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

Diagnosis: Dementia, legally blind, arthritis, asthma, cardiomyopathy, hypertension, and macular degeneration
Treatment: Increase in Personal Care Services (PCS) to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week
The insurer denied the increase in PCS to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week.
The denial is overturned.

The patient is an elderly female. Her conditions include dementia, legally blind, arthritis, asthma, cardiomyopathy, hypertension, and macular degeneration. Denial of an increase in personal care services (PCS) to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week is being appealed. The plan approved PCS 5 hours/day, 7 days/week, for a total of 35 hours/week.

Uniform Assessment System (UAS) evaluation performed last month shows moderately impaired cognition and functional status total dependence with housework; maximal assistance with meal preparation, managing finances, and shopping; extensive assistance in managing medications, phone use, bathing, lower body dressing, locomotion, walking, and toileting; limited assistance with phone use and upper body dressing; and supervision with bed mobility and eating. The patient has occasional bladder incontinence. Compared to functional status 4 months ago, it shows a decline in functional status with bathing, toileting, and lower body dressing.

A letter from provider notes this patient has more significant cognitive decline and loss of independent function. The patient lives alone. She has gait imbalance and is at high risk of falling. She has incontinence and requires constant attention for skin integrity. She has increasing needs for assistance with ADLs (activities of daily living). The letter recommends 24 hours, split shift care. Medical records have been provided supporting the patient's chronic conditions. 

The requested increase in PCS to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with ADLs, health maintenance activities, and routine support services. Denial of an increase in PCS to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week is being appealed. The plan approved PCS 5 hours/day, 7 days/week, for a total of 35 hours/week.

This patient has multiple chronic conditions. UAS evaluation performed last month shows the patient requires assistance with all ADLs, except bed mobility and eating. She is incontinent of bladder. Compared to UAS evaluation completed 4 months ago, there is a decline in functional status with bathing, toileting, and lower body dressing. An appeal statement from the provider notes the patient has more significant cognitive decline, bladder incontinence, loss of independent function, and increasing needs for assistance with ADLs. The approved PCS of 35 hours/week is insufficient to meet the patient's needs for assistance with ADLs. The requested increase in PCS to 12-14 hours/day, 7 days/week, for a total of 84-98 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Glioblastoma
Treatment: Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day, Live-In; 91 hours per week
The insurer denied Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day, Live-In; 91 hours per week.
The health plan's determination is overturned. 

The patient is a female with past medical history of coronary artery disease, diabetes mellitus type 2, chronic kidney disease stage II, anemia, recurrent urinary tract infection (UTI), depression, anxiety, insomnia, glioblastoma status postresection, seizure disorder, impaired cognition, and pressure ulcer of the sacrum who was admitted to rehabilitation following resection of glioblastoma.

Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day, Live-In is medically necessary for this patient.

There is documentation from the rehabilitation center as well as the insurance denial letters that the patient required moderate assistance with toileting and some assistance with transfers and mobility and therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in PCW services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day, Live-In are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decompensated Heart Failure
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The determination is overturned.

This is a male patient who presented to the emergency department (ED) complaining of dyspnea, edema and orthopnea. His medical history was remarkable for nonischemic cardiomyopathy, heart failure with reduced ejection fraction (15%), infective endocarditis, mitral and aortic valve replacement, atrial fibrillation, chronic obstructive pulmonary disease (COPD), chronic kidney disease, hypertension, hyperlipidemia, diabetes, peripheral arterial disease, polysubstance use disorder and medical noncompliance. He had been discharged from the hospital after an admission for opioid withdrawal and decompensated heart failure. He was undomiciled. His physical exam was remarkable for wheezing and lower extremity edema. An electrocardiogram showed sinus tachycardia with first degree atrioventricular (AV) block; there were T wave inversions that were new compared to prior tracings. The patient was treated with supplemental oxygen, bronchodilators and intravenous furosemide. Lokelma and insulin were administered for treatment of his hyperkalemia. He was admitted to the hospital for management of decompensated heart failure and hyperkalemia. The patient left the hospital against medical advice. At issue is the medical necessity of an inpatient stay.

Based on the documentation provided, an inpatient level of care was medically necessary.

