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

Diagnosis: Gastroenteritis, infected leg ulcer
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

 
The patient is an adult male with past medical history significant for diabetes mellitus, thyroid disease, hepatitis C virus (HCV), and polysubstance abuse, who presented to the emergency department with complaints of fever and diarrhea.

Vital signs on presentation included: Temperature 102.2 degrees Fahrenheit, Blood Pressure 149/89, Pulse 102, Respiratory Rate 18, Oxygen saturation 100% (percent) on Room Air. Laboratory results included the following: White Blood Cells (WBC) 8.1, Hemoglobin (Hgb) 13.4, Hematocrit (HCT) 40.3, potassium 3.1, creatinine 0.75, glucose 81. Chest X-ray (CXR) was negative.

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and ceftriaxone). Wound culture from his left leg venous stasis ulcer grew Staphylococcus aureus. Patient received IV hydration for possible gastroenteritis (diarrhea-12 episodes per day). Clostridium difficile testing was negative. Podiatry consulted for chronic leg ulcer. 

Patient improved clinically, remained afebrile and hemodynamically stable. He was discharged to continue outpatient management. 

According to documentation, etiology of symptoms remained unclear, requiring empiric IV antibiotics. Based on these abnormal findings in a high-risk patient with multiple co-morbid conditions including polysubstance abuse, inpatient hospital admission was medically necessary for IV antibiotics and additional diagnostic considerations.  

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 hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary embolism.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient was recent post-partum a few days prior to admission who presented to the emergency department (ED) with complaints of some chest pain, dizziness, diaphoresis, and palpitations. The patient recently had undergone a Dilation and curettage (D&C) due to retained products of conception and received 3 units of packed red blood cells (PRBC) at that time. Vital signs at presentation were: Temperature 98.8 degrees Fahrenheit, Heart Rate 77, Respiratory Rate 18, Blood Pressure 132/84 and oxygen saturation 100% on room air. The patient was in no acute distress, alert, and oriented x 3, lungs were clear, heart sounds normal, a trace of pedal edema was present, and the neuro exam was non-focal. White Blood Cells (WBC) 8,900, Hematocrit 25.1, Potassium 3.2, Blood Urea Nitrogen and Creatinine were within normal limits.

The patient had a computed tomography angiogram (CTA) of the lungs which revealed a left upper lobe (LUL) pulmonary embolism (PE). No right heart strain noted. Electrocardiogram (EKG) showed Normal Sinus Rhythm, no acute ST-T changes. The patient was started on Lovenox subcutaneous (SC) as she was breast feeding. The patient remained stable after admission, was afebrile and hemodynamically stable with oxygen saturation remaining at 98 - 100%. The patient had an echocardiogram which was essentially normal, no right heart strain. The patient remained stable after admission receiving SC Lovenox and was discharged.

This patient did not need acute inpatient hospitalization. She could have been placed in observation status while diagnostic testing and treatment were initiated. Observation period can be for up to 48 hours and this patient could have been kept in Observation while diagnostic testing and treatment were initiated and she could have been discharged home on SC Lovenox after a period under observation.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 
The medical necessity for inpatient admission is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Glaucoma. 
Treatment: Lumigan. 

The insurer denied Lumigan. 
The health plan's determination is overturned. 

The patient is requesting Lumigan (bimatoprost) for the treatment of primary open-angle glaucoma. Coverage was previously denied as it was not identified that the patient previously failed or was unable to use formulary alternatives including latanoprost and travoprost (generic Travatan Z). Upon appeal, it is identified that the patient has tried and failed latanoprost, travoprost, Travatan Z, and Alphagan. 

An exam documented the patient using Alphagan, dorzolamide-timolol and latanoprost with intraocular pressures of 21, 23 millimeters of mercury (mmHg) in the right eye (OD) and 18, 19 millimeters of mercury (mmHg) in the left eye (OS). As intraocular pressures were still elevated, Alphagan was discontinued, and it was recommended that latanoprost be changed to Rocklatan with continuation of dorzolamide-timolol. 

An exam documented the patient using dorzolamide-timolol and Travatan Z with intraocular pressures of 26, 18 millimeters of mercury (mmHg) in the right eye (OD) and 24, 19 millimeters of mercury (mmHg) in the left eye (OS). It was noted that the patient's intraocular pressures were better with branded Travatan from Spain. 

