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

Diagnosis: Coronary artery disease (CAD), atrial fibrillation, hypertension, cerebrovascular accident (CVA), diabetes, hypothyroidism, hyperlipidemia, dementia, osteoarthritis, and decubitus ulcer

Treatment: Personal care aide (PCA) level 2 and Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week

The insurer denied coverage for: Personal care aide (PCA) level 2 and Consumer Directed Personal Assistance Program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week

The denial is overturned

This is an elderly patient with heart disease, multiple strokes, diabetes, decubitus ulcer and dementia. She lives alone in a studio apartment. The plan approved personal care aide (PCA) level 2 and Consumer Directed Patient Assistance Program (CDPAP): 12 hours/day - 4 days/week; 12 hours/day - 3 days/week - for a total of 84 hours/week. The request is for PCA level 2 and CDPAP: 12 hours/day - 7 days/ week; 12 hours/day - 7 days/week (split shift) - for a total of 168 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as "severely impaired." She is totally dependent for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also totally dependent for bathing, personal hygiene, dressing, eating and bed mobility. She is non-ambulatory and essentially bed bound. She is incontinent of bowel and bladder. Her condition has declined compared to the prior UAS report. The patient has severe cognitive deficits, totally dependent for IADL/ADL (activities of daily living), bed bound, decubitus ulcers, multiple falls (one of which resulted in hospitalization) and completely incontinent; all of which support a condition and functional needs at a level or unpredictable as to require the requested PCA level 2 and CDPAP: 12 hours/day - 7 days/ week; 12 hours/day - 7 days/week (split shift) - for a total of 168 hours/week. The patient requires more than just safety monitoring during nighttime hours as she requires Level I or Level II personal care service tasks; given her risk for further decubitus ulcers, falls and joint contractures. 

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) level 2 and consumer direct personal assistance program (CDPAP): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Autism Spectrum Disorder.
Treatment:  Applied Behavior Analysis (ABA) behavior assessment- 12 units.

The insurer denied Applied Behavior Analysis (ABA) behavior assessment- 12 units.  The determination is overturned.

This is a male patient with a history of autism spectrum disorder. He has previously been approved for ABA (Applied Behavioral Analysis) therapy services, and the following review is evaluating the medical necessity of ABA services. A letter by his provider noted that the patient met Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) criteria for the diagnosis of autism was submitted for review. It was noted the patient had undergone clinical observation, Autism Diagnostic Interview-Revised (ADIR) interview, review of records, parent interview and the Viland-3. At issue is the medical necessity of Applied Behavior Analysis (ABA) behavior assessment- 12 units.

Yes. The ABA therapy is medically necessary. The patient has been diagnosed with autism spectrum disorder. He has had testing, which was noted to include observation, history from family as well as objective measures of anxiety, intelligence and behaviors on the autism spectrum. Per the documentation provided, it is clear that patient meets criteria for autism spectrum disorder and thus would be eligible for ABA therapy. It is the gold standard treatment for autism spectrum disorder. The patient is noted to struggle with impaired social emotional reciprocity, deficits in verbal and nonverbal communicative behaviors and restricted repetitive patterns of behaviors.
Given the above, the requested ABA therapy is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia, diabetes, hypertension, rheumatoid arthritis, overactive bladder, and unsteady gait.
Treatment:  Increase Home Care/Personal Care HHC (Home Health Care) Level 2 To 70 Hours Per Week.

The insurer denied: Increase Home Care/Personal Care HHC Home Health Care) Level 2 To 70 Hours Per Week.  The denial is overturned.

The patient is an elderly female. Her conditions include dementia, diabetes, hypertension, rheumatoid arthritis, overactive bladder, and unsteady gait. This is an appeal for denial of increase home care/personal care to 70 hours per week. The health plan approved 48 hours per week. Uniform Assessment System (UAS) evaluation completed recently shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing finances, transportation, bathing, dressing, walking, locomotion, and toileting; and extensive assistance with bed mobility and eating. The patient has frequent bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, shows decline in cognition, meal preparation, bathing, dressing, walking, locomotion, and toileting.

Appeal statements note there has been a recent decline in the patient's mental status and physical mobility. She was hospitalized and in a nursing home for three months last year after a fall resulted in a wrist fracture. Her gait has declined, and she is prone to falls. She is homebound.

