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

Diagnosis: Hemorrhoid.
Treatment: Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female. She is status-post Caesarian section the week prior to presentation. She presented to the Emergency Department with a three-day history of rectal pain (9/10), which had failed to respond to topical medications. Her PMH (past medical history) is positive for a gastric sleeve procedure for morbid obesity. In the ED (emergency department), the patient was noted to be afebrile with stable vital signs (heart rate of 91). Routine laboratory studies revealed a mild anemia (hemoglobin 10.8). Her WBC (white blood count), INR (international normalized ratio) and electrolytes were all within normal limits. Her physical exam documented edematous thrombosed external hemorrhoids, which were painful to touch. Surgical Consultation was obtained with recommendation for conservative treatment in observational status overnight with reassessment in morning for possible surgery. The patient was subsequently transferred to be closer to her son, who was in the NICU (neonatal intensive care unit). The Surgical Progress Note indicates that the patient is prepped and ready for surgery. Her hemorrhoids are noted to be less swollen and tender, however, so it is elected to pursue a course of continued medical management. She received Toradol, Tylenol, Anucort HC 
(hydrocortisone) suppositories, topical HC (hydrocortisone) cream, stool softeners, laxatives and sitz baths. Surgical Progress Note of Dat #4 documents hemorrhoids to be less swollen and tender, her diet has been advanced, and she has had a BM (bowel movement). She was discharged home on Tylenol, Motrin, HC (hydrocortisone) cream, and sitz baths.

The Health Plan has denied the coverage of the inpatient admission as not medically necessary. The Provider has appealed the decision.

The Inpatient Hospital Admission was not medically necessary.

The severity of the patient's condition, thrombosed external hemorrhoids, and the services rendered, stool softeners, topical care and analgesics, do not rise to the level necessitating acute inpatient care. The medical records document improvement in the patient's condition following being placed in observational status overnight, such that surgery was no longer felt to be required. At this point, she could have been discharged home with continued care on an ambulatory basis. The services rendered from that point forward could have been appropriately delivered at an alternative level of care and did not require inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Stay
The insurer denied an Inpatient Hospital Stay.
The determination is overturned.

This is a male patient with a past medical history (PMH) of diabetes mellitus type 2 (DM2) and benign prostatic enlargement (BPE) status/post (s/p) transurethral resection of the prostate (TURP) who was admitted with complaints of (c/o) a fever and body aches. His vital signs were notable for blood pressure (BP) 97/59, pulse 113. The physical exam was unremarkable. Lab work was notable for a white blood cell count (WBC) of 14.66 with (w/) left shift, creatinine 1.45, urinalysis (UA) w/ positive (+) leukocyte esterase (LE) and bacteria too numerous to count (TNTC), elevated lactic acid. Imaging studies included a chest x-ray (CXR) which showed no acute pathology. The patient was diagnosed with sepsis secondary to a urinary tract infection (UTI) and was treated with intravenous fluids (IVF) and antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was medically necessary at an inpatient level of care. This patient with a history of DM2 and BPE presented to the emergency department (ED) with a reported high-fever, leukocytosis with left shift, elevated lactate and tachycardia with evidence of a urinary tract infection. He was provided with intravenous antibiotics and hydration, to which the patient responded well. This patient met sepsis criteria with tachycardia, leukocytosis and a fever, increasing the clinical risk of monitoring this patient at a lower level of care than inpatient, especially given his history of diabetes, concomitant acute kidney injury, and hypotension. He required close monitoring, aggressive IV hydration, intravenous antibiotics, and cultures to ensure that his sepsis was adequately controlled, his lactate was down-trending, and that he did not become more hemodynamically unstable. Overall, this patient required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes
Treatment: Continuous glucose monitoring device (CGM)
The insurer denied the continuous glucose monitoring device (CGM).
The health plan's determination is overturned. 

This is a male with type 2 diabetes, hyperlipidemia, hypothyroidism, and status-post kidney transplant. Hemoglobin (HGB) A1C was 10.9%. The patient is on Toujeo and three rapid-acting insulin doses with meals per day. He is testing his glucose on average 2.7 times per day. The request for a Guardian continuous glucose monitor is under review.

Continuous Glucose Monitoring (CGM) Device is medically necessary for this patient. This patient has uncontrolled type 2 diabetes on multiple daily insulin injections with a very elevated HGB A1C level of 10.9%. In this clinical situation, as outlined above, the use of continuous glucose monitor (CGM) has been shown to reduce hyperglycemia. Without CGM, this patient is at risk of ongoing hyperglycemia which would increase his risk for retinopathy, neuropathy, and worsening nephropathy. Therefore, the requested continuous glucose monitor is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Retroperitoneal lymph node
Treatment: PET (positron emission tomography) scan with CT (computed tomography) for attenuation 
The insurer denied PET scan with CT for attenuation. 
The determination is upheld.

