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

Diagnosis:  Chronic Obstructive Pulmonary Disease (COPD).
Treatment: Personal Care Aide (PCA) 10 hours per day, 7 days a week.
The insurer denied Personal Care Aide (PCA) 10 hours per day, 7 days a week.
The denial is overturned.

This is a case review for a female with medical history notable for chronic obstructive pulmonary disease on oxygen, chronic kidney disease, heart failure, arthritis, stage 2 sacral pressure ulcer, type 2 diabetes, and coronary artery disease. The patient is approved for 8 hours per day, 7 days per week (56 hours per week) of personal care aide services. The patient and her care team requested an increase to 10 hours per day, 7 days per week (70 hours per week) and this request was denied by the health plan. This denial is the subject under review.

A letter of medical necessity was provided by the patient's physician. The letter states that the patient was hospitalized three times and has had a medical and functional decline. One of these hospitalizations was the result of a fall. The physician stated that with her worsened condition, all of her functional needs for her activities of daily living (ADLs) are not being met, and they requested an increase in personal care aide hours.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone. She was alert and oriented times three with minimally impaired cognition. She is able to direct her own care. For her Instrumental activities of daily living (IADLs), she requires total dependence for housework and shopping. She requires maximal assistance for transportation, stairs, and meal preparation. She requires extensive assistance for finances, medication, and phone use. For her ADL's, she requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, and locomotion. She requires limited assistance for bed mobility and eating. She is incontinent of urine and stool and uses pull-ups and Chux for management. A task tool associated with the assessment recommended 6 hours and 23 minutes per day to address her personal care needs.

The health plan's determination is overturned.

The requested health service of Personal Care Aide (PCA) 10 hours per day, 7 days a week is medically necessary for this patient.

The patient has had a functional decline. She relies on personal care aides to complete nearly all ADL's and IADL's including toileting. She is not able to do this independently. She is also incontinent of urine and stool. Her physician attested that additional hours were medically necessary to meet her personal care needs. Additionally, she can be expected to have unscheduled personal care needs related to toileting. Her UAS demonstrates that she has had a decline in ability to tend to her own toileting needs. Failure to provide assistance with these needs could result in infection and/or progression of her skin ulceration.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is upheld.

This is a male patient with a history of obesity, osteoporosis, kidney stones, and hyperlipidemia. The patient is requesting continued coverage for Wegovy. Continued coverage was declined because the plan did not receive weight data from the patient's provider documenting 5 percent (%) weight loss with initial treatment and continuation of at least 5% weight loss after the initial treatment. The only medical record provided by the patient's provider was a progress note. Wegovy was not listed in the active medications, and a weight of 191 pounds was documented. The information provided in the case materials includes a several page list of weights and different medications. The initial weight was listed as 193 pounds and later was noted as 181 pounds. It also appears that the patient was on Mounjaro in October, not Wegovy. However, it does not appear that this list was created or certified as accurate by the patient's provider. At issue is the medical necessity of Wegovy.

The requested health service/treatment of Wegovy was not medically necessary for this patient. The only weight documented by the patient's provider was 191 pounds. There are no other weights clearly documented by the patient's provider. Many weights were provided. Regardless of the origin of the data, there is no documentation that the patient has maintained 5% loss of the baseline weight. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the Wegovy was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Macromastia.
Treatment: Breast reduction surgery.
The insurer denied coverage for breast reduction surgery.
The denial is upheld. 

