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

Diagnosis: Heart disease, non-Hodgkin's lymphoma, cognitive decline and osteoarthritis

Treatment: Increase to Home Care / Personal Care HHC - Personal Care Aide Live-In per diem increase to 24 Hour(s) per Day (Split-Shift)

The insurer denied coverage for increase to Home Care / Personal Care HHC - Personal Care Aide Live-In per diem increase to 24 Hour(s) per Day (Split-Shift)

The denial is overturned

 
This is an advanced elderly patient with medical problems including heart disease, non-Hodgkin's lymphoma and osteoarthritis. She lives alone in a private residence. The request is for an increase in personal care aide (PCA) from Live-In per diem to 24 Hour(s) per Day (Split Shift).

According to the Uniform Assessment System (UAS) report the patient's cognition is described as minimally impaired. However, the clinical records are consistent with her cognition as more severely impaired. She is totally dependent for much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She is also totally dependent for bathing, lower body dressing and toilet use. She requires maximal assistance for upper body dressing and toilet transfer. Extensive assistance is needed for personal hygiene, locomotion and ambulation. Limited assistance is needed for bed mobility and supervision for eating. This patient is frequently incontinent of bladder and occasionally incontinent of bowel. There have been reported falls over the prior 90 days and her functional ability has declined when compared to the previous UAS report. 

The PCA logs document the need for personal care service tasks throughout the night; including but not limited to repositioning, changes of clothing due to incontinence and assistance with transfers for bladder/bowel management. The patient's clinical condition, cognition and functional deficits are at a level and unpredictable as to require the requested PCA 7 days per week, 24 hours per day split shift. Based on the clinical records, a PCA is unlikely capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift. This physician would agree that attention to the patient's functional needs are more appropriately provided and maintained by the requested PCA, increase to 24 Hour(s)/Day (Split Shift).

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 an increase in Home Care / Personal Care HHC - Personal Care Aide Live-In per diem increase to 24 Hour(s) per Day (Split-Shift), total 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Home Health Care. 

The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day, Split Shift. The health plan's determination is overturned. 

This is a case review for a female patient with medical history notable for Alzheimer's dementia, incontinence, and unstable gait. The patient was approved for 49 hours per week of level 2 personal care services. The patient and her care team requested an increase to 24 hours per day (2-12 hour split-shift). 

The requested Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 24 Hours per Day, Split Shift is medically necessary for this patient.
The patient has advanced dementia and incontinence. She requires hands on assistance for all functional needs, including toileting and diaper changes. She is not able to direct her own care. Due to her dementia and incontinence, she requires multiple nightly toileting trips and changes of soiled diapers. The patient's personal care needs can be reasonably expected to be continuous and unscheduled in nature. Therefore, 24 hour split shift care is medically necessary for the patient. Failure to provide for her personal care needs could result in skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vascular dementia
Treatment: Skilled nursing facility long term custodial care
The insurer denied coverage for skilled nursing facility long term custodial care.
The denial is upheld.

This is an adult with vascular dementia and diabetes mellitus.  He was admitted to the nursing and rehabilitation center skilled nursing facility (SNF).  Currently under review is the medical necessity of skilled nursing facility long term custodial care.

The clinical records do not demonstrate the care provided at the nursing and rehabilitation center as long term, custodial or permanent.  The patient was admitted to the center's SNF.  During this time, the patient received skilled care and physical and occupational therapy services with modest functional improvement.  Agree with the insurer regarding the lack of a "social work note or doctor's note, stating that the patient and/or responsible party agree to the permanent placement plan."  Skilled nursing facility long term custodial care was clearly not the appropriate level of care for this patient.  

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

The medical necessity for skilled nursing facility long term custodial care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent Syn 300.
The insurer denied: Dupixent Syn 300.
The denial is upheld.

The patient is a young school aged female with atopic dermatitis, treated with systemic and topical steroids. Her provider is requesting Dupixent. The patient also has alopecia areata, and her clinical documentation notes only total hair loss of scalp. Eczema is not noted on clinical exam. The health plan denied coverage of the request due to their requirement for use of two topical steroids, a topical calcineurin inhibitor, and phototherapy. The denial is being appealed.

