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

Diagnosis: Alzheimer's, coronary heart disease, diabetes, ataxia

Treatment: personal care worker (PCW) services of 7 days per week, 24 hours per day, continuous care by more than 1 person

The insurer denied coverage for personal care worker (PCW) services of 7 days per week, 24 hours per day, continuous care by more than 1 person

The denial is overturned.

This case involves an elderly patient with a history of Alzheimer's as well as coronary heart disease, diabetes, ataxia, difficulty walking, osteoporosis, hypertension, and urinary incontinence.  The documentation indicated per mental state examination, she had a total score of 3.  It is noted she was alert however confused and forgetful.  The submitted documentation indicated, according to the family she wakes up at night and walks around.  She was observed ambulating indoors with a cane with an unsteady gait.  She was also observed transferring with assistance.  She does have a commode however refuses to use it.  She does have an increase in bowel incontinence.  The patient does require assistance with medication administration.  There have been no documented falls within the prior 90 days of assessment.  The patient did report mild pain to her legs, shoulders, hands, low back, neck, and feet.  There is also no documented urgent care or emergency department visits within the 90 days prior to assessment.  She does have a documented tremor to the bilateral upper extremities with expressive aphasia.  She also had a syncopal episode where emergency medical services were called however, she was treated at home.  The submitted documentation indicated the recommendation has been made for a personal care worker 7 days a week 24 hours a day by more than 1 person.  According to the submitted documentation she has been approved for a worker 7 days a week 8 hours a day.

This patient with Alzheimer's dementia is reportedly unable to take care of herself, has difficulty with ambulation and requires a wheelchair to get around. She also needs help with all the activities of daily living including toileting. The main issue here is her cognitive status and the fact that she cannot make appropriate decisions because of that. She also lives with her husband who requires assistance himself and cannot take care of her. Due to her cognitive impairment, she is at high risk of adverse events including falls and other injuries. She is appropriate for 24/7 care based on the above reasons. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the requested Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day, continuous care by more than 1 person is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer 
Treatment: Advanced Imaging. 
The insurer denied PET/CT. 
The denial is overturned in whole.

This is a male with history of recurrent diffuse large B-cell lymphoma (DLBCL) status/post (s/p) Rituximab-Etoposide Phosphate, Prednisone, Vincristine Sulfate [oncovin], cyclophosphamide, doxorubicin hydrochloride [hydroxydanorubicin] (R-EPOCH) with intrathecal methotrexate (MTX) and Rituximab-Dexamethasone, Ara C, Cisplatin (R-DHAP) with progressive disease s/p radiotherapy and outpatient fludarabine/cyclophosphamide (Flu/Cy) chemotherapy followed by Car-T therapy with Yescarta. Most recent positron emission tomography (PET)/computed tomography (CT) performed previously was consistent with a complete metabolic response. He has palpable inguinal lymph nodes, and it is difficult to determine whether they are malignant. Request is for the medical necessity for the requested PET/CT.

The health plan's determination is overturned in whole. 

The requested PET/CT is medically necessary and standard of care in the patient's setting. PET/CT is the most appropriate imaging modality to monitor the patient's inguinal lymphadenopathy. PET/CT is required to monitor the patient's inguinal lymphadenopathy as progressive disease here would significantly alter disease management recommendations. If the patient presents with progressive disease, it is critical that it be detected at an earlier time point to minimize the risk for re-dissemination of his disease. PET/CT in the patient's situation is supported by the National Comprehensive Cancer Network (NCCN) Guideline and high-quality clinical outcomes published in the medical literature. PET/CT is widely utilized throughout the oncology community for similar patients in the patient's setting nationwide.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Post-operative complications of pain, nausea, dizziness and post-obstructive diuresis. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

This patient with a past medical history of hyperlipidemia, pituitary microadenoma, right kidney hydronephrosis, hyperprolactinemia, bilateral knee osteoarthritis, right ectopic ureter/ kidney stones presented for right robotic ureteroneocystostomy. Surgery was uneventful, patient admitted for further postoperative monitoring of her pain/wound dressing/care, intravenous fluids, intake /output. On post-operative day (POD) #1, patient was stable however she had mild nausea and became dizzy while ambulating. The patient had high urine output for which she received intravenous replacement fluids. On POD#2, the patient's nausea resolved and she ambulated without dizziness. The patient was stable for discharge with leg bag and wound drain was removed that day. 

