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

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD). 
Treatment: Inpatient admission. 

The insurer denied coverage for the inpatient admission. 
The denial is upheld. 

The patient has a history of smoking. He was seen at an urgent care center with complaints of chest pain and shortness of breath (SOB). A chest x-ray revealed possible pneumomediastinum versus Bleb, so the patient was asked to go to the emergency department (ED). In the ED, the patient was noted to have a temperature of 99, heart rate of 60, and was hemodynamically stable. The patient had a computerized tomographic angiography (CTA) done. No pulmonary embolism (PE) was noted. The patient was noted to have bilateral (B/L) bullous disease with some possible air fluid level. Centrilobular emphysema also noted to be consistent with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) Emphysema. 

The patient was admitted to the hospital and the Pulmonary consult recommended oral (PO) antibiotics (Abx) Augmentin for possible infection. 

Interventional Radiology (IR) also consulted on the patient for his bullous disease. No intervention was recommended. Thoracic surgery was consulted and recommended outpatient follow up. The patient remained stable after admission. 

This patient was discharged home later that day with PO Abx and PO medicines. 

This patient did not need acute inpatient hospitalization. He could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hrs. This patient remained stable after admission, was afebrile, not hypoxic, and was tolerating PO. He was stable to be discharged home on PO meds after a period in Observation status. This patient was in the hospital only for a few hours after admission. Inpatient hospitalization was not required. 

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

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

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Cosentyx 300 milligrams (mg) every two weeks. 
The denial is upheld.

The patient is a female with a diagnosis of psoriatic plaques and arthritis. Psoriasis body surface area affected at baseline 70%. She has tried and failed clobetasol ointment. She has an elevated creatinine and hypertension. Her psoriasis has cleared with clobetasol 300 milligrams (mg) every four weeks but her joint pain has persisted. The subject under review is the medical necessity of Cosentyx 300 mg every two weeks.

The health plan's determination is upheld in whole.

The requested health service/treatment of Cosentyx Pen Inj 300 mg every two weeks is not medically necessary for this patient.
Scientific evidence has not been established via well-designed, controlled studies with adequate follow-up that demonstrate the safety and efficacy of the proposed treatment. There are no randomized-controlled studies that show the efficacy of safety of Cosentyx when administered every two weeks. Cosentyx every two weeks is not generally accepted medical practice and management of psoriasis and psoriatic arthritis in the United States. Further studies are necessary to determine the role and utility of this dosing for plaque psoriasis and psoriatic arthritis patients.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Surgical Services. 
The insurer has denied total thyroidectomy with right modified radical neck dissection. 
The denial is overturned.

The patient is a female with a 7-year history of hypothyroidism who was recently noted to have increased swelling of her thyroid gland. She underwent a fine needle aspiration (FNA) biopsy of the thyroid as well as of an enlarged right cervical level III lymph node. The thyroid FNA was positive for papillary thyroid carcinoma and the lymph node was found to be involved with metastatic carcinoma. She was recommended to undergo a total thyroidectomy with a right modified radical neck dissection. The question at hand is whether this operation is medically necessary.

The health plan's determination is overturned.

The requested service, total thyroidectomy with right modified radical neck dissection is medically necessary for the treatment of the patient's biopsy proven papillary thyroid carcinoma with cervical nodal metastasis. The requested service is standard of care for the presenting problem.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebrum hemorrhage, glaucoma, constipation, benign prostatic hyperplasia with urinary tract symptoms, hypertension, and hyperlipidemia.

Treatment: Increase to 24 hours per day (split-shift), 7 days per week, total 168 hours per week, Consumer Directed Personal Assistance (CDPAS).

The insurer denied coverage for an increase to 24 hours per day (split-shift), 7 days per week, total 168 hours per week, Consumer Directed Personal Assistance (CDPAS).

The denial is upheld.

According to the documentation submitted, this is an elderly male with a history of glaucoma, constipation, benign prostatic hyperplasia with urinary tract symptoms, hypertension, and hyperlipidemia. The patient was recently hospitalized for a traumatic fall at home resulting in a cerebrum hemorrhage. He was transferred to a rehabilitation and nursing facility for physical and occupational therapy. He was screened as corona virus disease (COVID-19) positive.  

The patient's rehabilitation physician noted that the patient's condition was stable and found to have medication induced edema. He was stated to have decreased cognition and needed increased hours from home care on return home. This note did not document the physician's recognition of the number of current hours approved. The patient was stated to be alert, awake, alert and oriented times one with generalized weakness, a normal cardiopulmonary and abdominal examination, and no functional assessment was documented. There is no physician documentation of the patient's cognitive severity, functional assessment or opinion related to the patient's medically necessary needs.  