This patient presented to the hospital with decompensated heart failure. He had multiple high risk features. He had a history of chronic kidney disease (CKD). His serum creatinine level was increased compared to his baseline and increased further during his admission. In heart failure patients, preexisting CKD as well as acute kidney injury in the setting of CKD have been associated with an increased risk for in-hospital mortality, prolonged hospital stay and failure for renal function to return to baseline levels. He was hyponatremic with a serum sodium level of 134 mmol/L (millimoles/liter). Hyponatremia in patients hospitalized with heart failure decompensation is associated with increased in-hospital and post-discharge mortality, prolonged hospital length of stay, and frequent rehospitalization. His markedly elevated BNP (brain natriuretic peptide_ level was a negative prognostic indicator. In the Acute Decompensated Heart Failure National Registry (ADHERE) registry, admission BNP values in the highest quartile [BNP greater than or equal to 1730 pg/mL (picograms/milliliter)] were associated with a 2.23-fold increase in in-hospital mortality compared with BNP in the lowest quartile (less than (<) 430 pg/mL), even after adjustment for potential confounders and regardless of ejection fraction. This patient's anemia and hyperkalemia were additional high risk features. Given his risk for major adverse events, he required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left shoulder pain.

Treatment: arthroscopy, shoulder, surgical; biceps tenodesis (procedure code 29828).

The insurer denied coverage for arthroscopy, shoulder, surgical; biceps tenodesis (procedure code 29828).

The denial is upheld.
 

This is the case of a patient with a history of left shoulder pain. Per the office visit, the patient has been having symptoms for 1 year. The pain is moderate with a rating of 8/10. The symptoms are constant and has clicking, popping, weakness, and giving way to the left shoulder. According to the clinical notes the patient had physical therapy. An MRI (magnetic resonance imaging) of the left shoulder showed a focal tear of the supraspinatus tendon at the footprint, partial tearing of the infraspinatus tendon, evidence of minimal focal low grade partial tearing of the subscapularis tendon at the footprint and question of an anterior labral tear.

The medical records were inconsistent to substantiate the necessity of surgery. An operation is necessary if there is a defined pain generator and failure to improve with conservative treatment. The facts are the patient has chronic neck pain with radicular symptoms. He has had placement of a spinal cord stimulator and rhizotomy. He was evaluated on several occasions over years and found to have limited to no objective findings of shoulder pathology, i.e. No areas of tenderness, normal motion and normal strength. He was reported to have an impingement sign which is clearly subjective and more than likely related to his radicular complaints (clinical correlation supports this). 

His MRI findings would be more consistent with a degenerative process. He has sustained no trauma and it would be extremely unlikely to have a symptomatic SLAP (Superior Labrum Anterior and Posterior) tear. It is a well-known fact many people over 50 have asymptomatic rotator cuff tears. Once again, no trauma occurred which could result in the damage reported. 

The final aspect is he had received two cortisone injections over a period of a year. He did not receive other conservative treatments. Notes reflect that patient did physical therapy on his own and one note indicates referral for physical therapy. However, no specifics are provided in the submitted materials. 

Based upon the clinical presentation (i.e. chronic cervical radicular pain syndrome, ill-defined pathology consistent with degenerative disease and no data confirming a formal period of physical therapy,  the surgery should be denied. 

There were no extenuating circumstances to substantiate necessity of operative intervention. 

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 arthroscopy, shoulder, surgical; biceps tenodesis (procedure code 29828) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity and Pre-diabetes.
Treatment: Ozempic 0.25 OR 0.5 Pen INJCTR.
The insurer denied the Ozempic 0.25 OR 0.5 Pen INJCTR.
The denial has been upheld. 
The proposed treatment is not medically necessary.

This patient is a male diagnosed with obesity and pre-diabetes. This request is for Ozempic. As reported, the patient has nonalcoholic fatty liver disease (NAFLD). His Autism limits his ability to tolerate dietary changes.  The patient's glycated hemoglobin (A1C) late year was 5.7 percent; on middle of last year was 6.0 percent; and beginning of last year was 5.5 percent.

Semaglutide is a glucagon-like peptide one 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 for patients who do not have diabetes such as this patient. There are no extenuating circumstances in this case. The request is not medically necessary.

