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

Diagnosis: End stage heart failure, chronic kidney disease
Treatment: Consumer Directed Personal Care Aide for 168 
Hours/Week
The insurer denied: Consumer Directed Personal Care Aide for 168 Hours/Week
The denial is upheld.

This patient is an elderly female with medical conditions that include end stage heart failure, kidney stones, heart failure, chronic kidney disease, and cirrhosis. The denial of consumer 
directed personal care aide for 168 hours per week is being appealed. The health plan approved 35 hours per week. The patient is requesting additional care and supervision due to weakness. Uniform Assessment System evaluation completed 4 months ago shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, and bathing; extensive assistance with managing finances, dressing, walking, locomotion, and toileting; and limited assistance with phone use, personal hygiene, bed mobility, and eating. She has a Foley catheter. She has infrequent bowel incontinence. A letter from the Social Worker notes the patient is currently in hospice care and needs 24/7 supervision.

The proposed treatment is not 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. Continuous 
or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has end stage heart failure. The denial of consumer directed personal care aide for 168 hours per week is being appealed. The health plan approved 35 hours per week. Uniform Assessment System (UAS) evaluation completed 4 months ago shows the patient needs assistance with all activities of daily living. She has a Foley catheter. This patient has significant limitations with activities of daily living. However, the information does not support that the patient has continuous needs, such as frequent assistance with toileting, transfers, and turning/repositioning. Therefore, the proposed increase consumer directed personal care aide to 168 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dyspnea, Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who presented to the emergency department (ED) complaining of three days of dyspnea, chest pain, abdominal pain, cough and lower extremity edema. Her medical history was remarkable for nonischemic cardiomyopathy, heart failure with reduced ejection fraction (30 percent [%]), hypertension, chronic kidney disease, asthma and obesity. An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin I level was .05 nanograms/milliliter (ng/ml) and was unchanged when re-measured. Her brain (or B-type) natriuretic peptide (BNP) level was 2315 picograms per milliliter (pg/ml). Her serum creatinine level was 1.65 milligrams per deciliter (mg/dl), which was her baseline. A chest x-ray showed mild cardiomegaly and mild pulmonary vascular congestion. A chest computed tomography (CT) scan showed no evidence of a pulmonary embolism. There was possible right lower lobe atelectasis versus pneumonia and right middle lobe atelectasis. The patient was treated with intravenous furosemide, morphine and nebulized bronchodilators. She was admitted to the hospital. Twice daily intravenous furosemide, bronchodilators, steroids and antibiotics were prescribed. She had persistent dyspnea, chest pain, lower extremity edema and developed wheezing. Her serum creatinine level rose to 1.94 mg/dl. Her troponin level was .06 ng/ml. Her furosemide was held. Her creatinine level was 1.74 mg/dl. She was discharged. The medical necessity for an inpatient admission is at issue.

Based on the documentation provided an inpatient level of care was medically necessary.
This patient presented with acute decompensated heart failure (ADHF). Her brain (or B-type) natriuretic peptide (BNP) level was markedly elevated at 2315 pg/ml. In the Acute Decompensated Heart Failure National Registry (ADHERE) registry, admission BNP values in the highest quartile (BNP greater than or equal to (>=) 1730 pg/mL) was associated with a 2.23-fold increase in in-hospital mortality compared with a BNP in the lowest quartile (less than [<] 430 pg/mL), even after adjustment for potential confounders and regardless of ejection fraction. The patient developed acute kidney injury in the setting of her chronic kidney disease. Acute kidney injury in patients hospitalized with decompensated heart failure is associated with significantly higher in-hospital mortality, longer duration of hospital stay, increased risk for readmission and increased risk of in-hospital complications including cardiac arrest and cardiogenic shock. This patient's high risk features warranted careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection
Treatment: Inpatient admission

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

The patient was an adult female admitted for nausea and vomiting. On examination, the patient had abdominal tenderness in the right upper quadrant and epigastric areas. Laboratory studies were remarkable for elevated venous potential of hydrogen (pH) at 7.44, hypokalemia at 3.4, thrombocytopenia at 173, elevated aspartate aminotransferase (AST) at 54, elevated alanine transaminase (ALT) at 41. White blood cell (WBC) count was 8.4. Urinalysis demonstrated 3+ proteinuria, blood, small leukocytes. Electrocardiogram (ECG) demonstrated sinus bradycardia. She was found to have urinary tract infection and was treated with antibiotics and intravenous (IV) fluid. Her condition improved and was discharged in stable condition.