The requested Increase Home Care/Personal Care HHC (Home Health Care) Level 2 To 70 Hours Per Week is medically necessary.

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 is an appeal for denial of increase home care/personal care to 70 hours per week. The health plan approved 48 hours per week.
This patient has multiple chronic conditions and hospitalization after a recent fall. Uniform Assessment System (UAS) evaluation completed recently showed the patient requires extensive assistance to total dependence with all ADLs (activities of daily living). She has frequent bowel and bladder incontinence. Compared to UAS (Uniform Assessment System) evaluation completed last year, shows decline in cognition, meal preparation, bathing, dressing, walking, locomotion, and toileting. Appeal information notes the patient's mental status and physical mobility have declined since hospital admission last year. The patient is homebound. The information provided shows that this patient has significant limitations in functioning. This patient's needs for assistance have increased between UAS (Uniform Assessment System) evaluations. The approved personal care assistance of 48 hours per week is insufficient to meet the patient's needs for assistance with all ADLs (activities of daily living). The requested increase to 70 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shock from ICD (implantable cardiac defibrillator); lightheadedness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male that presented to the hospital following three shocks from his implantable cardiac defibrillator. Accompanying symptoms included lightheadedness and dyspnea. The patient's past medical history was notable for "septal defect repair", mechanical aortic valve replacement (AVR), stoke, myocardial infarction status post revascularization and heart failure with a reduced left ventricular ejection fraction of 15% (percent). The patient also has a subcutaneous defibrillator that was implanted for primary prevention several months prior to presentation. On arrival to the hospital, the patient's vital signs were stable (blood pressure 130/91 millimeters of mercury [mmHg', pulse 85 beats per minute). Physical examination revealed clear lungs and mechanical heart valve sounds at the aortic position. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic changes. Serum blood testing revealed a potassium of 5.9 and an international normalized ratio (INR) that peaked at 4.69. Implantable cardioverter defibrillator interrogation revealed a single shock for supraventricular tachycardia and the patient was admitted to the telemetry ward for observation and treatment. The patient ultimately underwent diagnostic electrophysiologic testing and no ablation was performed. The patient was discharged on escalating doses of beta blocker therapy.

The proposed treatment was medically necessary.

This patient presented with an implantable cardioverter defibrillator shock as a result of a rapid heart rhythm. The patient has an extensive cardiac history including mechanical aortic valve replacement, myocardial infarction, stroke and heart failure with a severely reduced ejection fraction of 15%. Hospitalization for diagnostic testing and treatment is clearly needed given the increased morbidity and mortality associated with both supraventricular and ventricular arrhythmias in this patient population. (Reference 1, 2) 
This patient required additional work up to assess the nature of his arrhythmia and potentially eliminate recurrent arrhythmia that might result in additional future implantable cardioverter defibrillator therapies. The patent appropriately underwent diagnostic electrophysiologic testing and was ultimately treated with escalating doses of beta blocker therapy. This patient's comorbid conditions and presentation required a higher level of care. In conclusion, inpatient hospital admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity.
Treatment: Ozempic.
The health plan denied Ozempic.
The determination is upheld.

The patient is a male diagnosed with obesity. This request is for Ozempic. As reported, he has pre-diabetes and non-alcoholic fatty liver disease (NAFLD). He has been resistant to lifestyle therapy for over 4 years. His most recent hemoglobin A1C values were 5.6 percent (%), 5.6 %, and 5.4%. His most recent weight was 123.7 kilograms (kg); his body mass index (BMI) was 40.62.

At issue is the medical necessity of Ozempic.

The health plan's determination of medical necessity is upheld in whole.  The requested health service/treatment of Ozempic is not medically necessary for this patient.

Ozempic (semaglutide) is a glucagon-like peptide-1 receptor (GLP1R) agonist [1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity [2, 3, 4]. Recent studies published in major peer reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity [5, 6, 7]. This medication is now available for the treatment of obesity in the form of Wegovy. There are no studies showing safety or efficacy of the requested medication, Ozempic, for patients who do not have diabetes, such as this patient. There are no extenuating circumstances in this case. Therefore, the request is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Myocardial infarction, stent insertion
Treatment: Brilinta 90mg (milligrams) tablets 
The insurer denied Brilinita 90mg tablets
The determination is upheld.