An exam note documented the patient using dorzolamide-timolol and Travatan Z with intraocular pressures elevated to 29, 29 millimeters of mercury (mmHg) in the right eye (OD) and 23, 25 millimeters of mercury (mmHg) in the left eye (OS). It is noted that Alphagan was unhelpful. The patient was to continue dorzolamid-timolol and switch from Travatan Z to Lumigan. 

At issue is the non-formulary medication (Lumigan). 

The formulary drug has been ineffective and is not as effective as the non-formulary drug. Latanoprost and travoprost, have been documented to be ineffective for this patient, therefore the patient has tried and failed the formulary alternatives. According to peer reviewed medical literature, Lumigan (bimatoprost) is established as more effective than latanoprost and travoprost at lowering intraocular pressures in patients with primary open angle glaucoma.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, dizziness, memory loss
Treatment: Increase Consumer Directed Personal Assistant (CCPAS) to 24 Hours per Day, Split Shift
The insurer denied: Increase Consumer Directed Personal Assistant (CCPAS) to 24 Hours per Day, Split Shift.
The denial is overturned.

This elderly female has conditions including Alzheimer's dementia, hypertension, hypothyroidism, right hand weakness, dizziness, memory loss, and is status post right hip fracture. She is appealing denial of increase in consumer directed personal assistant (CDPAS) to 24 hours per day, split shift. The health plan approved an increase to 70 hours per week. A letter from the provider notes the patient is homebound and bedbound. She needs assistance throughout day and night, to include assistance with ambulation, toileting, transferring, and turning/repositioning. The letter notes an aide cannot sleep for five consecutive hours. A letter from another Provider notes the patient has cognitive and physical limitations as well as dementia. Additional home assistance is recommended. Medical records are provided supporting the patient's chronic conditions.

The proposed treatment 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. This patient has multiple chronic conditions. She is appealing denial of increase in consumer directed personal assistant (CDPAS) to 24 hours per day, split shift. The health plan approved increase to 70 hours per week. The appeal statements support the patient is dependent with all activities of daily living and requires frequent assistance with toileting, transfers, and turning/repositioning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The approved consumer directed personal assistant 70 hours per week is insufficient to meet the patient's needs. The proposed consumer directed personal assistant 24 hours per day, split shift, is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Consumer directed personal assistance program (CDPAP): 7 hours per day - 7 day(s) per week - a total amount of 49 hours per week.
The insurer denied the consumer directed personal assistance program (CDPAP): 7 hours per day - 7 day(s) per week - a total amount of 49 hours per week.
The denial is overturned.

The patient is a female with medical history notable for vertigo, gait imbalance, dementia, ambulatory dysfunction, and legal blindness. The patient is approved for 3.5 hours per day, 7 days per week (24.5 hours per week) of consumer directed personal assistance program (CDPAP). The patient and her care team requested an increase to 7 hour per day, 7 days per week (49 hours per week) of CDPAP, and this request was denied by the health plan. This denial is the subject under review.

A Uniform Assessment System (UAS) was completed and was available for review. Patient was alert and oriented to person and place only, with minimally impaired cognition. Recall was one out of three after five minutes. She is not able to describe the steps of procedural tasks. She is legally blind but has limited vision capability. From a functional standpoint, she requires total dependence for housework. She requires maximal assistance for meal preparation, managing finances, managing medications, and shopping. For her activities of daily living (ADLs), she requires extensive assistance for bathing, dressing lower body, walking, locomotion, toilet transfer, and toilet use. She requires limited assistance for hygiene and dressing upper body. She is independent with bed mobility and eating. She ambulates with the assistance of a cane and some weight bearing assistance. She is occasionally incontinent of urine and continent of stool. She uses liners and pull ups to manage incontinence. Compared with a prior assessment, she showed similar level of function for Instrumental activities of daily living (IADLs) but a decline in functioning with her ADLs. A task tool associated with the most recent assessment recommended 35 hours per week of personal care assistance to meet her needs, an increase from 24.5 recommended on prior assessment.

