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

Diagnosis: Cerebrovascular Accident (CVA).

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

The patient has a diagnosis of hypertension and cerebrovascular accident (CVA). The treating provider is requesting plan approval for inpatient admission.

The patient had a chief complaint of left hemi-facial, left upper extremity numbness, and left lower extremity numbness. It was noted that the patient had a prior stroke with no residuals and that the symptoms had been going on for three days. The neurological examination was normal. In the assessment, it was noted that the patient was not a TPA [tissue plasminogen activator] candidate and that she will be admitted to be worked up for possible stroke. The patient was seen by her doctor who noted that the patient was admitted with cramping pain of the left leg that progressed to the shoulder and left neck and arm and had been going on for three days. The neurological examination was normal. The plan was to obtain and magnetic resonance imaging (MRI) of the brain and if that was negative then no additional workup was needed.  There was a discharge diagnosis that noted the discharge diagnoses of pain in the lower extremities and stroke. It was noted that the patient had an MRI of the brain which showed no acute intracranial process. The treating provider ordered as inpatient.

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

The patient presented with symptoms atypical for stroke, i.e arm and leg discomfort, the patient's neurological examination was normal, and an inpatient admission was not medically necessary.   Inpatient admission was not considered medically necessary for this patient.

"Conclusion: Routine hospitalization of all patients with TIA [transient ischemic attack] or minor ischemic stroke may not positively affect short-term clinical outcome." (Majidi, et al., 2017).

Based on the above, the medical necessity for the inpatient admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Inpatient Hospital.
The health plan denied the requested inpatient stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a female who had presented to the hospital for an evaluation of seizures. The patient had a prior history of a seizure disorder and averaged 1 seizure/month at baseline. Her history was also notable for hypertension and a genetic deformity to her right hand and foot. On the day of presentation, per the emergency department (ED) attending's note the patient had experienced 3 seizures. The patient was noted to have been treated with Divalproex sodium as an outpatient. The patient denied medication non-compliance. In the ED the initial neurological exam was non-focal. Labs were drawn and her valproic acid level was 34 [therapeutic range is 50-100 micrograms (mcg)/milliliter (mL)]. A decision was made to transfer the patient to the floor for further evaluation.
On the floor the patient was seen by neurology. The patient's subtherapeutic valproic acid level was noted. The patient's neurological exam was otherwise unremarkable. Neurology recommended increasing the patient's dose of valproic acid to 500 milligrams (mg) twice daily (BID) (from 250mg BID) and for there to be the patient's family involved to support medication adherence. Outpatient follow-up was recommended. The patient was discharged later than same day to her home.
At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld, in whole.

No, the requested health service/treatment of the inpatient stay was not medically necessary for this patient.
The patient presented to the hospital after having had multiple seizures within the course of a day while at home. However, upon arrival to the hospital she was at her baseline. Her neurological exam was non-focal. Her labs showed no significant metabolic abnormalities, nor did she show any hemodynamic instability. She had a non-focal neurological examination. While the patient was taken to the floor, she was only seen by neurology. At that time, it was discovered that the patient had been non-compliant with her prescribed therapy, which was most likely the etiology for her seizures. No neurodiagnostic testing was ordered or otherwise performed for the patient. Her neurological exam was normal, and she was otherwise advised to follow-up as an outpatient and supportive care was recommended.
Given the patient's overall clinical stability in this case, the inpatient level of care would have exceeded the patient's needs for those services which were provided. The patient had no further seizures. She had no clinical worsening while hospitalized (neurologically or otherwise). She had no other significant limitations that would have otherwise necessitated the inpatient setting for the episode of care provided.
Therefore, the inpatient stay was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vitiligo

Treatment: Otezla

The insurer denied coverage for Otezla.

The denial is overturned. 

This male patient has a history of vitiligo of the face and ears.

