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

Diagnosis: Acute appendicitis. 
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission. 
The denial is upheld. 

This case involves a pediatric patient who was seen in the emergency department with abdominal pain. The patient's pain was in the right lower quadrant periumbilical area and was of moderate severity. The pain was gradual over the course of 7 hours with progression waxing and waning. Nothing relieved the symptoms and the patient experienced associated vomiting. Vital signs were stable. The white blood cell count was elevated to 17.6 with mean platelet volume of 6.8 and platelets elevated at 424. Neutrophils were elevated at 84.2 with lymphocytes decreased to 10.8 and with absolute neutrophils at 14.9.  A computerized tomography (CT) of the abdomen done with intravenous contrast noted that the appendix was distended with fluid and measured up to 9 millimeters (mm). There were no signs of perforation. The impression also noted a fatty liver. The patient was admitted and underwent a laparoscopic appendectomy. The patient received intravenous fluids and medication while undergoing monitoring. The patient was discharged once hemodynamic stability was achieved. The inpatient hospital admission was denied coverage with claims that the procedure was conducted without complication and the patient remained stable while being monitored. An appeal was submitted stating that the patient was admitted for the management of acute appendicitis and required inpatient admission for the emergency surgery and close monitoring. 

The Milliman Care Guidelines state that for pediatric patients diagnosed with acute appendicitis and who are being recommended for laparoscopic appendectomy, the goal length of hospitalization is ambulatory. The information provided for the review stated that the patient presented with abdominal pain and emesis. A CT confirmed evidence of appendicitis without perforation. The patient was not admitted until the following day where upon the patient underwent the appendectomy without complication. The patient was discharged later in the afternoon once the patient was stable postoperatively. Based upon the provided information, it was determined that the patient did not require inpatient care. The procedure could have been safely and effectively conducted on an ambulatory basis using monitoring as a means of providing care to the patient as needed. There were no complications during or after the surgery and the patient could have had the care rendered on an observational or outpatient basis. As such, the inpatient hospital admission was not considered 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld 

This patient is an adult with diabetes, hypertension and peripheral vascular disease who presented to the emergency department (ED) with complaints of shortness of breath (SOB) and productive cough with yellow sputum for 3 days. The patient also reported some fever and chills. The patient was seen in Urgent Care and diagnosed with pneumonia and sent to the ED for evaluation.

At presentation to the ED the temperature was 98.5 degrees Fahrenheit, pulse 89, respiratory rate 24, blood pressure 140/86 and oxygen saturation 96%. A lung exam revealed scattered rhonchi. Heart sounds were normal. The abdomen was soft. The patient was awake and alert with an unremarkable neurologic exam. Lab results included a white blood cell (WBC) count of 8.5, Hemoglobin of 10.2, Sodium 132, Blood urea nitrogen 27, Creatinine 1.6, and Procalcitonin <0.09. A chest x-ray showed no acute pathology. A computed tomography of the chest revealed no infiltrates, no pleural effusions or traumatic pneumothorax. The patient was diagnosed with possible pneumonia and placed on intravenous (IV) Zosyn. The patient was seen by Infectious Disease and the diagnosis was bronchitis. The patient was switched to Rocephin and Azithromycin. This patient remained stable after admission and was discharged on oral antibiotics.

This patient did not need acute inpatient hospitalization. He could have been placed in Observation while diagnostic testing and treatment were initiated. A CURB 65 (pneumonia severity score) score was zero. This patient could have been placed on oral antibiotics if clinically indicated and discharged home after a brief period in observation with close follow-up in an outpatient setting.

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 hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ankle fracture. 
Treatment: Inpatient admission. 
The insurer denied coverage for an inpatient admission. 
The denial is upheld. 

This is a patient with a history of fractures. The patient presented to the hospital for right ankle open reduction and internal fixation (ORIF). The patient underwent the procedure without complications and received prophylactic antibiotics post-operatively. Non-Absorbable sutures were utilized. The patient's pain was controlled by a patient-controlled analgesia (PCA) and transitioned to oral pain medication. The patient tolerated physical therapy and the pain was adequately controlled. The Labs and vitals were stable. The patient was medically cleared for discharge. 
 