The requested Dupixent is not medically necessary.

According to the recommendations provided by Simpson et al (2017), steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. Topicals are the mainstay treatment for atopic dermatitis, including topical steroids and calcineurin inhibitors, and this patient has tried only topical steroids. This patient has not tried and failed all standard measures for atopic dermatitis.
The provider states that "Topicals are not strong enough to combat the patient's condition. They are not warranted given the extent/severity of disease, AD [atopic dermatitis] is a chronic lifelong condition necessitating a continuous permanent solution, not temporary short term use topicals. Additionally, unlike the suggested topicals and phototherapy, Dupixent with also benefit patient's asthma and food allergies. It will help the patient as a whole systemically, not just locally apply a band aid." However, there is no extent or severity documented for the atopic dermatitis, and the patient is only noted to have alopecia areata on physical exam. Dupixent is not approved for alopecia areata.
Therefore, given the above, Dupixent is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Taltz.
The insurer denied coverage for Taltz.
The denial is overturned.

The patient is an adult with a diagnosis of psoriasis and psoriatic arthritis. The patient has a long history of severe disease which has failed therapy with methotrexate, Enbrel, Humira, and Cosentyx.  The patient was started on Taltz with improvement, but not resolution. The physician added Otezla 30 mg (milligram) tablets twice daily (bid). The request is for continuation of Taltz in combination with Otezla.

Based on the submitted documentation, the use of Taltz and Otezla is medically necessary. The patient has severe psoriasis and psoriatic arthritis which has been resistant to numerous therapies. The patient previously required methotrexate in combination with etanercept. The patient has failed monotherapy with numerous biologics. The use of Otezla in combination with Taltz has provided symptomatic disease state relief for his conditions without noticeable side effects. The use of this combination is approved under the direction of the supervising dermatologist.

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 Taltz is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign paroxysmal vertigo, polyarthralgia, left hip bursitis.

Treatment: coverage for personal care aide (PCA) level 2: 8 hours per day - 5 days per week - for a total of 40 hours per week.

The insurer denied coverage for personal care aide (PCA) level 2: 8 hours per day - 5 days per week - for a total of 40 hours per week.

The denial is upheld.

 
This is an adult with diagnoses that include benign paroxysmal vertigo, polyarthralgia, left hip bursitis and plantar fasciitis. She lives with her spouse in a private residence. The insurer approved a personal care aide (PCA) level 2: 6 hours/day - 5 days/week (30 hours/week) and the request is for a PCA level 2: 8 hours/day - 5 days/week - (40 hours/week).

The Uniform Assessment System (UAS) report notes: The patient's cognition is described as "minimally impaired." She requires maximal assistance to total dependence for much of her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. She requires maximal assistance for bathing and lower body dressing. Extensive assistance is reportedly required for personal hygiene, upper body dressing, bed mobility, locomotion, ambulation and toilet transfer/use.  She is occasionally incontinent of bladder and continent of bowel. Limited assistance is needed for eating. There had been no reported falls over the prior 90 days. Her functional ability is also much the same when compared to the previous UAS report. The patient's condition and functional deficits are not at a level or unpredictable as to require an increase in PCA 40 hours/week. The patient may benefit from additional monitoring for safety. However, safety monitoring under PCA does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the approved PCA services 30 hours/week.   

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 - 5 days per week - for a total of 40 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection
Treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

This case involves a man admitted to the hospital with three days of fever and penile pain with urination. The pain radiated to the lower back and was associated with decreased urine stream and frequency. No prior history of kidney stones was noted. On arrival in the emergency department (ED), the temperature was 101.7 degrees F (Fahrenheit), with a lactic acid of 2. There was a suspicion of urinary tract infection, and therefore a computed tomography (CT) abdomen was completed, which showed no obstructive uropathy or hydronephrosis. 

The inpatient hospital admission was not medically necessary.