The patient has failed numerous therapies commonly used in the treatment of vitiligo, including topical Xeljanz.  The patient has not responded to excimer light therapy or dexamethasone.  Given the patient's age, other systemic therapies used to treat vitiligo would have a greater side effect profile compared to Otezla.  The data for the use of Otezla is minimal and limited to case studies.  Although there is mixed data on the efficacy of Otezla in treating vitiligo (either alone or in combination with Narrowband Ultraviolet B [NBUVB] Therapy), it is an appropriate next step for this patient based on the submitted documentation.  As such, the decision is reversed and the use of Otezla is approved under the supervision and direction of the Dermatologist.  

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

The carrier's denial of coverage for Otezla is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Home Health Care assistance 56 hours per week. 
The insurer denied personal care assistance 56 hours per week. 
The denial is upheld.

The patient is a female with a past medical history significant for coronary artery disease, gastritis, diabetes, hypertension, osteoarthrosis, breast cancer, hyperlipidemia, hypertension, and recent history of hypersensitivity pneumonitis. This review is for the medical necessity of personal care assistance 8 hours per day 7 days a week for a total of 56 hours per week. Services were denied based upon lack of medical necessity.

No, the requested health service is not medically necessary for this patient. Additional services beyond 56 hours a week are not medically necessary.
Office visit note states her functional status is somewhat improved with no hypoxemia, her psychological issues improved and she is no longer anxious and wishing to die.
Uniform Assessment System (UAS) State of New York was reviewed, which recommends 26.54 hours per week. UAS State of New York was reviewed and recommended 24.21 hours per week
The patient requires assistance with activities of daily living (ADL)/Instrumental activities of daily living (IADL) due to pain in both knees, generalized weakness associated with osteoarthritis and muscle ache and pain, limited ability to bend, reach, lift, carry items and stand for prolonged periods of time. The Personal Care Aide (PCA) prepares all meals. During non-PCA hours patient can reheat food herself. The patient has no incontinence needs.
While it reasonable to say that the patient's physical status did decrease from previous evaluation, the patient has 56 hours a week allotted for PCA services. Medical necessity notes 26.54 hours of service per week. This is well above the documented need. On appeal there was no specific rationale other than patient's medical status deteriorating requiring additional services. This however was not reflected in the recent UAS and also the physician note.
Therefore, additional hours are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain
Treatment: Knee surgery
The insurer denied Knee surgery. The health plan's determination is upheld.

This case describes a female patient who underwent left primary total knee replacement. She was doing well until the summer months at which time she began experiencing pain and stiffness and swelling in the left knee. The patient was evaluated by her surgeon and plain radiographs confirmed a well positioned total knee with no fractures and no apparent loosening. An aspiration of the knee was performed on that date with 10 cc (cubic centimeters) of normal colored joint fluid. The patient was referred for a magnetic resonance imaging (MRI) scan of the left knee which revealed synovial inflammation and debris. The scan also identified areas of bone resorption around the patella and femoral components of the total knee replacement. 

The requested knee surgery is not medically necessary for this patient. The provided medical records and progress notes fail to document the medical necessity of the knee arthroscopy for this patient. Peri-prosthetic infection was not ruled out for this patient. This is a known cause of post-operative pain, swelling and stiffness in patients who have had total knees in place for many years. In addition, the current, peer-reviewed literature has documented that knee arthroscopy performed on total knee replacements increases both infection and revision surgery risk. Thus, the knee surgery is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Dental Implant Tooth # (number) 27
The insurer denied the Implant Tooth #27.
The determination is overturned.

The patient presented for evaluation and treatment of tooth number (#) 27. Provided for review are previous letters of appeal and denial, a narrative from her doctor explaining challenges with chewing function, full mouth panoramic radiographic image, multiple pages of claim forms, intra-oral clinical photos, multiple correspondence between the applicant and the health plan, appeal acknowledgement letters, and clinical notes. At issue is the medical necessity of the planned treatment of extraction of implant placement (6010) for tooth #27. 

Yes, the requested health service/treatment of surgical placement of implant body in site #27 is medically necessary in order to provide support stability and retention of the denture.

This will reduce the need for a vestibule as well as reduce the compression of the tissue around the tori which would otherwise cause ulceration. The clinical images along with the radiographic images support the clinical notes and assessments. A narrative from her doctor explains the challenges with chewing function.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: Total Amount of 70 Hours per Week.
The health plan's determination is overturned. 