On POD#1, the patient complained of dizziness with walking although able to get out of bed to chair and walk to bathroom. No emesis, some nausea, improved with Zofran. The patient was tolerating regular diet, noted to have high urine output, received replacement intravenous fluids but blood pressure was normal, pulse was normal and all serum electrolytes were normal. The patient appeared to have mild high urine output postoperatively, but had normal/stable vitals, electrolytes, was capable of oral intake, with nausea improved with Zofran. Operative wounds acceptable, renal function/ labs/ electrolytes acceptable. 

Per Milliman Care Guidelines (MCG) Health (25th) Urologic Surgery or Procedure general recovery guidelines, patient appears to have met the discharge parameter within 24 hours post procedure. As per the guidelines, this procedure is normally performed in the ambulatory surgery setting with an occasional overnight stay to ensure a safe hospital discharge. This patient had mild postoperative issues, but overall, she was medically and hemodynamically stable, taking oral solid/liquid nourishment and ambulating. 

The health care plan acted reasonably and with sound medical judgement and in the best interest of the patient. 

The inpatient admission was not considered medically necessary for this patient. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache, Myalgia, Neck Stiffness, Skin Rash. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient presented to the emergency department (ED) with history of Anxiety and complaint of Headache, Myalgia, Neck Stiffness, Skin Rash after 2nd dose of Pfizer Vaccine received 1 week prior.  Vital signs at presentation Temperature 99.9 Fahrenheit, Heart Rate 117, Respiratory Rate 20, Blood Pressure 182/96, and oxygen (O2) saturations 98 % (percent) on Room Air. The patient was alert and oriented to person, place, and time. Lungs clear, cardiovascular system was normal, and abdomen was soft non tender. Some skin rash was noted. No meningeal signs were elicited.  White Blood Cell count (WBC) was 12.2, electrolytes within normal limits (WNL), Troponin - mild elevation 0.14. Electrocardiogram (EKG) No acute changes. Head computed tomography (CT) was negative.  The patient was admitted for Community Acquired Pneumonia (CAP) and severe systemic inflammatory response syndrome (SIRS) syndrome. The patient was started on Ceftriaxone and Azithromycin. Also given Tylenol.  The patient remained stable after admission. By the next day, myocardial infarction (MI) had been ruled out. The patient remained afebrile and hemodynamically (HD) stable, was tolerating oral intake, white blood cell count (WBC) 10.2 and the repeat Troponin level was normal. Antibiotics were discontinued and the patient was discharged home. Clinical impression was Foot and Mouth disease/ Viral Syndrome. 

This patient did not need acute hospitalization. He could have been placed in observation status while diagnostic testing and treatment were initiated. This patient likely had a SIRS type of reaction to the Covid vaccine. Pneumonia was less likely and even if present was mild. The patient had a low PSI (pneumonia severity index) score and confusion, urea, respiratory rate and blood pressure (CURB)-65 score was zero. The patient was stable to be kept in observation status while diagnostic testing and treatment were initiated. The patient remained stable and was tolerating oral intake, was afebrile and HD stable and discharged home. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for the inpatient admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fall. 
Treatment: Hospital admission. 

The insurer denied coverage for hospital admission. 

The denial is upheld. 

This case involves a toddler who presented to the emergency department after a fall.  The documentation indicated he had a fall from approximately 5-6 feet.  The mother reported he hit his head and was not moving.  The patient did arrive to the emergency department with a Glasgow Coma Scale of 15. The physical examination did reveal soft tissue swelling of the left forearm.  The vital signs were normal, and it was recommended he undergo laboratory and diagnostic studies.  He underwent a chest x-ray which was negative in addition to a pelvic x-ray which was negative.  A computed tomography (CT) scan of the head in addition to a CT scan of the cervical spine was negative.  The left forearm x-ray did reveal an ulnar fracture.  Recommendation was made to admit the patient in follow-up with Orthopedic recommendations.  The documentation detailed he did receive a cast to the left upper extremity.  He underwent a consultation by Orthopedics and given a lack of adverse events, he was discharged the following day. 

This admission was not indicated. The patient had a negative head CT and was acting normally by the time of presentation. The risk of a bleed in a healthy child following a negative head CT is quite small. In fact, the risk of a clinically important intracranial injury was low enough that the patient could have been sent home after several hours of observation without a head CT. His only other injury was an ulnar fracture, which was treated by casting. This is not associated with a high risk of compartment syndrome and does not require admission. The patient had no other injuries. 

The health plan acted reasonably with sound medical judgment. 