A lower level of care was appropriate for this patient with an uncomplicated urinary tract infection (UTI). The documentation shows an individual with fever and suspected UTI without evidence of anatomic abnormalities on the CT abdomen and pelvis. He was treated with IV fluids and one dose of IV (intravenous) Rocephin before being discharge home. The patient felt dramatically better after the initiation of the treatment and no longer required hospitalization. Observation stays are designed to evaluate and treat acute medical problems, which are expected to improve rapidly. This patient with no chronic past medical problems, who is alert and oriented x3, without other evidence of hemodynamic instability or end-organ damage, did not necessitate an inpatient stay.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Thigh Pain from Gun Shot Wound
Treatment: Inpatient Admission
The insurer denied the inpatient admission.
The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) following a gunshot wound (GSW) to the left thigh. He presented by Emergency Medical Services (EMS). The patient has a past medical history that includes morbid obesity. His vital signs at presentation were normal with a heart rate of 95 beats per minute and a blood pressure of 155/92 millimeters of mercury (mmHg). He was awake, alert and oriented with a Glasgow coma score of 15/15. The patient had one wound of the left thigh. The primary and secondary survey did not reveal any other injuries. The examination showed no active bleeding, no hematoma, and normal distal pulsations. The neurovascular examination of the left leg was normal.

The computed tomography (CT) angiogram was normal. The x-ray showed no fracture. The patient was observed overnight. He was provided intravenous (IV) analgesia, and antibiotics. The examination on the following day after admission showed soft compartments of the left thigh, normal distal pulsations and capillary refill. The note states that he was suitable for discharge if he was able to ambulate. No other injuries or sequelae from the GSW to the left leg were identified and the patient was discharged to police custody.

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

The inpatient admission was not medically necessary. The medical records support that the patient presented to the ED following a GSW to the left thigh. He was appropriately evaluated for the presenting condition with a surgical assessment. This patient was clinically stable and was without evidence for neurovascular compromise. He was provided pain medications and antibiotics and was considered to be fit for discharge the day after admission. An alternate level of care would have reasonably satisfied the clinical needs of this patient and would have provided for IV fluids, analgesia and serial monitoring including an overnight stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hyperbilirubinemia

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

This patient is a newborn weighing 2660 grams. Upon discharge, the total bilirubin was 9.6 milligrams per deciliter (mg/dl) which did not require treatment. The patient was exclusively breastfed, and the mother was unsure of the volume of intake. At 83 hours-old, the total bilirubin (performed as an ambulatory patient) was 19.9 mg/dl. The pediatrician referred the patient to the hospital for admission and treatment with phototherapy. 

According to the standard of care as contained in: Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation from the American Academy of Pediatrics (AAP). The infant's risk factors for developing severe hyperbilirubinemia included: gestational age of 35 weeks, exclusive breast feeding with possible sub-optimal intake. Risk factors for neurotoxicity included gestation < (less than) 38 weeks, increasing with lower gestational ages. According to the AAP, the threshold for phototherapy for this infant was approximately 18 mg/dL.  Accordingly, phototherapy was indicated.

Subsequent to admission, the treating physicians instituted triple phototherapy (intensive phototherapy) and performed serial bilirubin measurements as recommended by the AAP. The total bilirubin was 14.7 mg/dl and phototherapy was discontinued as recommended by the AAP for a level < 2 mg/dL below the phototherapy threshold. The morning after admission, a 'rebound' bilirubin was 12.8 mg/dL. The infant was feeding better and was discharged with a plan for a follow-up bilirubin in two days and follow-up with the pediatrician in 1-2 days.

This infant's admission was in accord with the existing standard of care for hyperbilirubinemia in a preterm 35 week gestation, exclusively breast fed infant. 

The insurer denied coverage of an inpatient admission citing Milliman Care Guidelines (MCG, P-265, Neonatal Jaundice, Edition not cited). In response, the hospital appealed. Importantly, the care of this infant was in accord with the Revised, American Academy of Pediatrics Guideline that was published in August 2022. The most recent MCG edition, 26th, was in-part based on the previous AAP Guideline from 2004. Therefore, at the time of this infant's birth and treatment, it was no longer valid. 

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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Daytime Sleepiness.
Treatment: Xywav.
The insurer denied Xywav.
The determination is overturned.