Based on the submitted documentation, the medical necessity for the requested 168 Personal Assistance (PAS) hours is not supported.  

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

The insurer's denial of coverage for increase to 24 hours per day (split-shift), 7 days per week, total 168 hours per week, Consumer Directed Personal Assistance (CDPAS) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hyperlipidemia, osteoarthritis, and vascular dementia

Treatment: Personal care services, 8 hours a day, 7 days a week for a total of 56 hours a week

The insurer denied coverage for personal care services, 8 hours a day, 7 days a week for a total of 56 hours a week.

The denial is overturned.

The patient has a history of hypertension, hyperlipidemia, osteoarthritis, and dementia.  The patient lives alone and was noted to suffer from vascular dementia, memory loss, poor endurance, and an unsteady gait.  Due to these conditions the patient does require hands-on assistance as well as prompting and cueing with most of the activities of daily living.  She required assistance with toileting due to her cognitive impairment.  The patient experienced frequent episodes of urinary incontinence and needed to be changed frequently in order to avoid skin breakdown and infection.  Although the patient preferred to use the toilet, she needed assistance transferring off and on.  The patient needed help with post elimination hygiene on the toilet and with her polyps.  The patient had difficulty ambulating and used a walker in the home.  She required contact-guard assist because she had an unsteady gait.  She needed assistance to bathe and needed assistance with grooming due to dementia.  Her meals had to be prepared and set up for her.  

The patient lives alone and is noted to suffer from memory loss, poor endurance, and an unsteady gait which increases her risk for falls and other potential complications from that. She previously had 56 hours of personal assistance services (PAS) approved and after a thorough review of her situation her hours were recommended to decrease to 28 PAS hours weekly. 

The information provided indicates that she has significant cognitive impairment from vascular dementia and that she needs help with all her activities of daily living (ADLs). She is also frequently incontinent of urine and needs to be changed frequently. She needs help getting on and off the commode after elimination. Increasing her hours will likely prevent any adverse incidents, will reduce or ameliorate the physical effects of her condition and assist the patient to maintain her independence and continue to live in her home. The 4 hours PAS daily will not be enough for the PAS provider to complete the tasks necessary to provide for her needs. Being alone for several hours a day will increase her risk for falls and delay in care for serious illnesses such as infections and fractures. Not increasing the hours of her PAS will likely cause the patient to move from her current living situation into an institution especially if she suffers an adverse event.

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

The insurer's denial of coverage for personal care services, 8 hours a day, 7 days a week for a total of 56 hours a week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke.
Treatment: Acute rehabilitation admission.
The insurer denied coverage for the acute rehabilitation admission.
The denial is overturned.

This is a patient who had multiple strokes years ago and was hospitalized for a recent stroke.  His deficits include expressive aphasia, dysphagia, percutaneous endoscopic gastrostomy (PEG) tube, and poor standing balance.  He was scheduled for hospital discharge, pending "at goal feeding" due to the recent PEG tube placement.  Under review is the medical necessity of an acute rehabilitation admission. 

This physician agrees with the treating physicians and therapists that the acute rehabilitation transfer from the hospital upon discharge would have been clinically appropriate and medically necessary.  The patient has functional deficits that were amenable to acute inpatient rehabilitation, particularly intensive physical and occupational therapy.  His ability to perform activities of daily living and functional mobility had the potential for significant improvement with intensive acute rehabilitation therapy.  Ongoing swallowing status particularly given the recent PEG tube placement would have been best provided by a speech therapist in the acute rehabilitation setting.  Ongoing physician monitoring and nursing care while in the acute inpatient facility would have also been appropriate.  

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, acute rehabilitation admission was medically necessary.

The insurer's denial of coverage for acute rehabilitation admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anoxic brain injury. 
Treatment: Acute Rehabilitation Facility. 

The insurer denied the Acute Rehabilitation Facility. 
The denial is overturned. 

The patient is a male with history of anoxic brain injury secondary to seizure and cardiac arrest with ventricular fibrillation with resuscitation. He has history of seizure. There are no ongoing acute clinical conditions. 

The request is by the treating physician for transfer to an acute inpatient rehabilitation with a specialized Disorder of Consciousness program and management for Traumatic Brain Injury. This will be in addition to regular PT (physical therapy), OT (occupational therapy) and Speech Therapy. 

