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

Diagnosis: Hydrocephalus, hypertension, transaminitis, coronary artery bypass graft, subdural hemorrhage, heart failure, and osteoarthritis
Treatment: CDPAP (consumer directed personal assistance program), live-in, 24 hours per day, 7 days a week
The insurer denied: CDPAP (consumer directed personal assistance program), live-in, 24 hours per day, 7 days a week
The denial is overturned.

The patient is an elderly female. Her conditions include hydrocephalus, hypertension, transaminitis, coronary artery bypass graft, subdural hemorrhage, heart failure, and osteoarthritis. She was hospitalized last year with pneumonia and is now oxygen dependent. Denial of CDPAP (consumer directed personal assistance program), live-in, 24 hours per day, 7 days a week is being appealed. The health plan approved 12 hours per day, 7 days a week, for a total of 84 hours per week. An appeal statement notes that the patient's provider reports the patient has dizziness and fatigue since being diagnosed with hydrocephalus. She has had multiple falls. There is a nighttime log showing need for physical assistance during overnight hours. Night logs show the patient receiving assistance approximately every 1-2 hours with medication, meals, toileting, and positioning.

The requested CDPAP (consumer directed personal assistance program) Live-In, Per Diem, 24 hours per day, 7 days a week is medically necessary.

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of CDPAP (consumer directed personal assistance program), live-in, 24 hours per day, 7 days a week is being appealed. The health plan approved 12 hours per day, 7 days a week, for a total of 84 hours per week. This patient has multiple chronic conditions, including recent hospitalization for pneumonia and recent diagnosis of hydrocephalus. Appeal statements indicate that her functional status has declined since being diagnosed with hydrocephalus. There are nighttime logs that show the patient receiving assistance with ADLs (activities of daily living) approximately every 1 to 2 hours. The information provided supports the position that the patient requires frequent assistance with toileting, transfers, and turning/repositioning that cannot be met with the currently approved CDPAP (consumer directed personal assistance program) 84 hours per week. The requested CDPAP (consumer directed personal assistance program) live-in, 24 hours per day, 7 days a week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest Pain.
Treatment:  Inpatient Hospital Admission.
The insurer denied the inpatient hospital admission.  
The denial is upheld.

This adult male patient was hospitalized for chest pain. He presented to the hospital emergency department after being referred by an urgent care center for evaluation of jaw pain radiating to his neck and followed by mid-sternal chest pain. There was ST elevation on his electrocardiogram (EKG) and treatment included an ST-elevation myocardial infarction (STEMI) alert, aspirin (ASA), enoxaparin, beta blocker (BB), statin, angiotensin-converting enzyme inhibitor (ACEi) and cardiac catheterization. The patient's past medical history is pertinent for hypertension (HTN) and diabetes mellitus (DM). 
The patient's vital signs revealed: blood pressure (BP) 149/90, heart rate (HR) 120, respiratory rate (RR) 20 and oxygen saturation (O2sat) 99% (percent) on room air (RA). There were no arrhythmias or elevated troponin documented. Chest x-ray and chest computed tomography angiogram (CTA) were negative. Cardiac catheterization showed no coronary artery disease (CAD). Left ventricular ejection fraction (LVEF) was 55-60% by transthoracic echocardiogram (TTE). There were no procedural complications, and the patient was treated medically and discharged to home. 

This is an appeal of the denied claim that the requested acute inpatient hospital stay was medically necessary for this patient.

The proposed inpatient hospital admission was not medically necessary.

Based on the peer reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per Milliman Care Guidelines (MCG) for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like acute myocardial infarct (AMI), pulmonary embolism or aortic dissection, pneumonia, hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which require inpatient admission. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. The care he received, including urgent cardiac catheterization like in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the acute inpatient hospitalization on the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID during pregnancy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld
 

The patient presented to the Emergency Department (ED) with weakness and dizziness. The patient's COVID swab was positive. The patient was tachycardic and febrile. Respirations were 16, oxygen (O2) saturation was 99%.

The patient was admitted to antepartum service for symptomatic COVID-19 infection (fever, fatigue, maternal and fetal tachycardia). She was started on intravenous (IV) fluids and Remdesivir. Maternal and fetal tachycardia resolved. The patient signed out against medical advice.

According to the standard of care, inpatient care is generally required for patients with respiratory compromise: 
1) Oxygen saturation <94 percent on room air. The patient's O2 sat was 99%.
2) Respiratory rate >30 breaths/minute. The patient's respirations were 16.
3) Lung infiltrates >50 percent. The patient did not have any.

Most patients are asymptomatic or have non-severe COVID-19 and can be managed at home. Outpatients should be followed closely for progression to severe or critical disease and given instructions for infection control, symptom management, warning symptoms, and obstetric follow-up (at least once within two weeks of COVID-19 diagnosis).

This patient was not critically ill and could have been managed as an outpatient.