This is a patient who suffers from daytime sleepiness. The patient was ruled out for sleep apnea. The patient had a multiple sleep latency test (MSLT) that showed reduced mean sleep onset latency down to 4 minutes and no sleep onset rapid eye movement (REM) consistent with the diagnosis of idiopathic hypersomnia. The patient was placed on modafinil without improvement in symptoms. The treating provider is requesting the coverage of Xywav and this is under review for medical necessity.

The requested health service/treatment of Xywav is medically necessary for this patient.
Idiopathic hypersomnia (IH) is a diagnosis applied to patients who are excessively sleepy and sleep for long periods of time without feeling refreshed. It is also referred to as non-REM narcolepsy or central nervous system (CNS) hypersomnia. The etiology of excessive daytime sleepiness (EDS) in patients with idiopathic hypersomnolence (IH) is unknown.
In comparison with narcolepsy, which is characterized by well-defined clinical, polysomnographic, and immunogenetic features, IH is not well delineated. The diagnosis of idiopathic hypersomnia is mainly based on clinical features and the absence of associated symptoms such as cataplexy, snoring at night, periodic leg movements, or the patient demonstrating REM sleep in two or more daytime naps on a Multiple Sleep Latency Test.
IH is a diagnosis of exclusion. Complete in-laboratory polysomnographic studies performed by qualified technicians are essential to exclude other sleep disorders, particularly sleep breathing disorder, periodic limb movement disorder, and narcolepsy. The MSLT is performed to evaluate the presence of pathological sleepiness. These individuals are studied during 5 daytime naps taken 2 hours apart.
This patient suffers from daytime sleepiness. The patient had an MSLT that was consistent with the diagnosis of idiopathic hypersomnia with reduced mean sleep onset latency down to 4 minutes. The patient failed modafinil. Xywav was Food and Drug Administration (FDA) approved for the treatment of IH. None of the stimulants (i.e. methylphenidate, amphetamine,..) was approved by the FDA for the treatment of idiopathic hypersomnia. There are not enough valid studies (good size sample with a randomized placebo-controlled design) that established the safety and efficacy of stimulants for the treatment of patients with IH. The FDA did not approve the Adderall for patients suffering from idiopathic hypersomnia (IH).
The latest updated guideline from the American Academy of Sleep Medicine that was published in Sleep journal in 2021 did not support the use of the amphetamines or Methylphenidate in the treatment of patients suffering from IH as in this patient case.
Therefore, the requested Xywav is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy loss (miscarriage)
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult gravida 3 para 1011 who presented to the emergency department complaining of vaginal bleeding. She stated she had a miscarriage the day prior. Her vital signs were normal and she had mild anemia with a hematocrit of 31. There were no signs of infection. Beta human chorionic gonadotrophin (Hcg) was weakly positive at around 600. Ultrasound was performed which revealed no intrauterine pregnancy and 19 millimeter thickened endometrial stripe and concern for retained products of conception. The cervix was dilated to one centimeter. The diagnosis of incomplete abortion was made, and the patient was taken to the operating room where vacuum and sharp curettage were performed under general anesthesia. The procedure and recovery were uncomplicated and the patient was discharged home on postoperative day number 1. The pathology returned products of conception. 

The health plan contends that the admission was not medically necessary because the patient was not unstable, did not have fever, signs of serious swelling or abdominal pain and cites Milliman Care Guidelines (MCG) Obstetric and Gynecologic Disease GRG 25th edition. The facility contends that the admission was medically necessary because a spontaneous miscarriage requires admission for high-risk patients and that "after the 12th week of admission patients are more likely to require medical or operative intervention", and that hospitalization was medically indicated for perinatal consultation and resource-intensive monitoring for hemodynamic instability. It cites National Guideline Clearinghouse recommendations.

The proposed treatment was not medically necessary.

Incomplete abortion without complications of sepsis or hemodynamic instability, and without operative and anesthesia complications, is commonly and safely treated on an outpatient basis, including when curettage is performed. There is no documentation of septic abortion, hemodynamic instability, or complications of anesthesia or the procedure. Therefore, the inpatient hospital admission was not medically necessary.