The patient is a male with past medical history of dementia, benign prostatic hyperplasia (BPH), hypothyroidism, osteoarthritis, urinary incontinence, and iron deficiency anemia who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services based on assessment tool performed via telephone assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, managing finances, managing medication, and shopping while extensive assistance with tasks of phone use and transportation. The patient was assessed at limited assistance with task of stairs while supervision with tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, and transfer toilet. With tasks of toilet use, bed mobility, and eating the patient was assessed as independent. There was a request to increase CDPAP services and the patient underwent an assessment tool via telephone assessing the patient at total assistance with ordinary housework, maximum assistance with tasks of meal preparation, managing finances, managing medication, and shopping. The patient was assessed at extensive assistance with task of transportation while supervision with tasks of bathing, personal hygiene, dressing upper/lower body, walking, locomotion, and transfer toilet. 

CDPAP Services: total amount of 70 hours per week are medically necessary for this patient.

There is documentation from both universal assessments that the patient required at least some level of assistance with all tasks except for toilet use, bed mobility, and eating where it was noted he was independent. There were detailed notes from the assessment that more specifically stated the patient did need set up help with toilet use, bed mobility, and eating. The patient has unpredictable and unscheduled care needs including transfer toilet, walking, and locomotion that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient's care needs cannot be met with medical supplies and adaptive equipment alone. The requested increase in CDPAP services is not solely for safety and supervision, but to assist the patient with safe completion of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). 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, CDPAP services 10 hours/day, 7 days/week, to total 70 hours/week 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 his own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gluteal Abscess.

Treatment inpatient hospital admission.

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This is the case of a male with a history of depression and eczema. He presented to the emergency department (ED) complaining of left buttock pain, after two prior visits to the ED for incision and drainage, stating no improvement. He had received a steroid injection at the site about a month prior. His vital signs were stable, and he was not toxic-appearing or with any signs of sepsis. The Infectious Disease consultant appears to support the reason for admission being an anaphylactic reaction to vancomycin. However, all of his blood pressure readings were consistent, so there is no documentation of hypotension that would warrant fluid resuscitation or inpatient care. It is also likely that he had a common vancomycin infusion reaction previously known as "red-man" syndrome. The gluteal abscess was managed with bedside incision and drainage. Parenteral antibiotic therapy was not clinically indicated.

There was no evidence of sepsis, fasciitis, local spread of the purulent infection, or toxic shock syndrome. The infection could have been treated with follow-up as an outpatient after drainage by surgery. There is no medical-decision-making statement that justifies admission and a need for intravenous (IV) antibiotics. A small gluteal abscess can be treated as an outpatient after incision and drainage (Lawrence, 2012) because it is not in danger of spreading to any vital structure or organ. IV antibiotics are usually unnecessary. (Kaplan, UpToDate; Stevens, 2014)

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

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

Diagnosis: Blood Clot in Lung
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned.

The patient in this case is a female admitted to the hospital. Her medical history is significant for diabetes and COVID pneumonia. She presented to the emergency department with symptoms of dry cough and fever for three days.  She had seen her primary physician and systolic blood pressure was reported as being in the 70s. She was sent to the emergency department (ED) based on that finding.  

Evaluation in the emergency department revealed saddle pulmonary embolism, sub-massive, associated with intraventricular flattening.  Echocardiogram revealed no evidence of right heart strain. The patient was admitted to the hospital and treated with intravenous heparin. She was hemodynamically stable at the time of admission.  She was initially admitted to the cardiac care unit (CCU) though records indicate that was because of bed availability issues.

The patient was transitioned to a direct oral anticoagulant (DOAC) while in the hospital.  Lower extremity ultrasound was done during this admission and revealed acute deep vein thrombosis (DVT).  She was also found to have leukocytosis with lymphocytosis and also had associated severe neutropenia.  She was started on intravenous (IV) antibiotics at the time of admission given her fever and severe neutropenia. Hematology was consulted and they recommended further evaluation to look for evidence of an underlying lymphoproliferative disorder. Evaluation revealed evidence of acute lymphoblastic leukemia.  She was transferred to a specialty hospital for further evaluation and treatment of that disorder.