Medical necessity for the breast reduction is not established. According to the plastic surgeon's consultation note, this patient complains of neck and back pain due to large breasts. These are the typical complaints of women who suffer from macromastia. Photos, however, are not provided for review. A work-up for other possible causes of the symptoms is not documented, and the patient has not seen a musculoskeletal specialist. The patient reports a history of conservative treatment with support bras and non-steroidal anti-inflammatory drugs (NSAIDS). The records, however, do not include any Primary Care Provider (PCP) notes that document attempts at medical treatment for chronic musculoskeletal pain such as chiropractic care, physical therapy, analgesics, or support bras. Confirmatory evidence of symptoms, such as a history of conservative therapy, photographic evidence of severe breast hypertrophy or a history of frequent primary care physician visits for musculoskeletal symptoms is necessary to support the history provided by the plastic surgeon. Other than the history of symptoms provided by the patient to the plastic surgeon, the records do not provide any documentation that supports a need for a reduction mammoplasty. If they exist, records documenting conservative care or physician visits for musculoskeletal pain should be submitted.  

The information provided in the records is not sufficient to confirm that breast reduction is medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for breast reduction surgery is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial numbness
Treatment: Inpatient stay
The insurer denied an inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns of left facial numbness. Pertinent history included right thalamic hemorrhagic stroke with residual left-sided weakness and sensory loss. Initial vital signs revealed a temperature of 98oF, heart rate (HR) 89, blood pressure (BP) 139/95, respiratory rate (RR) 18, and peripheral capillary oxygen saturation (SpO2) 95% (percent) on room air. Initial examination documented the patient as alert, oriented, with decreased sensation of left face in all dermatomes. Initial laboratory testing was relatively unremarkable. A computed tomography (CT) head did not reveal an acute abnormality, but did note a chronic right thalamic infarct and left basal ganglia infarct. 

Based on the clinical documentation provided, evidence based literature and standards of care, an inpatient hospital admission was not medically necessary. The patient had a history of a right thalamic stroke with residual left sided weakness and numbness who presented with left sided facial numbness. A comprehensive evaluation including a computed tomography (CT) head, CT perfusion, computed tomography angiography (CTA) brain/neck, magnetic resonance imaging (MRI) brain, and MRI orbits were performed and essentially unremarkable for an acute pathological process. Treatment plan consisted of the aforementioned diagnostic testing and initiation of gabapentin. Neurology consulted and felt the presenting symptoms were residual from the previous stroke. Following observation care, the patient was cleared for discharge. No other acute issues or complications were documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sickle cell disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
The patient has hemoglobin sickle cell (Hgb SS) disease and presented to the emergency room with chest pain, cough and body aches. She was noted to be anemic with a Hemoglobin (Hgb) of 6.4 and a Heart rate of 103. She has failed home medications. She was admitted for an uncomplicated pain crisis with intravenous (IV) hydration and oxygen. She left against medical advice (AMA).

This individual could have been initially managed at a lower level of care. She presented with an uncomplicated pain crisis. An uncomplicated sickle cell pain crisis does not require acute level care and can initially be managed in an observational setting. As this patient had a condition that could reasonably be expected to be stabilized within 24 hours, observational status would be appropriate.

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

Diagnosis: Deep vein thrombosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This case involves an adult under review for inpatient hospitalization for deep vein thrombosis (DVT).  Emergency department (ED) note reported the patient presented with leg pain and swelling since the previous week.  The patient denied any injury.  Past medical history was significant for chronic DVT status post inferior vena cava (IVC) filter.  Physical examination noted tenderness.  Ultrasound noted acute DVT in the left popliteal vein and posterior tibial vein.  Treatment plan was for admission.  History and physical reported the patient flew from Dallas to New York approximately 2 weeks ago and started experiencing pain.  The patient had a history of a blood clot in the right leg 10-12 years ago with IVC filter in place.  The patient was treated with Lovenox.  The patient was discharged with improved pain.  The patient was started on Lovenox and switched to Eliquis.  

Milliman Care Guidelines (MCG) recommends inpatient admission for DVTs when the patient is at high risk for acute complications, limb-threatening thrombosis, thrombolysis or pharmaco-mechanical thrombectomy needed, inferior vena cava filter placement appropriate, inpatient anticoagulation needed, pregnancy and planned delivery, severe pain requiring acute inpatient management, significant bleeding, or allergic, autoimmune (thrombocytopenia), or coagulopathic reaction in response to anticoagulation. 

