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

Diagnosis: Cellulitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient presented to the Emergency Department with pain and swelling of the right fourth digit after a cut, several days prior. Vitals signs were within normal limits and the patient was afebrile. White blood cell (WBC) count was slightly elevated at 12.6. The patient underwent incision and drainage at bedside. There were no reported complications. The patient was discharged.

Per Milliman Care Guidelines (MCG) Cellulitis, admission is indicated for one or more of the following: hemodynamic instability, altered mental status, failure of outpatient therapy, limb-threating infection, bacteremia, suspected necrotizing soft tissue infection, or severe pain requiring acute inpatient management. Per MCG Ambulatory Surgery Exception Criteria, a potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: preoperative situation, condition, or finding that warrants inpatient stay as indicated by 1 or more of the following: a. inpatient care needed for preoperative disease or condition (eg ["for example"], infection, coagulopathy, altered mental status, dangerous arrhythmia, hypotension, hypoxemia, tachycardia, tachypnea).

Pyogenic flexor tenosynovitis is an infection of the flexor tendon sheath of the hand. There was no indication that the patient had a deep space infection or that there were complications. The acute inpatient hospital admission was not medically necessary. This is managed as an outpatient/ambulatory procedure.  

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

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

Diagnosis: hypertension, glaucoma and Parkinson's disease.

Treatment: Personal care aide (PCA) service live in, 7 days a week.

The insurer denied coverage for personal care aide service live in, 7 days a week.

The denial is overturned.
 

This is an elderly patient with multiple medical problems including hypertension, glaucoma and Parkinson's disease. He is currently a resident in a nursing facility. The insurer approved personal care assistance (PCA) 8 hours/day, 7 days/week (total 56 hours/week). The request is for PCA service live in, 7 days a week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent.  However, he requires maximal assistance for bathing, lower body dressing, ambulation and toilet use. Extensive assistance is needed for personal hygiene, upper body dressing and toilet transfer. He is frequently incontinent of bladder and continent of bowel. Bed mobility and eating require limited assistance. Instrumental activities of daily living (IADL) range from extensive assistance to total dependence. The patient's medical condition and essentially maximal to extensive assistance functional needs are at a level or unpredictable as to require the requested PCA services 24 hours/day, 7 days/week (live-in). Of particular concern is his rapidly progressive Parkinson's disease, associated functional decline (as evident by the Uniform Assesment System) and lack of informal support. Based on the records reviewed, the patient's health and safety would be more appropriately provided and maintained upon his return home from the nursing facility by increasing PCA services to 24 hours/day, 7 days/week (live-in).

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 service live in, 7 days a 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 personal care assistance (PCA) service live in, 7 days a week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld 

The patient presented with abdominal pain consistent with gall bladder disease and underwent laparoscopic cholecystectomy. The patient had no significant medical findings that would support the need for in-patient hospital level of care. There was no need for significant fluid resuscitation or antibiotic therapy that would support the need for admission to in-patient status. 

There was no hemodynamic, pulmonary, neurological or metabolic reason for acute inpatient level of care.

This patient could have been treated in observation status while awaiting and being prepared for her surgical procedure and post-surgical discharge. The patient did not present with any comorbid conditions that would justify hospital admission. The admission was not medically necessary for this patient.

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

Diagnosis: Heart Failure
Treatment: Inpatient admission 
The insurer denied coverage for inpatient admission 
The denial is upheld 

 
This is an adult patient that presented to the hospital with cough and shortness of breath.  Past medical history was significant for ischemic heart disease with triple vessel coronary artery disease and a left ventricular ejection fraction of 35%(percent).  On arrival to the hospital vital signs were stable (Blood pressure 119/74, pulse 66). Physical examination revealed 1 plus (+) pitting edema at the ankles. 12 lead electrocardiogram revealed normal sinus rhythm without ST or T wave abnormalities.  Serum blood testing revealed no elevation in serum troponin (<(less than)0.01 nanograms/milliliter. Serum B type natriuretic peptide (BNP) was elevated (405). Chest X-ray revealed no significant abnormality.