The patient was hemodynamically stable, she was afebrile with normal oxygenation and negative cultures, did not have significant electrolytes disturbance or change in kidney function, did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting with dehydration. She was able to tolerate oral diet and did not require total parenteral nutrition and her work up was negative for acute process. 

Inpatient admission was not medically necessary, and observation was more appropriate.

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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ectopic erupted teeth. 
Treatment: D8080 Braces, D8670 Monthly Visit, D8620 Retainer. 

The insurer denied: D8080 Braces, D8670 Monthly Visit, D8620 Retainer. 
The denial is upheld. 

The patient is a teenage male. The denial of coverage for comprehensive orthodontic treatment is being appealed. The initial review denied treatment due to no automatic qualifying conditions and scoring less than 26 on the HLD (Handicapping Labio-Lingual Deviation) index.

The D8080 Braces, D8670 Monthly Visit, and D8620 Retainer is not medically necessary.

The patient in this case did not reach a score of 26 or greater on the HLD (Handicapping Labio-Lingual Deviation). This reviewer disagrees with the provider's scoring for two ectopic erupted teeth. There is not 3.5 mm (millimeters) of maxillary crowding, and there is not a tooth displaced 8mm (millimeters). The scoring by the plan was appropriate. Therefore, the D8080 Braces, D8670 Monthly Visit, and D8620 Retainer is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Dental issues
Dental/orthodontic

Diagnosis: anterior crossbite on teeth 7 and 10
Treatment: braces/monthly visits

The insurer denied braces/monthly visits. The health plan's determination is overturned. 

The patient in question is a male with an anterior crossbite on teeth 7 and 10. He presents with a Class III malocclusion with moderate crowding in the maxilla and mandible. He is treatment planned for braces and monthly visits. This is the subject under review.

Braces/monthly visits are medically necessary. This patient presents with an anterior crossbite on teeth 7 and 10, as well as significant crowding. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects.

If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason, braces/monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Wegovy 2.4mg (milligrams)/ 0.75ml (milliliters) Pen Injector
The insurer denied: Wegovy 2.4mg (milligrams)/ 0.75ml (milliliters) Pen 
The denial is upheld.

The patient is an adult female. She has a diagnosis of obesity. Her baseline body index (BMI) is 41.48. The patient has been taking samples of Wegovy, and her current BMI (body mass index) is 37.88. The health plan's denial of coverage of Wegovy is being appealed. She has tried and failed Ozempic. She has engaged in a trial of behavioral modification and dietary restriction for at least 3 months, and she has failed to achieve the desired weight loss. Wegovy will not be co-administered with semaglutide-containing products or GLP-1 (glucagon-like peptide 1) receptor agonists. The patient has provided information supporting prior weight loss program. She is using a weight loss app. She was referred to a weight loss clinic. She reports having a gym membership.

The treatment with Wegovy is not medically necessary. 

The information does not support that the patient is currently enrolled in a qualified comprehensive weight management program for at least 3 months. In addition, counseling in a physician's office is required. The reported weight loss app does not qualify for a comprehensive weight management program. Therefore, the requested Wegovy is not medically necessary, and the health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abnormal uterine bleeding

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a diagnosis of abnormal uterine bleeding with an unremarkable endometrial biopsy and stress urinary incontinence. The patient underwent a total vaginal hysterectomy bilateral salpingectomy and cystoscopy. The urogynecologist was involved and placed a retropubic mid urethral sling. The estimated blood loss was 100 milliliters (mL). The procedure was reported as uncomplicated. Progress notes postop documented that the patient was hemodynamically stable, afebrile with good control of the pain.  

