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

Diagnosis: Barrett's esophagus
Treatment: Esophagogastroduodenoscopy (EGD) (procedure code 43239)
The insurer denied coverage for: Esophagogastroduodenoscopy (EGD) (procedure code 43239)
The denial is: Upheld
 
The patient has a history of gastroesophageal reflux disease (GERD), Barrett's esophagus, and dyspepsia. A letter from the physician states that he still has symptoms even though the patient is getting treatment. The medical record submitted does not specify the current symptoms or the specific treatment that is being given. An endoscopy was done in April 2022 for Barrett's esophagus surveillance. Chronic gastritis and duodenitis were found. The gastroesophageal junction showed Barrett's esophagus but no evidence of dysplasia. A repeat endoscopy was performed in June 2023. Mild gastritis and duodenitis were seen. There was again no dysplasia. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline A-0203 for Upper Gastrointestinal (GI) Endoscopy. Barrett's esophagus is an indication if there was dysplasia or indefinite for dysplasia on a previous endoscopy. If the Barrett's mucosa does not have dysplasia, the recommended follow-up time until the next endoscopy is 3-5 years. Dyspepsia and GERD are indications to do an endoscopy when there is failure of medical therapy. However, this patient had an endoscopy one year earlier. The patient did not have other alarming sign such as dysphagia, involuntary weight loss, gastrointestinal bleeding, or vomiting. 

This patient had an endoscopy one year earlier and had Barrett's esophagus but without dysplasia. A diagnosis of gastritis and duodenitis was already known. The patient's medications could have been adjusted without the need for an endoscopy one year later. When there is no dysplasia, the advised follow-up endoscopy should be at the three-year interval. 

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 esophagogastroduodenoscopy (EGD) (procedure code 43239) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with a history of hypertension (HTN), and tobacco use who presented for an evaluation of hematuria, dysuria, and right lower quadrant pain for 3 days. He denied urinary clots, urethral discharge but did report subjective fevers. He was afebrile with a blood pressure of 128/84, a heart rate of 66, a respiratory rate of 19 and he was not hypoxic. On exam, he did not appear acutely ill. He was given 1g (gram) of intravenous (IV) ceftriaxone in the emergency room. His labs showed a creatinine of 0.97, and a white blood cell count (WBC) of 15.2. A urinalysis showed 21-50 WBCs, and moderate bacteria. 

The inpatient hospital admission is not medically necessary. The patient presented with hematuria, dysuria and flank pain. He was diagnosed with a urinary tract infection and possible pyelonephritis. He was hemodynamically stable. He did not have acute kidney injury. He did not have emphysematous pyelonephritis or a renal abscess. He did not have severe or persistent changes in mental status, nausea or vomiting. He did not have a documented indwelling device, urinary retention or ureteral obstruction. He did not have an immunocompromised state such as a renal transplant. He did not require prolonged IV antibiotics or IV hydration. He could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Multiple sclerosis.
Treatment:  Increase Personal Care Assistance Services From 30 to 35 Hours Per Week.

The insurer denied Increase Personal Care Assistance Services From 30 to 35 Hours Per Week.  The denial is overturned.

The patient is an adult female with a history of general debility due to multiple sclerosis. The request was for Personal Care Assistance through Home Health Care (Level 2) to be increased from 30 hours per week to 35 hours per week based on Uniform Assessment System (UAS) of 3 months ago. The health plan denied coverage of the request, citing that the approved increase from 25 to 30 hours per week should be adequate and enough to support the patient's current activities of daily living (ADLs), including locomotion, walking, bed mobility, eating, bathing, personal hygiene, dressing upper/lower body, toilet transfer, and toilet use. The additional hours requested are because of the patient's chronic medical conditions. She is wheelchair bound. To help with her activities of daily living, she requires extensive assistance with dressing, bathing, grooming, transferring, turning, positioning, toileting, ambulation, meal preparation, eating, housekeeping, and shopping. She has a high risk for falls. A review of the records showed that the patient has multiple chronic medical conditions, including multiple sclerosis, tremors, chronic pain, a history of falls, and vitamin B12 deficiency. The patient's Uniform Assessment System (UA) evaluation of 3 months ago showed that she is cognitively intact with modified independence and difficulty in new situations only; requires supervision with managing medications and locomotion; requires limited assistance with managing finances, phone use, walking, bed mobility, and eating; requires extensive assistance with bathing, personal hygiene, upper/lower body dressings, toilet use/transfer, maximal assistance for meal preparation, housework, and shopping. She lives with her minor son and minor daughter in a two-bedroom apartment located on the first floor.

The requested health service is medically necessary.

The patient is cognitively intact with modified independence and difficulty in new situations only. She requires supervision with managing medications and locomotion; requires limited assistance with managing finances, phone use, walking, bed mobility, eating; requires extensive assistance with bathing, personal hygiene, upper/lower body dressings, toilet use/transfer; and requires maximal assistance for meal preparation, housework, and shopping. The reason for denial by the health plan as noted in the clinical information above does not align with her disability features as stated in the Uniform Assessment System of 3 months ago. Therefore, the requested 35 hours per week are medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: atrial fibrillation, heart disease and osteoarthritis

Treatment: home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day - split shift

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day - split shift

The denial is Modified

 
This is an elderly female with chronic medical problems including atrial fibrillation, heart disease and osteoarthritis.  She lives with her spouse in a private residence.  The insurer approved personal care services (PCS) level 2; 35 hours/week.  The request is for home care / personal care HHC - level 2 PCS, per 15 minutes increase to 24 hours per day - split shift, denied by the insurer and leading to an external review.  