This patient presented with dyspnea and a mildly elevated  BNP level and no evidence of decompensated congestive heart failure on physical examination or on chest x-ray.  He was appropriately treated with diuretics and guideline directed medical therapies (Reference 1). The patient left against medical advice (AMA) the following day with cardiology and computed tomography (CT) surgical follow up for possible future revascularization. 

Masri et al compared patient outcomes following treatment of acute congestive heart failure in observation and inpatient settings and demonstrated no difference in mortality between the two groups. (Reference 2). In conclusion this patient could have been treated at a lower level of care and did not require 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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pancytopenia.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

According to the clinical documentation provided for review, the patient is an adult who presents with a history of type 2 diabetes, hypertension, and anemia. The treating provider is requesting plan approval for inpatient hospital admission for new onset pancytopenia.

The patient presented to the Emergency Department (ED) due to feeling lightheaded, described as near syncope. The patient was seen in the ED five days previously for anemia and was transfused 1 unit of blood but left against medical advice (AMA). The patient was pale on the exam. The patient's hemoglobin (Hgb) was 7.1, but she also had white blood cell count (WBC) of 3.5, and the platelets were 70. The patient was admitted for a workup of new pancytopenia. The patient gave a history of apple juice-colored urine, so hemolysis or delayed transfusion reaction was in the differential. The blood smear raised the possibility of myelofibrosis. The patient received 2 units of blood, had a hematology/oncology consult, and started vitamin B12 injections. The patient was admitted to telemetry. The patient was stable and discharged with further work-up outpatient.

This was a complex presentation by an individual, who previously signed out AMA and could not be presumed to keep her appointments, and she was symptomatic, and her diagnosis was far from clear. Because of the possibility of hemolysis, her hemoglobin could drop precipitously. 

"Pancytopenia is defined as a decrease of all three hematologic cell lines. The condition is not a disease in itself but a common pathway caused by a multitude of different etiologies that can be infectious, autoimmune, genetic, nutritional, and/or malignant. Determining the cause of pancytopenia is a challenge and is key in determining the proper treatment regimen and estimating prognosis." (Chiravuri, et al., 2022)

"Pancytopenia is characterized by a decreased number of at least two blood cell lines. Pancytopenia may progress acutely, such as with decreased blood cell counts in fulminant sepsis, disseminated intravascular coagulation, or rapid hemolysis. Alternatively, pancytopenia may evolve insidiously over weeks to months." (Sharma, et al., 2016)                                          

The health plan did not act reasonably, with sound medical judgment or in the best interest of the patient.

The insurer's denial of coverage for the inpatient hospital admission is overturned.

Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rash over body
Treatment: Current Procedural Terminology (CPT) code 87633 - CS infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets with diagnosis code Z20.822 
The insurer denied coverage for Current Procedural Terminology (CPT) code 87633 - CS infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets with diagnosis code Z20.822 
The denial is overturned

This patient is a child who presented for evaluation of a rash on the legs, trunk, and back, after recently having finished a course of penicillin for a strep infection. When presented with a child with a rash that is not immediately pathognomonic for an infection (e.g. varicella, measles, Coxsackie), it is clinically imperative to distinguish an allergic reaction from an infection. In the case of this child, this was particularly important because of the recent streptococcal infection that was treated with a penicillin, and therefore it was important to decide if this rash had an alternative explanation so that the child could be appropriately labeled as possibly allergic to the antibiotic or not. Moreover, an infectious illness could progress from rash to other symptoms and may need further medical attention in the next few days.