The requested increase in consumer directed personal assistance program (CDPAP) services for a total amount of 49 hours per week is medically necessary for this patient.
The patient showed a functional decline on her most recent UAS, which is corroborated by the testimony from the patient's daughter and her physician. She now needs hands on assistance for ADL's and cannot transfer or toilet independently. She has also developed some incontinence. It is reasonable to expect that she would need an increase in her personal care hours to meet these functional needs. The health plan did not increase her personal care hours despite the decline in functioning noted on the assessment and the recommendation for increased hours. These hours are not meant solely for safety monitoring and supervision, but for the provision of personal care needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Chest Pain
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a female with a history of anxiety. She presented to the emergency room with a one-hour history of chest pain made worse by moving and talking. The vital signs were normal, and she was in no acute distress. The physical exam was normal. Her labs were notable for a mildly elevated C-reactive protein, D-Dimer, and troponin. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. The chest computed tomography (CT) angiogram was negative for pulmonary embolus. The cardiologist evaluated the patient and noted that the pain had improved without any intervention, and it was not exacerbated by laying down. The patient was admitted for further treatment and evaluation.
Upon admission to a monitored bed, the patient was treated with her usual home medication. An echocardiogram was ordered, but because the troponin level increased somewhat, a cardiac catheterization was performed. It was negative for coronary artery disease, and the patient was discharged later on the day of admission.
At issue is the medical necessity of the inpatient hospital stay.
The health plan's determination of medical necessity is upheld in whole.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The chest pain was improving without specific intervention, there was no significant EKG abnormalities, hemodynamic instability, or abnormalities on the chest CT angiogram. The services provided - consultations, imaging studies, oral medication, and left heart catheterization - were not at the acute inpatient level of intensity. Therefore, based on the standard of care, as well as the peer reviewed literature cited in the references, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Inferolateral Ischemia.
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 hospital for elective cardiac catheterization after myocardial perfusion imaging that was performed for symptoms of exertional dyspnea that suggested inferolateral ischemia. His medical history was remarkable for hypertension, type 2 diabetes and hyperlipidemia. Upon presentation he denied chest pain or dyspnea. His blood pressure was 122/74 millimeters of mercury (mmHg) with a heart rate of 55 beats per minute. His room air oxygen saturation was 96 percent (%).
His cardiopulmonary examination was unremarkable. His electrocardiogram showed sinus rhythm at 58 beats per minute without ischemic changes. His renal function was normal. The coronary angiography showed a 90% stenosis of the posterior descending artery that was successfully treated with a stent. The procedure was uncomplicated. The patient was admitted to the hospital after the procedure. He had no acute complaints and was awake and alert, with normal vital signs. He remained stable overnight and was discharged.

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

Based on the documentation provided an inpatient level of care was not medically necessary. The patient presented for an elective cardiac catheterization and a possible percutaneous coronary intervention. He was hemodynamically stable upon presentation, without acute ischemic electrocardiographic changes. He underwent an uncomplicated coronary angiography and percutaneous coronary intervention (PCI). While some period of observation immediately following PCI is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, an inpatient admission is not generally required for most patients.

The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends an inpatient admission in patients with acute segment (ST) segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, an inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. According to the 2018 update to this document, with the exception of patients with ST segment elevation myocardial infarction, most stable patients can be discharged post-PCI once they are at their baseline functional and mental status and all of their baseline comorbidities are stable. Thus, based on the documentation provided, an inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Enlarged Prostate. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an elderly male with history of benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (LUTS) status post transurethral resection of the prostate (TURP) who presented with recurrent symptoms. The patient tried Flomax but developed nasal congestion. He was changed to finasteride which was ineffective. Cystoscopy demonstrated lateral lobe regrowth. The patient was identified to have a six-millimeter proximal ureteral stone. Past medical history includes hyperlipidemia and chronic kidney disease. The patient was noted to be American Society of Anesthesiologists (ASA) classification III due to age and history of hypertension (admission noted, records do not list hypertension or medications for hypertension). 
The patient underwent uncomplicated cystoscopy, transurethral prostatectomy, ureteroscopy, laser lithotripsy, and stent placement with minimal bleeding and no intraoperative complications. He remained hemodynamically stable during surgery with a maximum blood pressure of 150 intraoperative. In pre-op, the patient was normotensive and heart rate in the 50's. The patient was admitted for post-op intravenous hydration, pain control, and Foley monitoring. He had no medical issues during his hospitalization and was discharged to home the next day with a blood pressure of 113/64 and a heart rate of 57. 