A vaginal hysterectomy is an outpatient procedure (1,2,3,4). The safety of this approach has been documented in multiple studies.

Admission is usually not necessary unless there is a possible complication:
Heavy bleeding, 
Surgical complications (bladder ureter or bowel injury or hemorrhage)
Conversion to abdominal hysterectomy
Wound complications
Comorbidities.

This patient's procedure was uncomplicated. There was no evidence of any injury to other organs.

A vaginal hysterectomy is an outpatient procedure and includes appropriate postoperative monitoring and an overnight stay if required. In other words, the patient could have been monitored overnight without the need for an admission and once the provider ascertained that the patient was stable, the patient could have been sent home.

Based on above, the inpatient admission was not medically necessary for this patient care and management.

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 hospital admission is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Nasal Polyps
Treatment: Xhance
The insurer denied: Xhance
The denial is upheld.

The patient is an adult female with a history of nasal polyps, sinusitis and allergic rhinitis. She has been treated with Xhance for several years. There has also been treatment with systemic steroids, Flonase and Astelin. The provider is requesting treatment with Xhance. The request was previously denied as not meeting Plan criteria and the provider is appealing the denial. 

The health plan should not cover the proposed treatment. 

The patient has a history of nasal polyps, allergic rhinitis and 
sinusitis. There is not a detailed documentation of the failure of Plan formulary alternatives including dosing and length of therapy. There is not conclusive evidence in the scientific literature confirming that Xhance has greater efficacy than Plan formulary alternatives or has less adverse effects than Plan formulary alternatives. Therefore, based on the information provided, coverage of the Xhance by the Plan would not be confirmed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Services, 12 Hours a day, 7 days a week for a total of 84 hours. 
The insurer denied Personal Care Services, 12 Hours a day, 7 days a week for a total of 84 hours. 
The health plan's determination is overturned. 

The patient is a male with medical history notable for Alzheimer's dementia, urinary incontinence, gait dysfunction, and bladder cancer. The patient's physician provided a letter of support for this appeal. The letter states that the patient is homebound. He requires assistance for activities of daily living, including bathing, toileting, transferring, and ambulating with a walker. Due to the extent of his personal care needs, the physician requested an increase to 12 hours per day. 

The requested Personal Care Services (PCS): 12 Hours per Day / 7 Days per Week (Total of 84 Hours per Week) are medically necessary for this patient. 
The patient is of advanced age and suffers from dementia and mobility decline. He requires hands-on assistance for all activities of daily living including ambulating, transfers, toileting, and management of incontinence care products. His personal care needs can be reasonably expected to be continuous and unscheduled throughout the day. Therefore, the task tool recommendation for hours would likely underrepresent his true level of need. The requested increase to 12 hours per day would allow him to have personal care assistance available during most of the waking hours of the day to support his personal care needs. Therefore, the requested increase to 12 hours per day is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lung cancer
Treatment: Increase Personal Care Aide (PCA) Services to 
Live-in Per Diem For a Total Amount of 7 Days Per Week
The insurer denied: Increase Personal Care Aide (PCA) Services to Live-in Per Diem For a Total Amount of 7 Days Per Week
The denial is overturned.

The patient is an elderly male. His medical conditions include metastatic lung cancer. Denial of increase personal care aide (PCA) services to live-in per diem for a total amount of 7 days per week is being appealed. The health plan approved 2:7 hours per day, 7 days per week, for a total of 49 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 5 months ago compared to UAS (Uniform Assessment System) evaluation completed last year shows a decline in functioning and need for total assistance with lower body dressing, bathing, walking, and locomotion; maximal assistance with upper body dressing personal hygiene toileting, and bed mobility; and limited assistance with eating. A letter from the patient's provider notes the patient has weakness, fatigue and pain due to disease progression. The patient requires assistance with ADLs (activities of daily living), including walking, transferring, toileting, and repositioning in bed every two to four hours. A letter from another provider notes that the patient is rapidly declining. The patient requires assistance with all ADLs (activities of daily living), including walking, transferring, toileting, and repositioning in bed every two to four hours. A letter from another provider notes that the patient needs an orthopedic mattress. 