The health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Tract Infection
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.  The denial has been upheld. 

The proposed treatment was not medically necessary.

The patient is a female with no significant past medical history who presented to the Emergency Department (ED) with abdominal pain, nausea, and vomiting and was found to have a urinary tract infection. The patient did not meet sepsis criteria because even though she had leukocytosis and lactic acidosis, she was afebrile with a normal heart rate, respiratory rate, and mental status. Her renal function was normal. Computed tomography (CT) of the abdomen and pelvis were suspicious for cystitis and ascending pyelitis. On physical examination, the patient was tender in the right lower quadrant and suprapubic area with rebound tenderness.  She was admitted and started on intravenous (IV) fluids and intravenous ceftriaxone. The patient continued to require intravenous Zofran for nausea and vomiting. She was seen in consult by an Infectious Disease specialist. She required intravenous Toradol for her ongoing abdominal pain. On the day of discharge from the hospital, urine culture was final with susceptibilities and the patient was discharged on oral cefpodoxime to follow up with her primary physician (MD).

Per the Milliman Care Guidelines (MCG): Urinary tract Infection (UTI) - Inpatient care is required when a patient has urinary tract infection which is complicated by one or more of the following: hemodynamic instability, altered mental status, persistence or worsening of clinical finding (e.g. fever, pain, vomiting) despite observation care, pregnancy with suspected pyelonephritis, kidney transplant patient, significant uropathy, infection of indwelling prosthetic device, ureteral obstruction, impaired bladder emptying, renal or perinephric abscess, emphysematous pyelonephritis or cystitis, pyonephrosis, or acute renal failure.

This patient did not meet any of the above criteria and therefore, did not require an acute inpatient level of care.       

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

The patient could have been managed the same way with a lower level of care. She did not meet the plan criteria for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vascular ring compression.

Treatment: Durable medical equipment EO483RR x 3.

The insurer denied coverage for durable medical equipment EO483RR x 3.  The denial is upheld.

This is a young male child who was diagnosed with a vascular ring compressing his trachea. He has developmental delay, allergies and a history of pneumonia 2 years ago. He was hospitalized for one day in the past for a respiratory infection with the Respiratory syncytial virus (RSV) virus. He has had a chronic cough, and the cough resolved after he was treated with an antibiotic for otitis media. He also has obstructive sleep apnea.

He had a right aortic arch and persistent left sided retrocardiac opacity on his chest X-ray, and a chest computed tomography (CT) scan showed atelectasis. The chest CT scan also showed an aberrant right subclavian artery and mild compression of the trachea. The surgeon had recommended surgery, but the mother was not willing for this child to have the surgery.

The note from the appeals specialist indicated that he failed treatment with symbicort, duoneb, oxygen, albuterol, prednisone and manual chest physical therapy.

The child has a chronic cough which improved with antibiotics, administered for an ear infection. He has not had frequent admissions to the hospital for respiratory illnesses. He has not required a bronchoscopy to evaluate the degree of tracheal compression from the vascular ring. There is no evidence of bronchiectasis on his chest CT scan. There is no documentation that the mother has been performing manual chest physical therapy for her child. The medical record does not document that this child failed the treatments mentioned in the note from the appeals specialist which produces the durable medical equipment vest.

If the vascular ring is causing significant compression of the trachea, then the appropriate therapy is surgery to address the vascular ring and relieve the compression of the trachea. 

The VEST airway clearance device is considered an appropriate treatment for administering chest physical therapy in the home, and it is known to be an effective therapy for children with recurrent respiratory infections that result in recurrent pneumonia and bronchiectasis. The medical record does not support the need for ongoing daily treatment with the VEST high frequency airway clearance device in the home.

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 durable medical equipment EO483RR x 3 services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial Fibrillation. 
Treatment: Inpatient Hospital Admission. 

The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld. 

The patient is a male who presented to the hospital for elective catheter ablation of paroxysmal atrial fibrillation (AF). His medical history was remarkable for coronary artery disease, percutaneous coronary intervention, recovered cardiomyopathy, obstructive sleep apnea, obesity, ventricular ectopy and no sustained supraventricular tachycardia. All four pulmonary veins were successfully isolated. A slow pathway and right ventricular outflow tract premature ventricular complexes were also ablated. The procedure was uncomplicated. The patient was admitted to the hospital post-procedure. He remained in sinus rhythm and hemodynamically stable overnight and was discharged. 