The insurer has not provided any evidence for the statement "not enough proof that testing of genetic material for greater than five respiratory infectious pathogens improve clinical outcomes." The insurer needs to cite published literature for evidence. Identifying a virus or other pathogen by nucleic acid amplification provides invaluable clinical benefit. This aids in antimicrobial stewardship, as well as allows assignment of an etiology to the illness. One specific example of an infectious cause for a generalized diffuse papular urticarial rash that is identifiable by an Respiratory Virus Panel (RVP) is Mycoplasma. Moreover, he needed to be tested for COVID (Corona Virus) as he was exposed 5 days earlier, and it is effective and medically indicated to test for other viruses at the same time. 

The health plan did not act reasonably, with sound medical judgment and/or in the best interest of the patient.

The insurer's denial of coverage for the current procedural terminology (CPT) code 87633 - CS infectious agent detection by nucleic acid (DNA or RNA); respiratory virus, includes multiplex reverse transcription when performed, and multiplex amplified probe technique, multiple types or subtypes, 12-25 targets with diagnosis code Z20.822 is overturned. 

Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
treatment; braces/monthly visits
The insurer denied braces/monthly visits. The health plan's determination is overturned.

The patient in question is a male with an anterior crossbite on teeth 7 and 10. Teeth 4,5, 12 and 13 are also in crossbite. He presents with a skeletal Class I malocclusion with severe crowding in the maxilla and mandible. He is treatment planned for orthodontics to address the crowding and crossbites. 

Braces and monthly visits are medically necessary for this patient.
This patient presents with an anterior crossbite on teeth 7 and 10, as well as crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.
Teeth 7 and 10 are in a traumatic crossbite with their mandibular antagonists. Additionally, tooth 23 is rotated and is being pushed to due labial due to its occlusion with tooth 10. If this is not corrected, the damage that will likely occur to the patient's teeth will be much more time consuming and difficult to correct than the patient's existing orthodontic problem. Therefore, the requested Orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea. 
Treatment: Sleep study. 

The insurer denied Sleep Study: Continuous Positive Airway Pressure (CPAP) Titration in a sleep center. The health plan's determination is overturned. 

The patient is a male who had a sleep study where it was recommended to initiate a trial of Auto- continuous positive airway pressure (CPAP) due to the presence of obstructive sleep apnea (OSA). This study showed a apnea hypopnea index (AHI) of 8.7. Epworth score was 20. Device download over the past 90 days noted on 26% compliance over 4 hours with an average usage of 3 hours and 49 minutes per night with a residual AHI of 2.1. 

Sleep medicine visit noted that sleep apnea was confirmed after a home sleep study. It was noted that he is having trouble acclimating to the device and he thinks the pressure to too low and feels like he is suffocating. An in-lab titration study was recommended at that time. 

The requested Sleep Study: Continuous Positive Airway Pressure (CPAP) Titration in a sleep center is medically necessary for this patient per Milliman Care Guidelines (MCG) criteria and current literature. 

The patient will require a CPAP titration as he has already been trialed on Auto CPAP and was having difficulties with this. Based on current literature and the MCG criteria, Sleep Study: Continuous Positive Airway Pressure (CPAP) Titration in a sleep center.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Prostate cancer.
Treatment: Proton beam therapy.

The insurer denied proton beam therapy.  The health plan's determination is upheld. 

This is the case of a male patient, who presented with rising prostate-specific antigen (PSA). The patient underwent magnetic resonance imaging (MRI) followed by biopsy, which established diagnosis of favorable intermediate risk prostate cancer.  He was explained all treatment options. He is being evaluated for Proton beam therapy. 

The requested Radiation Therapy is not medically necessary for this patient.

The use of Proton Beam radiation therapy as definitive treatment for prostate cancer has medical literature with relatively short follow up with proton beam therapy as monotherapy for prostate malignancies. These studies show equivalent control rates to other types of radiation therapy for the shorter follow up periods. There are also retrospective studies with large numbers of patient that have shown worse gastrointestinal (GI) side effects as compared to photon beam radiation therapy with intensity modulated radiation therapy (IMRT). There is a lack of randomized studies regarding proton beam radiation therapy alone as treatment for prostate cancer that shows equivalent outcome or any improvement over other forms of radiation therapy such as photon IMRT. Until the current randomized trials ongoing are published in peer reviewed medical literature, this treatment for prostate cancer is considered not medically necessary.