This is a female patient who was seen by gynecologic oncology regarding a pelvic mass. It was noted that the patient received a positron emission tomography (PET) scan which showed a small nodule in the retroperitoneum on the right side measuring approximately 2.5 centimeters (cm) in largest dimension. It was felt that the mass was most likely benign, however, removal was recommended. Included in the note is a conventional computed tomography (CT) scan which also reported a soft tissue nodule in the right retroperitoneum measuring 15 x 25 millimeters (mm). The PET scan is noted to have been performed which again reported a soft tissue nodule measuring 2.3 x 1.6 cm adjacent to the right ureter. The note states that there is a plan for laparoscopic resection of the pelvic mass as well as for tumor markers.

The patient was seen in the office again noting that she had been doing well since surgery. She was noted to have benign findings. It was noted that the retroperitoneal lymph node visualized on PET scan was not visualized in surgery, and there was concern expressed that it could represent a lymphoma or other evidence of malignancy. Therefore, a repeat PET CT is requested. The final pathology was consistent with a mucinous cystadenoma. An appeal was placed on behalf of the patient stating that the patient preoperatively had a PET avid lymph node that was not visualized intraoperatively, so a PET scan is requested to evaluate if the node is still visualized. It states that it will prompt CT-guided biopsy if visualized. At issue is the medical necessity of the requested service.

The requested PET scan with computed tomography (CT) for attenuation is not medically necessary for this patient. The mass of concern, presumed to be retroperitoneal lymphadenopathy, was visualized on a conventional CT scan preoperatively. Therefore, if the need is present for surveillance of this mass, then a conventional CT would provide information regarding any change in size, any change in characteristic concerning for malignancy and/or new sites of disease. Conventional CT would be adequate for this patient's needs, therefore the PET scan is not demonstrated to be medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: atopic dermatitis.
Treatment: Dupixent.
The insurer denied Dupixent. 
The health plan's determination is upheld.

The patient is a female with atopic dermatitis (AD). She has tried and failed triamcinolone and clobetasol. She has also failed betamethasone and lidex cream. The medication under review is Dupixent.

Dupixent is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed or has a contraindication to the preferred therapy phototherapy. Phototherapy has been well-documented as an efficacious, safe treatment for eczema, as in this patient.
Meduri et al writes in "Phototherapy in the management of atopic dermatitis: a systematic review" that "narrowband (NB) ultraviolet B (UVB), should be used for the management of chronic AD". Sidbury et al writes "NB-UVB is generally the most commonly recommended light treatment by providers when considering its low risk profile, relative efficacy, availability, and provider comfort level". Therefore, Dupixent prior to a trial of UVB phototherapy is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dementia, pneumonia

Treatment: Personal Care Aide Level 2: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week - a total of 168 hours per week (split shift)

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

The denial is modified

 
This is an elderly patient with chronic medical problems.  She was recently hospitalized and treated for pneumonia.  She lives with her husband, who reportedly has dementia.  The insurer approved 11 personal care aide (PCA) hours/day, 6 days/week and 7.5 hours/day, 1 day/week (totaling 73.5 hours/week).  The request is for PCA 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 Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "modified independence."  She is totally dependent to maximal assistance for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  She requires maximal assistance for bathing, personal hygiene, dressing, bed mobility, locomotion and toilet transfer/use.  She requires extensive assistance for eating.  The patient is frequently incontinent of bladder and infrequently incontinent of bowel.  There have been no reported falls over the prior 90 days.  The patient's functional ability has reportedly declined since her recent hospitalization and treatment for pneumonia. However, the recent UAS is much the same as the prior report.

The patient's cognitive and functional deficits are not at a level or unpredictable as to require the requested PCA services 24 hours/day (split shift).  However, based on the records reviewed, a live-in PCA would be appropriate as they are likely capable of providing for the patient's functional needs and have the ability to consistently obtain an 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 by the provision of a live-in PCA Per Diem- 7 days/week- a total of 7 days/week.  

Based on the above, the insurer's denial must be modified. 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 Aide Level 2: 12 hours per day - 7-day(s) per week; 12 hours per day - 7-day(s) per week - a total of 168 hours per week (split shift) is not substantiated. However, a live-in personal care aide (PCA) Per Diem- 7 days per week- a total of 7 days/week is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity.
Treatment: Mounjaro.
The health plan denied: Mounjaro.
The determination is: Overturned.