In this case, the patient had evidence of a new acute DVT in the left leg. There was a history of DVT in the right leg with IVC filter in place. The patient was treated with Lovenox and switched to Eliquis. The diagnostic workup and treatment could have been completed under observational level of care. 

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

Diagnosis: Dehydration

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

This is an infant with no past medical history who was having a cough, rhinorrhea, and fever for 3 days. The child was not drinking and had not finished one bottle of apple juice during the day. The mother also noted that there was only one wet diaper during the day, so the mother decided to bring the child to the Emergency Room (ER) for evaluation. 

In the ER the infant was noted to be crying and producing tears. The child had a fever of 103 degrees and appeared pale and tired. On physical examination the infant was not in respiratory distress with no increased work of breathing, but the mucous membranes were noted to be dry. Blood testing was unremarkable with a serum bicarbonate (HCO3) of 23. A respiratory viral panel was positive for respiratory syncytial virus (RSV). The infant received 2 intravenous (IV) boluses of normal saline and when the child did not increase oral intake of fluids the decision was made to admit to the hospital for continued IV fluids with a diagnosis of dehydration.

The medical record documents that the patient had a mild degree of dehydration with tears and a HCO3 of 23. This child received two bolus treatments of normal saline in the ER which is the standard of care for the treatment of acute dehydration. There was no additional documentation of a repeat physical examination to document an improvement of the hydration status and whether the child had produced urine. When a child is being evaluated in the ER for dehydration it is the standard of care to treat with multiple IV boluses of normal saline, begin oral rehydration with sips of water, Pedialyte and soft foods like jello and apple sauce. It is then the standard of care to monitor the urine output and urine specific gravity to document a response to therapy. The only record of a urine specific gravity was noted to be 1.015. With oral rehydration and fever control with acetaminophen this child could have been safely discharged home with a follow up with the pediatrician in 24-48 hours. The medical record does not support the medical necessity for admission for mild dehydration.

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: Cellulitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This patient is an adult female with a history of polysubstance abuse who presented with bilateral antecubital fossa pain and erythema. Symptoms began after injecting cocaine. Vital signs were stable. The patient's temperature was 100. Her exam showed bilateral antecubital fossa swelling and erythema with discharge on the left. Her pertinent labs revealed a white blood cell count (WBC) of 16.6. Her upper extremity ultrasound did not show deep vein thrombosis. 
The patient was admitted with cellulitis. The plan of care included intravenous antibiotics. On the next day, a wound care consult identified an abscess in the left antecubital fossa and recommended incision and drainage. Infectious disease consult recommended continuation of intravenous antibiotics. The patient left against medical advice.

The proposed treatment is not medically necessary.

Indications for inpatient care of cellulitis include severe infection; suspicion of deeper or rapidly spreading infection; tissue necrosis; marked systemic toxicity or worsening symptoms that do not resolve after 24-48 hours of therapy; or patients with underlying risk factors or severe comorbidities. This patient does not meet criteria for inpatient admission. The patient did not have evidence of severe infection, spreading infection, tissue necrosis or systemic toxicity. In addition, the patient did not have severe comorbidities nor had the patient failed treatment at a lesser level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent 300 milligrams (mg) /2 milliliters (ml) syringe
The insurer denied the Dupixent 300 mg/2 ml syringe.
The determination is overturned.

This is a female patient with severe atopic dermatitis (AD). She has tried and failed clobetasol and intralesional triamcinolone. The prescriber is a dermatologist. The medication under review for medical necessity is Dupixent 300 milligrams (mg) /2 milliliters (ml) syringe weekly.

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary. The patient has tried and failed biweekly Dupixent. There are limited other systemic therapies approved for use in atopic dermatitis. In 2019, Thibodeaux et al published "A review of dupilumab in the treatment of atopic diseases." in which they demonstrated that weekly dosing of Dupixent had significant efficacy (1). Beck et al also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis" (2).