The Increase Personal Care Aide (PCA) Services to Live-in Per Diem For a Total Amount of 7 Days Per 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 increase personal care aide (PCA) services to live-in per diem for a total amount of 7 days per week is being appealed. The health plan approved 2:7 hours per day, 7 days per week, for a total of 49 hours per week. This patient has metastatic lung cancer. Uniform Assessment System (UAS) evaluation completed 5 months shows he needs maximal assistance to total dependence with all ADLs (activities of daily living), except limited assistance with eating. The appeal statements support the patient is dependent with all ADLs (activities of daily living). He requires assistance with all ADLs (activities of daily living), as well as repositioning every two to four hours. The information provided supports that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase PCA (personal care aide) from 49 hours per 
week to live-in, 7 days per week, is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left-sided hemiparesis
Treatment: Increase Personal Care Aide (PCA) Services For A Total Amount of 168 Hours Per Week
The insurer denied: Increase Personal Care Aide (PCA) Services For A Total Amount of 168 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her conditions include left-sided hemiparesis secondary to a stroke. She lives alone. Denial of increase personal care aide (PCA) services for a total amount of 168 hours per week is being appealed. The health plan approved an increase from 56 to 84 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 5 months ago shows modified independent cognition and functional status: total dependence with dressing, toileting, bathing, walking, locomotion, and bed mobility; extensive assistance with personal hygiene; and independent with eating. She has frequent bladder incontinence. A letter from the patient's provider notes recent hospitalizations due to COVID, respiratory failure, cystitis acute kidney injury, urinary tract infection, pancreatitis, sepsis, 
and atrial fibrillation. These hospitalizations resulted in worsening of the patient's physical and mental condition. She requires total care as well as repositioning every 4 hours. She is bedbound. 
She needs prompt assistance with hygiene due to urinary incontinence and a stage 1 pressure ulcer.

The Increase Personal Care Aide (PCA) Services For A Total Amount of 168 Hours Per 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. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of increase personal care aide (PCA) services for a total amount of 168 hours per week is being appealed. The health plan approved an increase from 56 to 84 hours per week. The patient has chronic left-sided hemiparesis and recent hospitalizations. Uniform Assessment System (UAS) evaluation completed 5 months ago shows she needs assistance with all ADLs (activities of daily living), except eating. She is incontinent of bladder. The appeal statements support the patient is dependent with all ADLs (activities of daily living). She lives alone. She is reported to bedbound, and she requires total care as well as repositioning every four hours. There has been a decline in her physical and mental condition since hospitalization. The information provided supports that the patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The requested increase in PCA (personal care aide) to 168 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity
Treatment: Ozempic
The insurer denied: Ozempic
The denial is upheld.

This is an adult male patient with obesity with a body mass index of 42 kilograms per meter squared (kg/m2) complicated by hyperlipidemia and obstructive sleep apnea. He has a family history of type 2 diabetes. The request for Ozempic is under review. The prior request was denied as the patient does not have type 2 diabetes. The provider is appealing this determination.

The requested Ozempic is not medically necessary.

This request is for Ozempic for the treatment of obesity. Ozempic is not Food and Drug Administration (FDA)-indicated for weight loss. The Ozempic prescribing information does not support the use of Ozempic in this clinical situation in the absence of type 2 diabetes. There are other drugs that are Food and Drug Administration (FDA)-indicated for weight loss. There is no documented medical reason to use Ozempic over other indicated weight loss drugs. The Endocrine Society guidelines on the management of obesity do not support the off-label use of 
Ozempic for the treatment of obesity. The American Diabetes Association guidelines do not support the use of Ozempic for the prevention of type 2 diabetes. Ozempic has risks, including nausea and vomiting. Therefore, no, the requested Ozempic is not medically necessary.