The inpatient admission was denied as not medically necessary. 

The proposed treatment was not medically necessary. 

The patient underwent an uneventful surgical procedure, was hemodynamically stable during the procedure and in the recovery and did not require intervention for respiratory or cardiac status. There were no intraoperative complications, no significant bleeding, no reports of excessive pain, no clinically significant electrolyte abnormalities, and no documentation of severe pain. The patient progressed well postoperatively and had no signs of infection. Thus, the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Dupixent 300 MG (milligrams)/2 ML (milliliters) SC (subcutaneously) SOPN (Solution Pen-Injector)
The insurer denied Dupixent 300 MG/2 ML SC SOPN.
The denial is upheld.

The patient is an adult female with atopic dermatitis previously to the face, chest, extremities and trunk. Prior treatments include triamcinolone, hydrocortisone, betamethasone, Elidel, and prednisone. She has done well on Dupixent, but has had increased disease activity recently involving 30 percent body surface area (BSA). The provider is requesting to increase her dosing to weekly. The health plan denied the dosage increase to weekly dosing.

The proposed treatment is not medically necessary.

Randomized controlled trials for dupilumab did not find a significant difference in response to weekly dosing compared with that to every other week (EOW) dosing. The article by Gao, et al performed a cohort study to examine the real-world experience for recurrence of atopic dermatitis prior to the next dose of dupilumab and how patients on weekly dosed dupilumab did in the cohort, all of whom were inadequately controlled on the approved dosing. This was a small study with only 23 patients. The 23 patients who had tried weekly dupilumab were called, with 17 patients completing the survey. It was observed that 12/17 patients (71 percent) reported recurrence prior to their next dupilumab dose, and all of them (100 percent) claimed that increasing every other week (EOW) dosing of dupilumab to every week dosing helped control their symptoms; this benefit was worth the effort of injecting oneself twice as often, and they 
planned to remain on weekly dosing. From this study, weekly dosing of dupilumab may be beneficial to some patients with atopic dermatitis, particularly those experiencing a recurrence of atopic dermatitis symptoms on the standard dosing.

The randomized, double-blind, phase 3 clinical trial by Worm, et al showed that continued response over time was most consistently maintained with dupilumab administered weekly or every two weeks. Longer dosage intervals and placebo resulted in a diminution of response for both continuous and categorical end points. No new safety signals were observed. The approved regimen of 300 milligrams of dupilumab every two weeks is recommended for long-term treatment. The trial did not note a significant difference between weekly and every other week dosing.

Therefore, given that only one small study showed a benefit in patients receiving weekly dosing, the request cannot be considered within standard of care at this time, and therefore, is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: gynecomastia.
Treatment: breast reduction.
The insurer denied breast reduction.
 The health plan's determination is upheld. 

This male has a history of gynecomastia. He complains of pain. A Mammogram confirms the diagnosis of gynecomastia. Office notes from the plastic surgeon are not provided for review. Mastectomies are planned. This is under review.

Breast Reduction Surgery is not medically necessary for this patient.
According to the Milliman Care Guidelines (MCG), 26th Edition, Mastectomy for Gynecomastia:
Mastectomy for gynecomastia may be indicated for 1 or more of the following:
Postpubertal male and ALL of the following:
1) Functional impairment (eg, chronic skin irritation, pain, related psychological disorder requiring therapy) [MET, the patient reportedly has pain]
2) Gynecomastia did not regress after cessation of medications (eg, calcium channel blockers, cimetidine, phenothiazines, spironolactone, theophylline) known to cause condition, medications cannot be discontinued, or no medications that induce gynecomastia are being used. [NOT MET, there is no documentation of patient's medications]
3) No evidence of breast cancer [MET based on mammogram]
4) No evidence of other medical causes for gynecomastia, as indicated by normal results for ALL of the following: [NOT MET. A Medical workup for other causes of gynecomastia not documented.]
5) Hormone evaluation (ie, testosterone, lueinizing hormone, follicle-stimulating hormone, estradiol, prolactin, beta-human chorionic gonadotropin), Liver enzymes, Serum creatinine, and Thyroid function tests
The records do not include any notes from the plastic surgeon that document a health issue due to the enlarged breast tissue that has not responded to medical therapy. In addition, the records do not document a work-up for reversible causes of male breast enlargement.