The medical records show surgery lasted approximately three hours and forty minutes. The operation was complex with several surgical incisions with implantation of hardware. The records show a non-complicated post operative course. The Pain Service reported pain of 1-2/10. A popliteal block was provided. Patient controlled analgesia (PCA) was utilized but no documentation of continuation. The records showed vital signs were stable. There was no evidence or concern for compartment syndrome. Her wound was without problem. The young girl was able to tolerate oral pain medications. She was ambulatory using crutches. She did not require other consultations nor imaging. She was clear for discharge. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral atherosclerosis, vascular dementia, dysphagia, hypertension, chronic kidney disease (stage 4),

Treatment: an increase in personal care worker (PCW) services to 7 days per week, 24 hours per day, live-in: 91 hours per week

The insurer denied coverage for an increase in personal care worker (PCW) services to 7 days per week, 24 hours per day, live-in: 91 hours per week

The denial is overturned

This is an elderly patient with a history of cerebral atherosclerosis, vascular dementia, dysphagia, hypertension, chronic kidney disease (stage 4), thyrotoxicosis and osteoarthritis. The patient is receiving hospice services. Live-in personal care worker (PCW) services are requested.

The records show a continual decline in several body systems. Life expectancy is limited. There is great risk for fall if the patient attempts to get out of bed on her own. She is bed bound and incontinent and leaving her in bed alone would not be appropriate. She does not have access to another caretaker. Her physician clearly has demonstrated her declining status and the need for additional care. 

An increase in personal care worker (PCW) services to 7 days per week, 24 hours per day, live-in; 91 hours per week is considered medically necessary for this patient.

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 personal care worker (PCW) services to 7 days per week, 24 hours per day, live-in; 91 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: R (right) knee osteoarthritis (OA) 
Treatment: Peripheral Nerve Stimulator (PNS)
The insurer denied a Peripheral Nerve Stimulator. 
The health plan's determination is upheld. 

The patient is a female with a past medical history (PMH) of R (right) knee osteoarthritis (OA) and pes anserine bursitis. Per the notes, she is not a surgical candidate secondary to her weight. She had a pes bursa injection with 70%(percent) improvement in symptoms. She was doing physical therapy (PT) as well and overall feeling a little better.

Peripheral Nerve Stimulator is not medically necessary for this patient.
There were two medical notes available for review. The later note indicates improvement in symptoms. There were no additional clinical evaluations which may provide further information about the length of time and previous treatments provided to this patient. Based on the two available notes, there is insufficient evidence to determine medical necessity for this device.
There is a role for PNS as a part of standard of care for specific patients; however, further clinical information including length of symptoms, length of various drug trials, physical therapy (PT), injection trials and modalities would need to be documented.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Diabetes mellitus
Treatment:  Freestyle kit sensor

The insurer denied coverage for Freestyle kit sensor.  The denial is upheld.

The treating provider has diagnosed the patient with a history of type two diabetes mellitus and malignant neoplasm of the right breast. The patient is being treated with Metformin and Ozempic. The patient will be starting Lupron, and there are concerns this may increase the patient's blood glucose levels. The treating provider has recommended and is requesting the approval of the Freestyle Libre to monitor the patient's blood glucose levels as she starts this new medication. 

Per Optum Prior Authorization Guideline; Continuous Glucose Monitors - NY Medicaid Criteria:

Product Name: Dexcom (sensor, transmitter, and receiver), Freestyle Libre (reader, sensor), Enlite sensor, Eversense (sensor,transmitter), Minilink transmitter, Paradigm transmitter.

Approval Criteria:  1) Diagnosis of diabetes [Met], AND 2) Patient is on an intensive insulin regimen (3 or more insulin injections per day or uses continuous subcutaneous insulin infusion pump) [Not Met], AND 3) Patient regularly monitors blood glucose 4 or more times per day [Met].

The patient is on oral agents and glucagon-like peptide 1 (GLP-1) analogs for type two diabetes management. The patient is not on an intensive insulin regimen (multiple daily insulin injections or pump therapy). Further, Lupron is not known to cause hyperglycemia in women. As such, the freestyle kit sensor is not medically necessary for this patient.