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: Stroke with right hemiplegia with gait dysfunction

Treatment: personal care aide (PCA) level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week

The insurer denied coverage for personal care aide (PCA) level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week

The denial is upheld

According to the medical records, the patient is an adult who had a stroke and is a right hemiplegic with gait dysfunction and weakness. The patient has had a myocardial infarction and stents placed. The patient has insulin for diabetes and lives with her daughter. The patient is receiving 35 hours of care per week and the request is for 56 hours.

The patient does require assistance, however is cognitively intact and lives in a home with her daughter. Therefore, some of the meal preparation, cleaning, and other tasks can be partially handled cooperatively. The purpose of home care is not for supervision or companionship and the notes provided do not sufficiently explain why added hours are needed or provide an accurate physical exam. The  patient is medically stable from her cardiac condition. As such, the requested additional hours are not medically necessary.

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 personal care aide (PCA) level 2, 8 hours per day, 7 days per week, for a total of 56 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: Asthma
Treatment: Inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a young female with moderate persistent asthma who presented with shortness of breath and wheezing.
She was well until a few days prior to presentation when she developed coughing with nasal congestion. On the day of presentation, she developed shortness of breath with wheezing. She tried albuterol nebulized treatments at home without significant improvement. She was on preventive asthma medications, but had not been adherent recently. Her past history was significant for 2 previous admissions for asthma. 

Inpatient Hospital Admission was medically necessary for this patient.
This is a teenage girl who presented in status asthmaticus. She continued to have significant symptoms despite appropriate and intensive treatments both in the emergency department and at home prior to presentation. She continued to have wheezing and retractions and required ongoing intensive treatments. This initially included bronchodilator treatment every 3 hours, along with close monitoring with additional treatments as needed.
The decision making at the time of admission for this patient was consistent with her young age, the presence of status asthmaticus with continued symptoms despite appropriate treatments, and the need for ongoing intensive therapies in an inpatient setting along with close monitoring for potential deterioration of clinical status.
This patient continued to have respiratory distress despite intensive therapies, and required ongoing care in an inpatient setting. An inpatient level of care is needed in this case, particularly when bronchodilator therapy is required more frequently than every 4 hours.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 Diabetes
Treatment: Januvia (sitagliptin)
The insurer denied coverage for Januvia (sitagliptin).
The denial is overturned.

The patient is an adult with medical diagnoses of hypertension, major depression, type two diabetes mellitus, obesity, and hiatal hernia. Per provider notes, the patient has uncontrolled diabetes with glycated hemoglobin (A1C) of 8.7% (percent). Metformin caused severe diarrhea and Tradjenta caused dizziness and diarrhea. The patient was given samples of Januvia and tolerated it well. The request is for Januvia, which is under review.

The formulary drug is likely to cause the patient an adverse reaction. Tradjenta's side effects includes joint pains, heart failure, cholecystitis, pancreatitis, and arthralgia.

The patient has experienced side effects on the formulary alternative.      

The formulary drug has been ineffective, based on the patient's clinical history.   

The patient has diarrhea after taking Tradjenta.     

The requested drug would be more effective than the formulary drug.

The patient had a trial with Januvia and did not have side effects as with the formulary drug.

According to the American Diabetes Association, "The choice of medication added to metformin is based on the clinical characteristics of the patient and their preferences. Important clinical characteristics include the presence of established arteriosclerotic cardiovascular disease (ASCVD) or indicators of high ASCVD risk, other comorbidities, and risk for specific adverse drug effects, as well as safety, tolerability, and cost. Although there are numerous trials comparing dual therapy with metformin alone, there is little evidence to support one combination over another. A comparative effectiveness meta-analysis suggests that each new class of noninsulin agents added to initial therapy with metformin generally lowers A1C approximately 0.71.0% (percent). If the A1C target is not achieved after approximately 3 (three) months, metformin can be combined with any one of the preferred six treatment options: sulfonylurea, thiazolidinedione, DPP-4 inhibitor, SGLT2 inhibitor, GLP-1 RA, or basal insulin; the choice of which agent to add is based on drug-specific effects and patient factors."

According to Venkata, S., et al, "DPP-4 inhibitors, known as gliptins, are a class of oral diabetic medications approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes mellitus in adults. DPP-4 inhibitors that have FDA approval include sitagliptin, saxagliptin, linagliptin, and alogliptin."                                                       

The formulary drugs were tried, and the patient did have an adverse reaction or contraindication.

The formulary drug is expected to be ineffective.

The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a formulary exception for Januvia (sitagliptin) is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Transient Ischemic Attack
Treatment: Inpatient Stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

The patient is a male who has a listed diagnosis of transient ischemic attack (TIA). It was reported that his speech became "nonsensical", and he had pain and numbness to vertex. His symptoms resolved prior to hospital his arrival. His head computed tomography (CT) reported no acute changes.

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 requested health service/treatment of an inpatient stay is not medically necessary. There is no evidence submitted that the patient had any uncontrolled or worsening medical issues. There is no evidence the patient had uncontrolled heart arrhythmias, life threatening metabolic abnormalities, new persistent or worsening neurological deficits, uncontrolled seizures, or any other condition to require immediate or urgent treatment that could not be safely performed at an alternate level of care.