Based on the above, the medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sudden Onset of Severe Left Lower Back Pain and Swelling with Bruising. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

This patient is a male who presented to the emergency department with pain and swelling of the left flank.  The records indicate that the patient had heavy alcohol consumption and did not recall details of the events leading up to the injury.  Vital signs were significant for a heart rate of 57 beats per minute and blood pressure of 153/102 millimeters of mercury (mmHg) at presentation.  There was a 6.0 by 5.0 centimeter area of soft tissue swelling / hematoma of the left flank.  Hemoglobin was 16.4 (normal).  Computed tomography (CT) scan showed a 4.5 by 2.0 by 2.5 centimeter hematoma within the subcutaneous tissues of the left flank with possible extravasation (bleeding). 

The patient was admitted to the hospital.  He remained clinically stable on day two.  He did not require surgical intervention.  He did require treatment for alcohol withdrawal with Librium.  Progress notes document that the flank hematoma did not worsen.  The hemoglobin value on day two was 14.1 and vital signs showed a normal heart rate of 70 beats per minute.  The hemoglobin value remained stable at 14.1 on day three.  He was able to be discharged from the hospital on day three. 

The health plan rationale for denial is that the patient's condition and ongoing care needs did not warrant inpatient admission.  Rather, the patient's clinical needs could have been appropriately satisfied with a lower level of care. 

No, the proposed inpatient admission was not medically necessary. 

An inpatient level of care was not medically necessary for this patient as the care provided could have reasonably been rendered with a lower level of care (observation). 

Yes, the health plan acted reasonably and with sound medical judgment and in the best interest of this patient with its determination. 
An observation level of care would have satisfied the clinical needs of this patient.  This level of care would provide for monitoring with repetitive vital signs, serial physical exams, lab data, imaging as required, surgical assessment, and overnight care. 

An inpatient designation was not medically necessary or mandated by generally recognized standards of medical care.  This patient was clinically stable at the time of presentation and remained stable throughout the period of hospitalization. This patient did not present with hemodynamic instability and the hemoglobin value remained stable.  While the patient did require treatment for alcohol withdrawal, he remained stable with Librium.  There was no medical condition that required inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative colitis
Treatment: Humira 40 mg
The insurer denied Humira 40 mg.
The determination is overturned.

The patient has moderate to severe Ulcerative Colitis diagnosed over 10 years ago. She was on Remicade in the past; she has been on Humira for six years. She presented with increasing symptoms approximately three days prior to Humira injections, including up to 10 bowel movements per day. She has been on Humira 40 mg every 10 days, with no flares since the increase. Colonic biopsies showed quiescent chronic inflammatory bowel disease.

The coverage is requested to continue Humira 40 mg every 10 days for the treatment of Ulcerative Colitis.

The request is supported as medically necessary based on current medical literature. This patient has a history of active Ulcerative Colitis requiring biologic therapy [1]. In the high-quality ULTRA 2 trial used for Food and Drug Administration (FDA) approval, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every 2 weeks [2]. The trial advanced non-responders at week 8 to weekly therapy as well as week-8 responders - both groups contained a fraction that responded to dosing frequency increase. In the ULTRA 3 trial, weekly Humira was started for inadequate response, or for flare [3]. In a subset analysis of ULTRA 2 patients, those on weekly therapy had week-52 response rate of 25% after failing therapy given every 2 weeks [4]. Current medical literature and guidelines for the treatment of Ulcerative Colitis recommend dose escalation when disease is uncontrolled [5-7]. In this case, the patient had colitis while on the standard dose of Humira, and required dose escalation; her disease has been controlled subsequently. Decrease to Humira 40 mg every 14 days or changing to a different medication may result in disease flare, disease complications, need for surgery, and hospitalization. Therefore, in this case, extenuating circumstances support the request to continue Humira 40 mg every 10 days.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Helicobacter Pylori
Treatment: Talicia Capsule
The insurer denied Talicia Capsule. 
The health plan's determination is upheld.

The patient is a male with Helicobacter pylori (H. Pylori). He has had postprandial abdominal pain. He was diagnosed with Helicobacter pylori infection with a breath test, which was confirmed two days later with endoscopic biopsies. He was treated with quadruple therapy (including Metronidazole, Omeprazole, Tetracycline), but subsequent testing (with a breath test) showed persistent infection. The coverage is requested for Talicia for the treatment of Helicobacter pylori infection.

The health plan's determination is upheld, in whole.