Since the incidents, the patient has not gone through any intensive rehabilitation program. 

On prior level of function, the patient was independent with ADLs (activities of daily living) an engaged to be married while living with his family, but since after the cardiac arrest, he is requiring total dependence for all activities of Daily Living (ADLs). He remains totally dependent on ADLs (activities of daily living). 

Yes, the Acute Rehabilitation Facility admission is medically necessary. 

The patient has met all the criteria for acute rehabilitation care Interqual Rehabilitation Level of Care: CNS/TBI (central nervous system/traumatic brain injury) Guidelines for Acute Rehabilitation in a patient with severe anoxic brain injury secondary to seizure and cardiac arrest with ventricular fibrillation. He is now totally dependent for ADLs (activities of daily living) and he requires an acute inpatient rehabilitation with a specialized Disorder of Consciousness program and management for Traumatic Brain Injury. This will be in addition to regular PT (physical therapy), OT (occupational therapy) and Speech Therapy. The plan is to discharge him to live with his family. 

Based on the above and for Anoxic Brain injury, he will benefit from an intensive Brain Injury rehabilitation program in a facility with specialized disorder of consciousness program that will also include PT (physical therapy), OT (occupational therapy) and SLP (speech-language pathology) while his seizure and cardiac issues are also managed. 

An initial 4 weeks with monitoring of progress is recommended. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

The patient requires an acute inpatient rehabilitation with a specialized Disorder of Consciousness program and management for Traumatic Brain Injury. This will be in addition to regular PT (physical therapy), OT (occupational therapy) and Speech Therapy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, diabetes, congestive heart failure, bowel/bladder incontinence and dementia.

Treatment: Increase in Home Care (HHC)/ Personal Care Services (PCS) HHC - Level 2 PCS, per 15 minutes, to 24 hour(s) per day (Live In).

The insurer denied coverage for increase in Home Care (HHC)/ Personal Care Services (PCS) HHC - Level 2 PCS, per 15 minutes, to 24 hour(s) per day (Live In).

The denial is overturned.

This is an elderly patient with multiple medical problems including arthritis, diabetes, congestive heart failure, bowel/bladder incontinence and dementia.  She lives alone.  She currently receives Home Care/Personal Care Services 56 hours/week.  Under review is the medical necessity of requested increase HHC - Level 2 PCS, to 24 hours per day (Live In). 

According to the clinical records, the Uniform Assessment System (UAS) reports do not document that the patient has had a significant functional decline during this time.  Activities such as bed mobility, bathing, hygiene, dressing, walking, and medication management have essentially remained the same. However, the patient's functional deficits are substantial.   She requires maximal assistance to total dependence for meal preparation, housework and managing medications.  Activities of daily living tasks such as personal hygiene, upper/lower body dressing, toilet use, and walking range from extensive to maximal assistance.  The patient is bowel and bladder incontinent, and her memory is described as poor.   Her arthritic condition renders her incapable of safe transfer activities or short distance ambulation without "extensive assistance" of her personal care aide.  This physician would agree that the requested 24 (live-in) care is clinically appropriate, medically necessary and provides the patient with the safest at home living environment at this time. 

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

The insurer's denial of coverage for increase in Home Care (HHC)/ Personal Care Services (PCS) HHC - Level 2 PCS, per 15 minutes, to 24 hour(s) per day (Live In) is overturned. Medical is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis

Treatment: Dupixent 300 milligram (mg)/2 milliliter (ml) SC (subcutaneous) SOPN (solution pen injector)

The insurer denied coverage for Dupixent 300 milligram (mg)/2 milliliter (ml) SC SOPN

The denial is upheld

The patient has a history of atopic dermatitis who has reportedly been treated with Dupixent (no documentation is provided to demonstrate length of treatment).  The insurance company prescription fill analysis indicates that the patient has not filled prescriptions for any medications used to treat atopic dermatitis other than triamcinolone and betamethasone cream.  The requested medication is Dupixent.  

Based on the provided documentation, the requested medication, Dupixent, is not medically necessary for this patient's condition.  There is no medical and scientific literature that strongly support the administration of Dupixent for this patient's condition and disease severity as an accepted standard of practice in the United States compared to alternative therapies.  

The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this individual in the documentation provided that would make it medically necessary.  