The health plan's determination is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class III malocclusion and mild crowding
Treatment: braces
The insurer denied braces/monthly visit. The health plan's determination is overturned. 

The patient in question is a male presenting with a skeletal Class III malocclusion and mild crowding. He has an anterior open bite. He is treatment planned for 30-36 months of Braces with the extraction of teeth 4, 13, 21 and 28 to address the crowding and open bite.

Braces and Monthly Visit are medically necessary for this patient.
Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite. The orthodontist has treatment planned orthodontics with four premolar extractions to close the open bite.
Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with normal occlusion. However, it has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion. Given the patients malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Revision of gastric bypass (via endoscopy). 

The insurer denied: Revision of gastric bypass (via endoscopy). 
The denial is upheld. 

This patient is an adult female (body mass index of 32.5 kilograms per meter squared [kg/m2]) who sought evaluation for the condition of refractory medically complicated obesity. 
The gastroenterology note states that the patient has undergone sleeve gastrectomy 5 years ago and has subsequently gained weight. The patient has a comorbid health condition of gastroesophageal reflux disease (GERD). Per this consultation, the patient's weight prior to the sleeve gastrectomy procedure was 180 pounds. Her post-surgical nadir was 123 pounds. 

She maintained this weight loss until 2 years ago. Currently her weight is 140 pounds. She has completed nutritional consultation 4 months ago and follow up. She has been counseled on the necessary post-surgical diet and exercise requirements of the proposed intervention. The treating gastroenterologist has proposed the endoscopic sleeve gastroplasty procedure. The health plan has denied the request for coverage because the proposed endoscopic procedure is not a proven effective and safe procedure. 

The proposed treatment is not medically necessary. 

Based on the current evidence-based literature and the patient-specific objective clinical evaluation in this case, the endoscopic sleeve gastroplasty (ESG) procedure as treatment of medically complicated obesity is not medically necessary. The health plan has denied the request for coverage because the proposed endoscopic procedure is not a proven effective and safe procedure. The endoscopic sleeve gastroplasty procedure is a minimally invasive procedure proposed for the treatment of medically complicated obesity. This procedure represents an emerging endoscopic technology for which there is not yet a published position statement from the American Society for Metabolic and Bariatric Surgery. The theoretical goal of this and other endoscopic therapies is to decrease the invasiveness, risks, and barriers to acceptance of effective treatment of obesity. 

It is the position of the American Society for Metabolic and Bariatric Surgery that the use of novel technologies should be limited to clinical trials done in accordance with the ethical guidelines of the American Society for Metabolic and Bariatric Surgery and designed to evaluate the risk and efficacy of the intervention. [1] While the limited data suggests that endoscopic sleeve gastroplasty may be safe and reliable as an option for obesity treatment, at this time the published data does not support the definitive conclusion that the endoscopic sleeve gastroplasty procedure has garnered the support of such organizations as the American Society for Metabolic and Bariatric Surgery as a safe, effective and durable intervention for the treatment of morbid obesity or medically complicated obesity. Furthermore, the existing data does not address the role of endoscopic sleeve gastrectomy as a revisional bariatric intervention for a patient who has already undergone a sleeve gastrectomy intervention.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pyelonephritis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld.

 
This case involves an adult with a history of head trauma, secondary diplopia, polysubstance abuse, and bilateral knee pain who presented to the emergency room complaining of a 3-day history of hematuria and back pain.  On assessment, the patient's vital signs were stable and then slight elevation in his pulse rate of 95.  He had mild ptosis of the right eye and with some dysfunction on downward gaze of the right eye.  There is midline tenderness to the abdomen but no rebound, guarding, or palpable hernia.  He was documented with mild right forehead weakness partial with his neurological examination otherwise unremarkable.  On assessment, was determined that the patient likely had pyelonephritis.  He had decreased sensation on the right forehead and face with left leg strength graded 4/5, although this was reportedly baseline.  The patient had no computed tomography (CT) evidence of urolithiasis or hydronephrosis.  The patient received 1 liter (L) intravenous (IV) fluid bolus and Rocephin.  He was subsequently admitted for further work-up and remained on inpatient status until discharge.  

According to the Milliman Care Guidelines (MCG), the patient did not meet criteria for admission to receive inpatient care.  There is no evidence of hemodynamic instability, altered mental status considered severe or persistent nor was there persistent or worsening clinical findings despite observation care.  The patient was not a prior kidney transplant recipient, did not have significant uropathy, suspected infection of an indwelling prosthetic device, stent, implant, or graft and was not found to have urethral obstruction.  He did not have significantly impaired bladder emptying, renal or perinephric abscess, emphysematous pyelonephritis or cystitis and no pyonephrosis.  There is also no evidence of acute renal failure stage III acute kidney injury or acute kidney injury stage II nor was there a need for intravenous hydration support despite observation care.  

Given the presenting symptoms related to a urinary tract infection, the patient could have had his care safely and effectively rendered on an outpatient or observational basis.

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.