This is a patient with a history of multiple myeloma/monoclonal gammopathy of renal significance, chronic kidney disease, hypertension and mitral valve disease. He had an acute inferior wall myocardial infarction due to occlusion of his right coronary artery. This was treated with a stent. He has been taking ticagrelor (Brilinta) since for prevention of in-stent thrombosis. At issue is whether the formulary drugs clopidogrel, prasugrel will be or have been ineffective, would not be as effective as the non-formulary drug, Brilinta 90 milligram (mg) tablets or would have adverse effects.

Oral P2Y12 inhibitors are routinely prescribed following acute coronary syndrome and coronary artery stent implantation. The available agents include clopidogrel, prasugrel and ticagrelor. Clopidogrel is the least potent of the three and requires a longer time to platelet inhibition after a loading dose. Thus, current guidelines recommend the latter two over clopidogrel in patients with acute coronary syndrome.

In the report by Schupke, et al, among patients who presenting with acute coronary syndromes who underwent stent implantation, the incidence of death, myocardial infarction, or stroke was significantly lower among those who received prasugrel than among those who received ticagrelor. The incidence of major bleeding was not significantly different between the two groups. In a meta-analysis involving nearly 53,000 patients with acute coronary syndrome, stent thrombosis risk was significantly reduced by both ticagrelor and prasugrel versus clopidogrel. In comparison with clopidogrel, both prasugrel and ticagrelor significantly increased major bleeding. There were no significant differences between prasugrel and ticagrelor for all outcomes explored. Thus, clopidogrel would be less effective in preventing ischemic events and stent thrombosis in this patient.

Prasugrel and ticagrelor would be expected to be similarly effective. While both would have an increased risk of bleeding compared to clopidogrel, in patients without a marked increase bleeding risk, either of these agents would be appropriate. Based on the documentation provided, prasugrel would be an acceptable alternative to the non-formulary agent.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis. 
Treatment: Inpatient Hospital Admission. 

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

The patient is an adult female with no prior history of recurrent UTIs (urinary tract infections) or stones. She presented after developing dysuria and suprapubic pain with no improvement with Tylenol. She went to an ED (emergency department) and requested removal of IUD (intrauterine device). Urine was obtained at the time of the visit, but the patient was not aware of the results. The following day she developed fever, dizziness, worsening dysuria and bilateral flank pain and presented to the ED (emergency department). On presentation, the patient had temperature of 101.4, and tachycardia, with HR (heart rate) of 118. Her blood pressure was stable. She was noted to have abdominal tenderness and bilateral flank pain. Her WBC (white blood count) was elevated at 15.6, UA (urinalysis) with > (greater than) 100 WBCs (white blood cells), many bacteria and 4-10 RBC (red blood cells), positive nitrite, moderate leukocyte esterase. Creatinine was 1.02. CT (computed tomography) scan obtained demonstrated no hydronephrosis, punctate non-obstructing stone right, no stone left, mild left perinephric stranding. The patient received Toradol, Tylenol, IV (intravenous) hydration and IV (intravenous) antibiotics. The patient was noted to have improvement in heart rate to 97 and 87. Her BP (blood pressure) remained stable, and her temperature improved to 100.9, and then 98.1. The patient was admitted for IV (intravenous) antibiotics for pyelonephritis. Her pulse remained stable the following day at 78-83, her temperature was 98.5-99, and her blood pressure was stable. Her WBC (white blood count) improved to 10.0, creatinine 0.7. The subsequent day her creatinine was 0.59 and WBC (white blood count) 7.4. Urine culture grew > (greater than) 100,000 Escherichia coli sensitive to Keflex, ceftriaxone, cefuroxime, ciprofloxacin, gentamicin, nitrofurantoin and piperacillin, and Tazo. She was discharged to home on five additional days of antibiotics. 

The acute inpatient admission was denied coverage by the health plan as not medically necessary, citing that the patient could have been managed at the observation level of care. The denial is under appeal. 

The Inpatient Hospital Admission was not medically necessary. 

