. 
 
The patient is an adult with a history of atopic dermatitis.  The patient has failed topical steroids, tacrolimus ointment, oral prednisone, and recently discontinued Dupixent due to painful injections. The request is for topical Opzelura. 

Based on the submitted documentation, the use of Opzelura is medically necessary. The patient has failed topical steroids, topical tacrolimus, as well as oral steroids.  The patient has failed all Food and Drug Administration (FDA) approved and standard of care topicals. Furthermore, the patient has failed oral steroids and is unable to tolerate Dupixent injections and would ideally be maintained on a topical therapeutic agent. Opzelura topical is FDA approved for treatment of atopic dermatitis. The request is reversed based on the standard of care and the submitted documentation. 

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 Opzelura 1.5% EX CREA services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, glaucoma, recent right hip replacement, and cognitive deficits

Treatment is personal assistance service (PCS) aide hours, 5 days a week, 2-12 hours a day (split shift)

The insurer denied coverage for personal assistance service (PCS) aide hours, 5 days a week, 2-12 hours a day (split shift)
 
The denial is overturned

This is an elderly patient with heart disease, glaucoma, a recent right hip replacement and cognitive deficits. The patient lives with a daughter in a private residence. The patient is approved by the insurer for personal care service (PCS) aide hours, 5 days/week (live-in). The patient's daughter is requesting PCS aide hours, 5 days a week, 2-12 hours a day (split shift).  

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." Maximal assistance is required for bathing, dressing and toilet use.  Extensive assistance is needed for personal hygiene, bed mobility, locomotion, ambulation and toilet transfer. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. Limited assistance is required for eating. Compared to the previous UAS report, the patient's cognitive and functional status are much the same. However, the patient's cognitive and functional deficits are at a level or unpredictable as to require the requested PCS aide hours, 5 days/week, 2-12 hours a day (split shift). Based on the records reviewed, the approved live-in PCS is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home with the requested PCS aide hours, 5 days/week, 2-12 hours a day (split shift).

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, personal assistance service (PCS) aide hours, 5 days a week, 2-12 hours a day (split shift) is medically necessary.    

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 personal assistance service (PCS) aide hours, 5 days a week, 2-12 hours a day (split shift) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: left breast angiosarcoma, chronic obstructive pulmonary disease (COPD), and chronic pain

Treatment: 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 of 168 hours per week

The insurer denied coverage for PCA Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week

The denial is overturned

 
This is an elderly patient with diagnosed left breast angiosarcoma, COPD and chronic pain. She lives alone in a private residence. Her condition is terminal, and she was admitted to Hospice. The insurer approved PCA services 7 hours per day, 7 days per week (totaling 49 hours per week) and the request is for PCA services 2-12 hour split shift, 7 days a week (total 168 hours/week).

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "Moderately impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." She requires maximal assistance for bathing, personal hygiene, dressing, bed mobility, locomotion, ambulation and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. Her condition has declined compared to a prior UAS report. In a letter, hospice physician reviews the patient's rapidly declining terminal condition. The patient's progressive (terminal) medical condition and declining functional ability are at a level or unpredictable as to require the requested PCA services 24 hours/day, 7 days/week (split shift). Based on the records reviewed, the patient's health and safety are more appropriately provided and maintained at home with the requested PCA services 24 hours/day, 7 days/week split shift.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, PCA Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week is medically necessary.    

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 PCA Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week services is substantiated.