The patient is a male with a history of metabolic syndrome, hypertension, mixed hyperlipidemia, coronary artery disease, and obesity. He has been treated with Ozempic 2 milligrams (mg) weekly for weight loss. He has lost 37 pounds in the past 12 months; however, his weight has plateaued for the at least the past five months. He has been prescribed Mounjaro for the treatment of his obesity.
At issue is the non-formulary drug Mounjaro.
The health plan's determination is overturned in whole.
The formulary alternatives are Ozempic, Rybelsus, Trulicity and Victoza. All are members of a class of drugs called glucagon-like peptide 1 (GLP-1) agonists. They are Food and Drug Administration (FDA) approved for the treatment of type 2 diabetes. In addition, they all have been shown to aid in weight loss. Ozempic (semaglutide) is considerably more effective in facilitating weight loss than the other alternatives and is frequently prescribed off-label for this indication. In a large double-blind trial, patients treated with a weekly 2.4 mg dose of semaglutide (labelled as Wegovy) had a mean change in body weight from baseline to week 68 of 14.9 percent (%) as compared with 2.4% in patients treated with placebo. This patient has already been treated with Ozempic and, while he initially had a favorable response, his weight has now plateaued. Mounjaro (tirzeptatide) is a dual Gastric Inhibitory Polypeptide (GIP)/GLP-1 receptor agonist approved for the management of type 2 diabetes. It has been shown to be even more effective for weight loss than semaglutide. The recently published results from a large double blind randomized controlled trial showed a 21% reduction in weight at week 72 in patients treated with 15 mg of Mounjaro weekly. Thus, Mounjaro would be expected to be more effective than any of the formulary alternatives.
The side effect profiles of the above-mentioned drugs are similar.
Appeal type: Medical necessity
Decision: Upheld

Cancer
Inpatient hospital

Diagnosis: breast cancer
Treatment: inpatient stay
the insurer denied the inpatient stay. The health plan's determination is upheld. 

This is a female who initially presented with a self-detected axillary lymph node. She underwent diagnostic workup that showed a poorly differentiated triple negative breast carcinoma metastatic to axillary nodes. She underwent neoadjuvant chemotherapy. She then underwent simple mastectomy and axillary node dissection.

The inpatient hospital stay was not medically necessary. The patient was admitted post-operatively status/post mastectomy but had no complications intraoperatively. The procedure was not prolonged. She had no perioperative risk factors. She was not a high anesthesia risk and had no drug-related risks. She had no comorbid conditions. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart Disease. 
Treatment: Myocardial perfusion imaging. 

The health plan denied myocardial perfusion imaging. 
The determination is overturned. 

The patient is a male with a past medical history significant for coronary artery disease (CAD) status/post percutaneous coronary intervention (PCI) (Left circumflex artery PCI with right coronary artery chronic total occlusion and moderate left anterior descending artery disease), diabetes mellitus (DM) type 2, hyperlipidemia, obstructive sleep apnea (OSA), and peripheral arterial disease (PAD). He underwent an electrocardiogram (ECG) stress test in which the patient exercised for 6 minutes and 43 seconds and achieved a maximal predicted heart rate (MPHR) of 97 percent (%), with metabolic equivalents (METs) of 7.7. The patient reported no chest pain at peak exercise. The stress test report indicated there were no significant ST (segment)-T wave changes on ECG, but given baseline abnormalities, the test was deemed equivocal for ischemia. His Duke treadmill score was 6, indicative of low risk for cardiovascular events. Given these findings, the patient's provider has ordered a nuclear myocardial perfusion imaging stress test for further assessment of coronary artery ischemia. 

At issue is the medical necessity of the myocardial perfusion imaging. 

The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of myocardial perfusion imaging is medically necessary for this patient. This patient has significant cardiovascular disease including multivessel CAD with prior PCI. Initially, the patient completed an ECG stress test for evaluation of coronary ischemia. The results of which were personally reviewed and were indeterminate for coronary ischemia given the baseline ECG ST-T wave abnormalities. For this reason, the patient's treating cardiologist has appropriately ordered a nuclear myocardial perfusion imaging stress test for further evaluation of inducible myocardial ischemia. In this case, nuclear myocardial perfusion imaging is medically appropriate and necessary in this to exclude coronary ischemia as the etiology of the patient's exertional shortness of breath which may be an anginal equivalent given the indeterminate ECG stress test results. Furthermore, nuclear myocardial perfusion imaging stress test in this case would be recommended by both the 2021 American Heart Association (AHA)/American College of Cardiology (ACC) guidelines for the evaluation and diagnosis of chest pain and ACC/AHA/American Society of Nuclear Cardiology (ASNC) guidelines for the clinical use of cardiac radionuclide imaging for evaluation of coronary ischemia in this case [1, 2].
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Nasal Polyps. 
Treatment: Xhance 93 mcg (micrograms) spray. 
The health plan denied coverage for Xhance 93 mcg spray. 
The reviewer has overturned in whole the health plan's determination. 