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

The inpatient level of care was not medically necessary. This patient presented for catheter ablation for AF. Pulmonary vein isolation (PVI) was performed successfully along with slow pathway ablation as well as ablation of ventricular ectopy originating in the right ventricular outflow tract (RVOT). Uncomplicated slow pathway ablation and ablation of RVOT foci are commonly performed on an outpatient basis. 
Given the complexity of AF ablation, with transseptal punctures, catheter manipulation and ablation within the left atrium, full dose anticoagulation, and the proximity of the ablation lines to the esophagus, the complication rate is higher than that of catheter ablations for other supraventricular arrhythmias. Accordingly, despite at least two reports demonstrating the safety of same day discharge after PVI, many electrophysiologists admit patients for overnight observation post-procedure. This patient's procedure was uncomplicated, and he was hemodynamically stable. 

The health plan's determination of medical necessity in upheld in whole.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder. 
Treatment: Adderall XR. 

The insurer denied coverage for Adderall XR. 

The denial is upheld. 
 
This adult reportedly had attention issues and had a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD)-Inattentive type. She reportedly was taking Adderall brand name for 1 year and reportedly had better focus with this and was less overwhelmed as per notes. She reportedly had taken generic Adderall, amphetamine/dextroamphetamine, in the past and had reported severe side effects. She also reportedly had headaches and also was taking Bupropion for depressive and anxiety symptoms and had reported efficacy. 

The insurer denied coverage for Adderall (brand name-amphetamine/dextroamphetamine) stating that the request for formulary exception did not meet the criteria of failure, adverse effects, or contraindication to 3 formulary medications such as amphetamine/dextroamphetamine salts, dexmethylphenidate ER, Methylphenidate ER, Aztarys, Jornay PM, Mydayis, or Vyvanse. 

The reviewer agrees with the decision to deny coverage for brand name Adderall (amphetamine/dextroamphetamine) for formulary exception according to the insurer's criteria as she did not try and fail with lack of efficacy or have adverse effects or contraindication to 3 formulary medications according to the medical records provided. According to the medical records provided she had reports of severe side effects to generic amphetamine/dextroamphetamine but not to any of the other mentioned formulary medications to treat ADHD such as dextroamphetamine, methylphenidate, Dexmethylphenidate, Aztarys, Jornay PM, Mydayis, or Vyvanse. The American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder reports that pharmacotherapy with psychostimulants are considered first line treatment for ADHD. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication. 

The formulary drug is not expected to be ineffective. 

The non- formulary drug is not expected to be more effective than the formulary alternatives. 

The carrier's denial of a request for a Formulary Exception for Adderall XR (amphetamine-dextroamphetamine ER) is upheld.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Attention deficit hyperactivity disorder (ADHD). 
Treatment: Adderall. 

The insurer denied Adderall. The health plan's determination is upheld. 

The patient is a female diagnosed with attention-deficit/hyperactivity disorder, combined type that is requesting coverage of Adderall XR 30 milligrams (mg) capsule for management of attention deficit hyperactivity disorder (ADHD) concerns. After review of the provided documentation, the medication has been denied due to there having been no trial of a generic for the medication with adverse reaction due to an inactive ingredient within it.

A formulary exception is not indicated. After review of the provided documentation, the patient has not trialed a generic form of the requested medication (Adderall) and found to have had an adverse reaction to an inactive ingredient. Furthermore, according to generally accepted standards of care and current medical literature, while there is an indication for use of medication in the management of ADHD concerns, there is no indication of superiority of one medication over another with respect to the generic versus brand name of the requested medication when it comes to effectiveness in management of ADHD. Furthermore, there is no indication of any greater risk of adverse effects with generic versus brand name with regards to the requested medication. As a result, there is no indication in the provided documentation, that the patient would be unable to trial the generic form of the requested Adderall medication or any of the alternatives indicated on the approved formulary alternative list for management of ADHD.