Yes, the proposed inpatient admission was medically necessary.
This patient not only had a pulmonary embolism and deep vein thrombosis (DVT) but also had severe neutropenia associated with lymphocytosis and was diagnosed with acute lymphocytic leukemia (ALL) based on flow cytometry.  In addition, she had severe neutropenia (absolute neutrophil count [ANC] less than 500) associated with fever and cough.  She was treated with intravenous antibiotics at the time of admission and infection was evaluated and ruled out.  Due to these findings and the potential for her to have acute leukemia at the time of admission (the presence of severe neutropenia supported this diagnosis), the acute care hospital admission in this case was medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Parkinson's Disease.

Treatment: Formulary Exception for Ropinirole (XL) Extended Release.

The insurer denied coverage for Formulary Exception for Ropinirole Extended Release.

The denial is overturned.

This case involves a male who has been previously diagnosed with Parkinson's.  The documentation indicated the patient has been recommended to utilize ropinirole extended-release capsules to treat Parkinson's disease.  The physician indicated this medication has given the patient great motor benefits in the immediate release formulation; however it has been causing nausea and drowsiness.  He has previously utilized ropinirole XL with benefit.  The recommendation based on clinical assessment was to switch the patient back to ropinirole XL given his response previously.  The submitted documentation indicated this was previously denied as there are formulary alternative medications.

Patient's reactions to Parkinson's medication are highly idiosyncratic in terms of efficacy and side effects. In this case, the treating physician notes that member has derived clinical benefit with efficacy with the XL version of ropinirole but noted nausea and drowsiness with the immediate release formulation. Ropinirole XL has been shown to provide symptomatic efficacy in treating the symptoms of Parkinson's disease.

The immediate release formulation of ropinirole led to side effects including sedation and nausea-while the XL version had no significant side effects with clinical efficacy.

As noted above, patient's reactions to Parkinson medications are highly idiosyncratic in terms of side effects, efficacy in terms of medications and the timing of medications. Ropinirole XL has been well tolerated by member in this case-without side effects that were encountered with the immediate release formulation. Therefore, the requested drug Ropinirole XL is warranted in this case and would be more effective than the formulary option.

The insurer's denial of formulary exception for ropinirole Extended Release is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebellar ataxia.
Treatment:  Genetic tests (Athena Health Comprehensive Evaluation of Ataxia).

The insurer denied coverage for genetic tests (Athena Health Comprehensive Evaluation of Ataxia).  The denial is upheld.

This patient has a prior medical history that includes pituitary adenoma, temporomandibular joint pain, and cerebellar ataxia.  The documentation indicated she was being seen by neurology for evaluation for cerebellar atrophy.  She has had extensive imaging; however, she has not been given a definitive diagnosis.  She does have significant disability with a combination of upper and lower motor neuron findings adversely impacting her gait and mobility.  The documentation indicated she was seen for a follow-up where it is noted she was an extremely poor historian.  She was initially referred for movement issues.  The patient has had prior genetic studies from which genetic alteration consistent with ataxia was identified; however, there was no specific genetic disorder.  She has been previously recommended to undergo a neuro-ophthalmology evaluation.  The documentation indicated a prior MRI (magnetic resonance imaging) does show conspicuous cerebellar volume loss moderate to severe in degree for her age, which likely represented degeneration with differential diagnosis including inherited spinocerebellar ataxia.  There was also conspicuous enlargement of the pituitary gland.  The physical examination revealed no generalized bradykinesia with very slight postural/action tremor to bilateral upper extremity.  She did have a normal base gait with intact sensation.  It was recommended she undergo genetic testing due to persistent symptoms and follow-up.

The submitted documentation indicated the patient has undergone prior genetic testing confirming that she has a genetic alteration consistent with ataxia.  Currently there are no treatment options available for such ataxic syndromes, and therefore, there is no clinical necessity for undergoing repeated genetic testing due to ongoing symptoms.  As such, the health plan acted reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the genetic tests (Athena Health Comprehensive Evaluation of Ataxia) is not substantiated. The insurer's denial is upheld.