The documentation provided does not identify the severity of the patient's atopic dermatitis which would warrant systemic therapy.  It is noted that the patient has been treated with Dupixent; however, there is no documentation that demonstrates the length of treatment, the previously failed medications, or even the objective severity of the atopic dermatitis currently or prior to initiation of Dupixent.  The insurance company provided medication fill log indicates that the patient has only failed therapy with topical steroids.  The patient has no documented true contraindications to the conventional medications commonly used for atopic dermatitis.  

According to the dermatology literature, the conventional medications such as Protopic, Elidel, and (for moderate to severe atopic dermatitis) methotrexate are effective treatments for the management of atopic dermatitis (1,2).

The conventional medications, such as Protopic and Elidel topically and/or systemic methotrexate, should be tried and failed prior to initiating Dupixent.  Therefore, Dupixent is not medically necessary for this patient according to the standard of care.

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

The insurer's denial of coverage for Dupixent 300 milligram (mg)/2 milliliter (ml) SC SOPN is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension.
Treatment: Edarbyclor (azilsartan-chlorthalidone).
The insurer denied coverage for Edarbyclor (azilsartan-chlorthalidone).
The denial is upheld.

This is a patient with a history of hypertension, asthma, and obstructive sleep apnea. Hypertension was treated with propranolol and Edarbyclor therapies.  Coverage for renewal of Edarbyclor (azilsartan-chlorthalidone) was denied. There was no information stating that patient could not tolerate alternatives on the formulary such as Losartan hydrochlorothiazide, Olmesartan-hydrochlorothiazide, or Valsartan-hydrochlorothiazide.

The formulary drugs are not likely to cause an adverse reaction. According to American Heart Association/American College of Cardiology (AHA/ACC) and European Society guidelines for the treatment of hypertension, Valsartan is a primary agent for treatment. (Reference 1,2) In this case, there is no documentation of inefficacy or intolerance to formulary medications. In conclusion, there is no reason to believe that the formulary drugs would be less effective than Edarbyclor. 

The insurer's denial of coverage for Formulary Exception for Edarbyclor 40/12.5 mg (milligram) tablet (azilsartan-chlorthalidone) is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decompensated Heart Failure (HF)
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.

The patient has a history of non-ischemic cardiomyopathy (CMP) with an ejection fraction (EF) of 5-15% (percent), congestive heart failure (CHF), status post automatic implantable cardioverter defibrillation (AICD), obstructive sleep apnea (OSA), hypertension (HTN), and polysubstance abuse. Patient presented to the emergency room (ER) with complaints of increasing shortness of breath (SOB) and dyspnea on exertion (DOE). The patient was recently admitted to hospital for similar complaints. At discharge his Lasix dose was decreased to 40 mg (milligrams) from 80 mg. The patient feels that led to the worsening of his symptoms. As per history, there is also some suggestion of non-compliance with medications.

The patient was noted to be in respiratory distress. Respiratory Rate was 26. Lung exam revealed some rales at the bases. There was bilateral (B/L) pitting lower extremity (LE) edema noted. White blood cell count (WBC) was 5K (thousand), hemoglobin (Hb) was 14.5, blood urea nitrogen (BUN)/Creatinine (Cr) 19/1.3, and Troponin was elevated to 0.08. Pro BNP (B-type natriuretic peptide) > 3000, chest x-ray (CXR) revealed mild pulmonary vascular congestion. 

The patient was treated with sublingual (S/L) nitroglycerin (NTG) and he was placed on BIPAP (bilevel positive airway pressure). He was given intravenous (IV) Lasix 80 mg BID [twice daily]. The patient was also placed on Duonebs. The patient was admitted to Cardiac Telemetry floor for decompensated heart failure (HF). The patient was seen by Cardiology and Aldactone was started for his Class IV congestive heart failure (CHF). The patient was being considered for left ventricular assist device (LVAD) vs Cardiac Transplant due to his advanced New York Heart Association (NYHA) Class IV CHF.

Admission was appropriate given the patient's tenuous condition and history of severe  decompensated heart failure. The patient was treated with intravenous (IV) Lasix 80 mg BID after admission up until his discharge. Aldactone was added and other cardiac meds were adjusted per cardiology. The patient was placed on BIPAP. Myocardial infarction (MI) was ruled out (R/O). The patient needed close monitoring of his intake and output (I & O) and Cardiac enzymes, Electrolytes and BUN/Cr while being aggressively diuresed with Lasix 80 mg IV BID daily and Metazolone orally (PO). For this to be accomplished, the patient was appropriately admitted to a Cardiology Telemetry floor.

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

The insurer's denial of coverage for the inpatient admission is overturned. Medical necessity is substantiated.