This patient presented with signs/symptoms of pyelonephritis. Her tachycardia in the ED (emergency department) responded well to intravenous hydration, and she demonstrated no hemodynamic instability. Her fever in the ED (emergency department) responded to Tylenol and Toradol. She had no underlying medical conditions that complicated her medical care. The subsequent day, the patient's heart rate was normal, blood pressure was stable, and creatinine and white blood cells improved. The patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cervicalgia, pain in thoracic spine and low back pain.
Treatment:  Thoracic Spine MRI (magnetic resonance image).
The insurer denied: Thoracic Spine MRI (magnetic resonance image).
The denial is overturned.

The patient is an adult female that presented with a history of cervicalgia, pain in thoracic spine and low back pain. The patient reports the pain has not changed, and it is intense, burning and constant in the left neck/shoulder area. The patient's exam revealed hypersensitivity and patient jumping due to pain with light palpation to the left neck. Compression and distraction test is abnormal. It was noted that patient has a history of cancer and magnetic resonance image (MRI) would help potentially confirm whether or not her cancer has spread.

The proposed magnetic resonance image (MRI) is medically necessary.

Based on the provided documentation, the requested magnetic resonance image of the thoracic spine is recommended at this time, as the patient has a history of thoracic pain and reported worsening of symptoms from the most recent visit. The patient had undergone prior physical therapy. There were concerns about potential spreading of cancer, given the patient's cancer related history. As such, the request is recommended in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart failure
Treatment: skilled nursing facility (SNF) stay
The insurer denied the SNF stay. The health plan's determination is overturned. 

The patient had no prior significant medical history and was in very good health; he was a marathon runner and daily swimmer. He presented to the hospital with increasing cough and shortness of breath for the prior 3 weeks. He was found to have a large intramural thrombus, elevated troponin level, and new onset of systolic heart failure. He was hypoxic and required intubation and admission to the intensive care unit. He had a prolonged three-month hospitalization with multiple cardiac interventions. His workup revealed severe systolic congestive heart failure with new onset nonischemic cardiomyopathy. This resulted in significant weakness, 40-pound weight loss, and a stage 4 pressure ulcer. He had a percutaneous endoscopic gastrostomy (PEG) tube placed for dysphagia and muscle wasting. He was medically stabilized for discharge from the acute care hospital but had a significant functional decline after the hospitalization and was admitted to the skilled nursing facility for rehabilitation.

The requested Continued Skilled Nursing Facility (SNF) Admission is medically necessary for this patient.
The patient was in a state of good health prior to his admission to the acute care hospital. He had a prolonged hospitalization with multiple complications; he was intubated and required percutaneous endoscopic gastrostomy (PEG) tube placement, lost significant muscle mass, developed a stage 4 sacral pressure ulcer, and underwent numerous cardiac procedures to treat an intramural thrombus and new onset non-ischemic cardiomyopathy with resulting severely reduced ejection fraction. After spending nearly 3 months in the hospital and much time in critical care, it is reasonable to expect that he would require a prolonged period of rehabilitation in the skilled nursing setting. Receiving appropriate therapy after a prolonged hospitalization is an important factor in functional recovery for patients as they attempt to get as close as possible to their pre-hospital level of function. He had a significant decline in his physical status and ongoing skilled therapy was required through discharge. He required ongoing treatment for his sacral pressure wound. Therefore, the patient's ongoing stay in the skilled nursing facility was medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and Monthly Visits
The insurer denied Braces and Monthly Visits.
The determination is overturned.

This is a female patient with a Class II malocclusion with crowding and protrusive maxillary incisors. She has a 7 millimeter (mm) overjet and 4 mm overbite. She has severe maxillary crowding and severe mandibular spacing. She is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21 and 28 to correct the crowding, deep bite, protrusion. At issue is the medical necessity of braces and monthly visits.

Teeth number (#) 8 and 9 are protruding forward within the dental arch. This makes them more prone to trauma. There is strong medical evidence that that correction of patients with prominent maxillary front teeth can reduce the risk of incisor trauma. (1) Orthodontic treatment can make the teeth significantly less protrusive. If orthodontic treatment reduces the protrusion, it will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, there is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjets, which this patient has. (2) For these reasons, orthodontic treatment is deemed medically necessary.