Per Kudva, Y. C. et al. (2018), "Large randomized controlled trials demonstrated that use of the FreeStyle Libre system resulted in significant reductions in hypoglycemia, increased time in target range, reduced glycemic variability, and greater patient satisfaction compared with fingerstick monitoring. These benefits were seen in well-controlled type 1 diabetes (T1D) as well as sub optimally controlled type 2 diabetes (T2D) treated with intensive insulin therapy. Studies also showed high device utilization, suggesting that the FreeStyle Libre system may enhance patient engagement. Smaller observational and prospective studies have also shown improvements in both A1c (glycated hemoglobin) and a reduction in hypoglycemic events."

Per LUPRON DEPOT package insert / product description (2014); "Prescribing Highlights:

5.2 Hyperglycemia and Diabetes

Hyperglycemia and an increased risk of developing diabetes have been reported in men receiving gonadotropin releasing hormone (GnRH) agonists. The most common side effects associated with LUPRON DEPOT are hot flashes, pain (especially joint pain and back pain), injection site pain and fatigue."                                                         

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

The insurer's denial of coverage for Freestyle kit sensor is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer, incontinence
Treatment: Personal Care Worker (PCW) Services: 7 Days/Week, 24 Hours/Day, Continuous Care by More Than 1 Person (168 Hours/Week)
The insurer denied PCW services: 7 days/week, 24 hours/day, continuous care by more than 1 person (168 hours/week).
The health plan's determination is overturned.

The patient is a female with past medical history of hypertension, constipation, urinary incontinence, bowel incontinence, seizures, atrial fibrillation, deep vein thrombosis (DVT), and brain tumor who had been assigned PCW (personal care worker) services.

PCW services: 7 days/week, 24 hours/day, continuous care by more than 1 person (168 hours/week) are medically necessary for this patient.

There is documentation of progression of the patient's brain tumor with enrollment in hospice services 4 months prior. There is documentation of worsening cognitive and functional capacity due to progression of disease. The patient's medical provider documented medical necessity of turning and repositioning every 2 hours as well as frequent incontinence cares in the overnight hours. The patient also requires frequent repositioning for discomfort. The patient's overnight care needs would not allow a PCW 5 hours of uninterrupted sleep. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, PCW services 7 days/week, 24 hours/day, continuous care by more than 1 person (168 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 her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriatic Arthritis
Treatment: Rinvoq 15 milligrams (mg) oral tablets (24-hour extended release)
The insurer denied Rinvoq 15 mg oral tablets (24-hour extended release).
The denial is upheld.

The patient is an adult male with psoriasis and psoriatic arthritis, treated with topicals, phototherapy, and systemic steroids. His psoriasis is located on the hands and feet with nail changes and deformity of the finger and toe joints and morning stiffness. The provider is requesting Rinvoq. The health plan requires use of methotrexate or cyclosporine prior to use of Rinvoq.

The proposed use of Rinvoq is not medically necessary.

Rinvoq is currently approved for psoriatic arthritis only. While it has demonstrated efficacy for this condition, it is not currently first line therapy for psoriasis and psoriatic arthritis. In the phase 3 study by McInnes, et al, American College of Rheumatology (ACR) criteria showing 20% (percent) improvement/50% improvement/70% improvement (ACR20/50/70), 75% or greater reduction/90% or greater reduction/100% reduction in Psoriasis Area and Severity Index (PASI75/90/100) scores and minimal disease activity (MDA) responses were maintained with upadacitinib (Rinvoq) through week 56 and were generally numerically higher than with adalimumab (Humira); inhibition of radiographic progression was also maintained. However, numerous other therapies are used for psoriatic arthritis and Rinvoq has not been compared extensively to these. A trial of systemic immunosuppressants is well established in current guidelines and the patient has no documented contraindications to these. 

Therefore, Rinvoq is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), asthma, osteoarthritis, and diabetes
Treatment: Increase Home Health Aide Services to 40 Hours
The insurer denied: Increase Home Health Aide Services to 40 Hours
The denial is upheld

This adult female patient has medical conditions including coronary artery disease, hypertension, gastroesophageal reflux disease (GERD), asthma, osteoarthritis, and diabetes.  She is appealing denial of an increase in home health aide services to 40 hours.  Uniform Assessment System evaluation dated earlier this year shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing medications and transportation; limited assistance with managing finances, phone use, bathing, lower body dressing, and toileting; and independent with personal hygiene, upper body dressing, walking, locomotion, bed mobility, and eating.  She has frequent bladder incontinence.