Deleuran et al writes "This first-step analysis of a long-term, open-label study of dupilumab 300 mg weekly in patients who previously participated in randomized, double-blinded, placebo-controlled clinical trials of dupilumab is, to our knowledge, the longest published study with a systemic drug in adults with AD to date and the first report of dupilumab safety and efficacy beyond 52 weeks of treatment...the safety and efficacy profile from this study supports the role of dupilumab as continuous long-term treatment for patients with moderate to severe AD" (3). Therefore, it is appropriate, based on the patient's clinical findings and refractory disease for weekly Dupixent in this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoporosis, Alzheimer's. 
Treatment: Personal care aide (PCA) services 5.5 hours per day, 7 days per week, for a total of 38.5 hours per week. 

The insurer denied coverage for personal care aide (PCA) services 5.5 hours per day, 7 days per week, for a total of 38.5 hours per week. 

The denial is overturned. 

The patient is a centenarian with osteoporosis and Alzheimer's disease. The patient lives with spouse and son in a private residence. The insurer approved Personal Care Aide (PCA) services 5.5 hours per day, 4 days per week for a total of 22 hours per week. The request is for 5.5 hours per day, 7 days per week for a total of 38.5 hours per day. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as moderately impaired, decisions consistently poor or unsafe; cues/supervision required at all times. The patient is totally dependent for much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient requires extensive assistance for bathing, personal hygiene, lower body dressing, locomotion, ambulation and toilet transfer/use. The patient is frequently incontinent of bladder and infrequently incontinent of bowel. Limited assistance is needed for upper body dressing and bed mobility. The patient's functional ability has declined when compared to the previous UAS report. The patient's functional needs are daily and not just 4 days per week as approved by the insurer. It has also become more difficult for the patient's elderly spouse to assist. The patient's condition and functional deficits are at a level and unpredictable as to require the requested 5.5 hours/day, 7 days/week for a total of 38.5 hours/day. Based on the enclosed documents reviewed, the patient's health and safety can be more appropriately provided and maintained by the increasing PCA services to 5.5 hours/day, 7 days/week for a total of 38.5 hours/day. 

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

From a physical medicine and rehabilitation perspective, the requested PCA services 5.5 hours per day, 7 days per week, for a total of 38.5 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 personal care aide (PCA) services 5.5 hours per day, 7 days per week, for a total of 38.5 hours per week is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  High Blood Pressure.
Treatment:  Edarbyclor 40/25 milligram (mg) tablet.

The insurer denied Edarbyclor 40/25 milligram (mg) tablet.  The denial is upheld.

This case involves a female with a history of systemic lupus erythematosus (SLE), dyslipidemia and hypertriglyceridemia, active smoker and hypertension currently treated with Bumex, Toprol and Edarbyclor 40/25 milligrams (mg) daily. The patient's blood pressure has been documented to be well controlled on this regimen. Records indicate prior treatment failure and or intolerance to amlodipine, Cardizem, and chlorthalidone. The patient's treating provider has prescribed Edarbyclor 40/25 mg daily; however, the patient's health plan has denied coverage for this medication, since it did not meet established criteria for benefit plan exception. According to the plan, there was no documentation of inadequate treatment response and or adverse reaction to at least 3 formulary alternatives.

The documentation provided for this review does not show currently that the patient meets the plan's established criteria for Edarbyclor as a benefit plan exception. There is no documentation that the patient has experienced an inadequate treatment response and or adverse reaction to at least 3 formulary alternatives. There is no documentation to suggest that the formulary medications will be less effective or tolerated compared to the non-formulary drug, Edarbyclor. According to the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the prevention, detection, evaluation, and management of high blood pressure in adults, any of the listed formulary angiotensin II receptor blockers (ARBs) would be medically appropriate and could be considered for this patient. (1)