It is unclear whether a mild-moderate reduction in low dose exposure will translate into a clinically meaningful benefit and there is no proven superiority for proton beam radiation therapy (PBRT) over photon radiation therapy (3D [3 dimensional] conformal, intensity modulated radiation therapy (IMRT) or stereotactic radiation therapy). Further studies are needed to define comparative effectiveness of proton radiation therapy versus photon radiation therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, dementia, osteoarthritis
Treatment: Increase Consumer Directed Personal Assistance 
(CDPAP) Service for a Total of 84 Hours per Week
The insurer denied: Increase Consumer Directed Personal Assistance (CDPAP) Service for a Total of 84 Hours per Week
The denial is overturned.

This elderly female has conditions including coronary artery disease, diabetes, dementia, osteoarthritis, bipolar disorder, hypertension, and edema. She is appealing denial of increase consumer directed personal assistance (CDPAP) service for a total of 84 hours per week (consumer directed personal assistance program [CDPAP]: 12 hours per day - seven days per 
week). The health plan approved 30 hours per week. Uniform Assessment System (UAS) evaluation completed 5 months ago shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, managing finances and medications, shopping, bathing, lower body dressing, and toilet use; extensive assistance with phone use, personal hygiene, upper body dressing walking, locomotion, toilet transfer, and bed mobility; and independent with eating. She has occasional bladder incontinence. Compared to Uniform Assessment System (UAS) 
evaluation performed 2 years ago, there has been a decline in functioning with all activities of daily living (ADLs), except bathing and eating.

The health plan should cover the proposed treatment. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. She is appealing denial of increase consumer directed personal assistance (CDPAP) service for a total of 84 hours per week (consumer directed personal assistance [CDPAP]: 12 hours per day - seven days per week). The health plan approved 30 hours per week. The health plan denied the request based on Uniform Assessment System (UAS) assessments and finding that the approved consumer directed personal assistance (CDPAP) at 30 hours per week appropriately and safely meets the patient's personal care needs. 
Uniform Assessment System (UAS) evaluation completed 5 months ago shows the patient requires assistance with all activities of daily living, except eating. Compared to Uniform Assessment System (UAS) evaluation performed 2 years ago, there has been a decline in functioning with all activities of daily living (ADLs), except bathing and eating. She is incontinent of bladder. The information provided shows that this patient has significant limitations in functioning and has had a significant decline in functioning between Uniform Assessment System evaluations. The approved consumer directed personal assistance 30 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase consumer directed personal assistance hours to 84 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD)
Treatment: Quillivant XR (extended release)
The insurer denied Quillivant XR.
The denial is upheld.

The patient is a female with diagnosis of attention deficit hyperactivity disorder (ADHD). Requested medication is Quillivant extended release (XR) to treat her ADHD. This is currently being denied as non-formulary medication and lack of trial of 3 alternatives.

Medical records provided indicate diagnosis of ADHD made by a psychologist and developmental pediatrician when the patient was a young child. ADHD is primarily inattentive type. She is currently a teenager, has 504 accommodations in school, and has never been on medications to date. She is unable to swallow pills.

The subject under review is the medical necessity for Quillivant XR.

The requested medication Quillivant XR is not medically necessary for this patient. There has not been a demonstrated trial and failure of at least 3 preferred drugs such as amphetamine-dextroamphetamine extended release capsules and methylphenidate extended release tablets. This female with past diagnosis of ADHD years ago presented with increased school difficulty related to concentration. The family and patient desire a trial of medication. The patient does not swallow pills and has never tried any medications to treat ADHD. According to the health plan there needs to be a trial of at least 3 preferred drugs before non-formulary medications are considered, therefore Quillivant XR is not medically necessary.