The proposed 40 hours of home health services are not medically necessary.

Personal assistance services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient has multiple chronic conditions. She is appealing the denial of an increase in home health aide services to 40 hours.  Uniform Assessment System evaluation dated earlier this year shows the patient needs assistance with meal preparation, housework, shopping, managing medications, transportation, managing finances, phone use, bathing, lower body dressing, and toileting.  She is independent with personal hygiene, upper body dressing, walking, locomotion, bed mobility, and eating.  

There are no provider records or appeal statements.  The information provided does not support that the patient has functional needs requiring home health aide services to 40 hours.  Home health aide services are not indicated when no tasks are being performed.  The level of services needed for assistance as noted above do not require 40 hours of home health aide services.  The proposed increase in home health aide services to 40 hours is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COPD (chronic obstructive pulmonary disease)
Treatment: Skilled Nursing Facility Admission
The insurer denied the Skilled Nursing Facility Admission.
The determination is upheld.

The patient was readmitted to the Skilled Nursing Facility (SNF) for restorative physical and occupational therapy after a recent admission to the hospital for chest pain, generalized anxiety, chronic obstructive pulmonary disease (COPD), multiple seizures and major depressive disorder. She was admitted to the SNF for further physical/occupational/speech therapy. At issue is the medical necessity of a Skilled Nursing Facility.

The requested health service/treatment of Skilled Nursing Facility Admission was not medically necessary for this patient.

This patient was readmitted to the SNF for restorative physical & occupational therapy after recent admission to the hospital for chest pain, generalized anxiety, chronic obstructive pulmonary disease (COPD), multiple seizures and major depressive disorder. She was admitted to the SNF for further physical/occupational/speech therapy. On admission, she was alert and verbally responsive, hemodynamically stable had an oxygen saturation of 98 percent (%) requiring 3 liters per minute of supplemental oxygen and was on a prednisone taper for an acute COPD exacerbation and was noted to require extensive assistance with activities of daily living care. The physical therapy evaluation noted she had impaired transfers, ambulation, bed mobility skills and would benefit from skilled physical therapy (PT) to improve functional mobility/ambulation. The speech therapy initial evaluation stated the patient was discharged on a pureed diet, but her previous diet was mechanical soft consistency. Her speech was noted to be dysfluent, apraxic and low in volume. Her swallow function assessment concluded she would require a puree diet with nectar thick liquids. She was recommended for swallow therapy to improve cognitive skills and determine the least restrictive diet. The occupational therapy assessment noted physical impairments and associated functional deficit hindering her functional performance. She was recommended for occupational therapy intervention to facilitate and increase independence in activities of daily living and enhance her quality of life in order to return to her previous level of function. Per the clinical information provided, there was no documentation she requires nursing greater than or equal to (>=) 4 hours per day and per the physical and occupational therapy services she required total or maximum assist for most skills. The patient did not require skilled nursing services and/or having a new impairment or documentation of a rehabilitation potential with an expectation for clinical improvement. Also, there was no documentation that treatment was precluded in a lower level of care. Therefore, the Skilled Nursing Facility Admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male who presented to the emergency department complaining of intermittent, non-exertional left-sided chest pain and dyspnea. His medical history was remarkable for coronary artery disease, coronary artery bypass graft surgery, sick sinus syndrome, permanent pacemaker implantation, hypertension, hyperlipidemia, chronic kidney disease, intravenous drug use, heart failure with preserved ejection fraction and hepatitis C infection. 

The inpatient admission was not medically necessary.
This man, with known coronary artery disease, presented with symptoms that were thought to possibly represent acute coronary syndrome (ACS). Accordingly, observation until ACS could be ruled out was a reasonable approach. However, he was hemodynamically stable, with normal cardiac biomarkers, and no ischemic electrocardiographic changes. He did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under "observation" status. This approach has been shown to be both safe and effective and is in accordance with current guidelines.
The patient had a mild increase in his baseline serum creatinine level upon admission and during his hospitalization. However, he had no acute electrolyte or acid/base perturbations and no treatment other than holding his usual lisinopril dose was required. Inpatient Hospitalization was not medically necessary on this basis.