The request is not supported. The patient has failed one regimen recommended by American College of Gastroenterology guidelines for the treatment of Helicobacter pylori, a quadruple therapy regimen [1]. A rifabutin-based salvage regimen, as requested in this case, is not recommended next [1]. Specifically, the guidelines state that "Clarithromycin or Levofloxacin-containing salvage regimens are the preferred treatment options, if a patient received first-line bismuth quadruple therapy" [1]. The guidelines specifically recommend the formulary alternatives, which include Clarithromycin and Amoxicillin with proton pump inhibitor (Omeprazole, Lansoprazole, Esomeprazole, Pantoprazole, or Rabeprazole) [1]. The use of Talicia, while potentially effective, is recommended only as a salvage therapy, and is not preferred over the above guideline-recommended alternatives [1-3]. Furthermore, there is no reason to use Talicia rather than its individual components until it is documented or supported by current medical literature [1-3].
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Vitiligo

Treatment: Tofacitinib citrate powder cream (compounded product)

The insurer denied coverage for tofacitinib citrate powder cream (compounded product).

The denial is overturned.

The patient has a diagnosis of vitiligo.  The patient has failed therapy with topical steroid, triamcinolone, as well as non-steroidal topical tacrolimus.  The requested medication is topical compounded tofacitinib cream.  

Based on the submitted documentation, topical tofacitinib cream is medically necessary for the treatment of the patient's condition.  The patient has failed standard topical therapies, which would include topical steroids as well as non-steroidal option-tacrolimus ointment.  Vitiligo is an autoimmune disease and requires appropriate therapy.  The use of topical anti-inflammatory agents is within the standard of care prior to proceeding to systemic therapies with associated increased risks.  

Based on the above, the medical necessity for the Formulary Exception for tofacitinib citrate powder cream (compounded product) is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Kineret. 
The denial is overturned. 

The patient is a male with chronic, crystal proven gout. He also has a history of heart failure, chronic kidney disease (CKD) (stage 5, glomerular filtration rate [GFR] less than [<] 15), diabetes mellitus (DM), hypertension (HTN) and coronary artery disease (CAD) and five vein (5V) coronary artery bypass graft (CABG). The issue in this case is Kineret is being denied by the health plan. The reason for denial is Kineret is not a Food and Drug Administration (FDA) approved drug for gout and the patient has not tried formulary alternatives. However, allopurinol not an option due to chronic kidney disease (CKD) and Uloric is not an option due to cardiovascular disease (CVD). He cannot take nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine due to CKD and steroids due to diabetes mellitus (DM). The subject under review is the medical necessity for the Kineret.

The health plan's determination is overturned in whole.

The requested health service/treatment of Kineret 100 milligrams (MG)/0.67 milliliter (ML) subcutaneous (SQ) is medically necessary for this patient. He is unable to take formulary alternatives due to many co-morbidities and resultant contraindications. Thus, a trial of Kineret is a reasonable next step in the management of his chronic gout. According to UpToDate, "interleukin (IL) 1 is an important mediator of gouty inflammation and a potential therapeutic target in gout flares." A study published in Rheumatology in 2019 concluded that the "efficacy of anakinra (Kineret) was shown to be non-inferior to treatment as usual for the treatment of acute gout flares, suggesting that anakinra is an effective treatment alternative for acute gout flares." Moreover, a study in Arthritis Rheumatol in 2021 found that "anakinra was not superior to triamcinolone for the primary end point but had comparable efficacy in pain reduction and was favored for most secondary end points. Anakinra is an effective option for gout flares when conventional therapy is unsuitable."
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent Fever and Diarrhea.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male who has a history of asthma. He presented to the ED (emergency department) with a fever of 102, chills, myalgia, nausea, emesis and diarrhea for one day prior to presentation.

In the ED (emergency department), the patient's temperature was 103.2. The patient also evidenced tachycardia. The white count was 12.5. The evaluation was consistent with gastroenteritis. The patient received supportive care and was discharged once deemed stable.

No, the Inpatient admission was not medically necessary.
The care as provided was medically appropriate, but not medically necessary at the level at which it was provided.

Despite the patient's presentation the care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet he did not evidence a change in mental status, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission.  As such, the care could have been rendered at a lesser level in its entirety.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain and Numbness
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male with neck and left scapular pain after a recent trauma. Exam reveals no weakness. Patient was started on IV (intravenous) decadron and opioids. MRI (magnetic resonance imaging) showed multilevel cervical stenosis. 

Yes, the Inpatient admission was medically necessary.
The patient had severe radicular pain that required IV (intravenous) decadron and imaging studies and possible therapeutic intervention. This patient's symptoms and treatment required acute inpatient level of care. Therefore, this hospitalization was medically necessary and appropriate for this patient.

This hospitalization should be covered. The care that was provided could not be provided at a lower level of care. The patient required IV (intravenous) medications that could not be delivered at lower level of care. In addition, the patient had consultations and imaging studies that would require acute inpatient stay. Finally, there was a chance that he might require surgery. Therefore, it was appropriate to keep the patient at this level of care.