The patient is seeking approval for Xhance spray for nasal polyps. The patient is appealing for approval of Xhance 93 micrograms (mcg) Spray. The patient trialed Flonase for an extended period of time without significant relief. He has a history of chronic rhinitis. Office note noted a deviated septum. This note stated the patient gained significant relief from Xhance. 

The non-formulary drug would be more effective for this patient. 
The patient does meet coverage criteria for Xhance as the patient has experienced inadequate treatment response to an alternative intranasal corticosteroid with Flonase. This fulfills the health plan criteria for use. According to current literature, intranasal corticosteroids is standard treatment of chronic rhinosinusitis in addition to nasal polyps. It is reasonable to use this medication for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Home health care
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 20 Hours per Day, 7 Days per Week - for a Total of 140 Hours per Week. The health plan's determination is upheld. 

This is a case review for a male with medical history notable for vascular dementia, Alzheimer's disease, mobility issues, and wandering. The request for additional hours states that the increase is necessary for the following reasons: "Aggressive and very strange behaviors; hurting himself; progressing confusion; worsening memory; falling frequently; not enough sleep."

The requested Consumer Directed Personal Assistance Program (CDPAP) Services: 20 Hours per Day, 7 Days per Week - for a Total of 140 Hours per Week is not medically necessary for this patient.
The patient has worsening dementia and is exhibiting wandering and other behaviors. The increase in hours was requested primarily to address these behaviors and for safety monitoring. Personal care aide hours are not allowable for the sole purposes of safety monitoring and security in the absence of performing another personal care function. There is no documentation that the patient has any personal care needs (e.g. toileting) that are not being met with his current allotment of hours. Although he may require increased supervision as recommended by his physician for safety monitoring, this is not sufficient justification for the medical necessity of an increase in CDPAP hours. Therefore, there is insufficient evidence to justify the medical necessity of the increased hours.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Epilepsy (intractable w/o status epilepticus).
Treatment: Formulary exception for Briviact 75 Milligram Tablet.
The insurer denied: Formulary exception for Briviact 75 Milligram Tablet.
The denial is overturned.

The patient is an adult female with seizure disorder. She has tried and failed lamotrigine, levetiracetam, carbamazepine, cenobamate, and lacosamide. The provider has requested Briviact.

The health plan should cover the Formulary Exception for Briviact.

The patient has tried and failed at least three preferred formulary medications (clonazepam, levetiracetam, carbamazepine, lacosamide, and lamotrigine) without adequate control of her seizures. Briviact is FDA (United States Food and Drug Administration) approved for her condition (Steinhoff and Staack, 2019). Further trials of the preferred agents are not warranted here. Therefore, given the above, the health plan should cover the Formulary exception for Briviact.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: leg pain
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

This case involves a woman admitted to the hospital with left lower extremity pain and swelling for two days. The patient had a more difficult time walking and typically ambulates with two canes. She reported stopping all home medications. Additionally, she reported sore throat congestion and fever, attributed to an upper respiratory infection, which improved with supportive care. She was assessed in the emergency department with a duplex study, which was negative for deep vein thrombosis (DVT). Lasix was offered to improve the edema, but she declined. The staff found her bed sheets saturated in urine, but she would not allow the linens to be changed or rolled over. The nursing staff reported she has homicidal ideation towards her mother with a plan to hit her over the head with a cane. During the interview, she became agitated when talking about her mother but was redirectable.

The inpatient hospital admission was not medically necessary. The patient has chronic lymphedema without evidence of deep vein thrombosis (DVT) or heart failure. There was no visible trauma or radiographic evidence of fractures of the legs. Vital signs were stable, and labs were unremarkable. In addition, she did not qualify for inpatient psychiatric admission, as she was not actively homicidal or suicidal, and her aggressive behavior was attributed to her schizoaffective disorder and likely personality disorder. The medical work-up qualified for a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: Braces and Monthly Visits
The insurer denied: Braces and Monthly Visits
The denial is overturned.

The patient is an adolescent male requesting orthodontic treatment. The patient has a skeletal Class I malocclusion, moderate upper and lower crowding, deep bite, and left posterior crossbite. The prior denial was due to a score of 21 on the handicapping index scale.  

The proposed treatment is medically necessary.

Although the patient only had a handicapping index score of 21, his upper lateral incisors and his lower canines (teeth #'s 7, 10, 22 and 27) are all in crossbite. When anterior teeth like these are in crossbite with gingival attachment loss and recession, it is an automatic qualifier for treatment (benefits). The patient has medical necessity and orthodontic treatment is needed to correct these problems.