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive skills are described as minimally impaired.  She reportedly requires extensive assistance to total dependence for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  The patient reportedly requires extensive assistance for bathing, personal hygiene, dressing, locomotion, toilet transfer/use and ambulation.  She is reportedly at the supervision level for bed mobility and eating.   The patient is reportedly frequently incontinent of bladder and continent of bowel.  Her ability to perform activities of daily living and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There have been no reported falls over the prior 90 days.  The patient's cognitive status and functional ability have also declined when compared to the prior UAS report.

Based on the records reviewed, attention to the patient's functional needs are more appropriately provided and maintained by increasing PCS to 8 hours/day, 7 days/week, (56 hours/week) and shared household responsibility of other adult living in the home.  The patient may also have the option of restructuring and flexibly using the 56 PCS hours weekly to better maintain and meet her functional needs.  

Based on the above, the insurer's denial must be modified. 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 home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 24 hours per day - split shift services is not substantiated. 

However, increasing home care / personal care HHC - level 2 PCS, per 15 minutes increase to 8 hours/day, 7 days/week (total 56 hours/week) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low back pain, anemia, pneumonia
Treatment: Inpatient rehab stay (skilled nursing facility)
The insurer denied the inpatient rehab stay (skilled nursing facility).
The denial is overturned.

The patient is an adult female with a history of low back pain with weakness and frequent falls. She was in a skilled nursing facility (SNF) for 54 days without showing tangible improvement and continued to stay until she was discharged to an acute hospital due to severe anemia. She was also treated for pneumonia with levofloxacin. Also, the patient had cervical (C) 4-C7 decompression and lumbar (L) 2-L5 decompression. She was on tube feeding. The stay in the SNF included several medical issues including pneumonia, diarrhea, anemia, and low back pain.

The patient has relevant medical history of chronic pain syndrome, anemia, hyperlipidemia, ischemic heart disease, anemia, diabetes mellitus, and peripheral arterial disease. Before admission, the patient was living alone in a private house with a chair lift installed and using a cane for support. She was admitted to the SNF and as of day number (#) 34, she required supervision for bed mobility, sit-to-stand, lower/upper body dressing, ambulating 10 feet; required moderate assistance with toilet transfer and toilet hygiene; most other activities of daily living (ADLs) were not attempted because of medical conditions with the patient still showing impairments with balance deficits, decreased dynamic balance, decreased strength, decreased functional capacity, etc ("and the rest"). She continued to show progress with therapy.

The health plan denied continued coverage for the SNF because it was not medically necessary from day #47 onward and that custodial care was more appropriate due to lack of progress.

The requested health service was medically necessary.

The proposed stay in the SNF was medically necessary because the patient had medical issues that limited her progress at intervals and included pneumonia, anemia, and severe lower back with surgical decompression while she continued to show progress in rehabilitation.

As of day #34, the patient required supervision for bed mobility, sit-to-stand, lower/upper body dressing, and ambulating 10 feet; required moderate assistance with toilet transfer and toilet hygiene, with most other ADLs not attempted because of medical conditions with the patient still showing impairments with balance deficits, decreased dynamic balance, decreased strength, decreased functional capacity, etc. Therefore, continued stay in SNF was medically necessary until discharge.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Amyotrophic Lateral Sclerosis (ALS).
Treatment:  Radicava ORS (oral suspension).

The insurer denied coverage for Radicava ORS (oral suspension).  The denial is overturned.
 
This is an adult female diagnosed with Amyotrophic lateral sclerosis (ALS) less than 6 months ago. This is a fatal condition with limited treatment available. There are very few agents that have proven to slow down the process of neurological deterioration. Radicava was recently approved by the Food and Drug Administration (FDA) as a treatment for ALS. Studies suggest that the condition is maintained in check if the symptoms of ALS are mild. 

Based on the review of the medical record it is my opinion that the prescribing of Radicava is indicated for this patient. 

Radicava is indicated for the treatment of ALS, and clinical studies have shown that this medication is effective. As summarized by Up to Date "Edaravone [Radicava] slows functional deterioration in patients with ALS. Edaravone is a free-radical scavenger that is thought to reduce oxidative stress, which has been implicated in the pathogenesis of ALS. While the evidence for the benefit of edaravone is clearest in patients with early ALS, as defined in the pivotal trial, there is no reason to believe that the population evaluated in that trial is biologically distinct from the greater ALS population.

We suggest edaravone for all patients with ALS". Edaravone [Radicava] was approved in intravenous (IV) formulation in 2015 and in oral formulation in 2022 for the treatment of ALS in Japan and Korea and received United States Food and Drug Administration (FDA) approval for all people with ALS in 2017.

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 Radicava ORS (oral suspension) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke
Treatment: Wheelchair
The insurer denied wheelchair.
The determination is overturned. 

The patient is a female who was diagnosed with a stroke. She was admitted to the hospital with acute heart failure. Her history includes atrial fibrillation, hypertension, and hyperlipidemia. The records indicate that she has had mobility problems and has fallen while using a cane and a walker. She suffers from shortness of breath and weakness. A request was made for a wheelchair.
At issue is the medical necessity of the wheelchair.

The requested health service/treatment of Wheelchair is medically necessary for this patient.
Mobility assistance may be required for a variety of reasons and for varying durations because the etiology of the disability may be due to a congenital cause, injury, or disease. Some patients may need mobility assistance on a short-term basis, while those with chronic conditions or enduring disabilities may require mobility assistance on a permanent basis. Manual wheelchairs are used for patients who are unable to walk but have sufficient upper extremity function to propel a wheelchair. Considering this patient's chronic medical condition and documentation of severe mobility restrictions, the wheelchair is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: mobility issues.
Treatment: Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day, Live-In.
The insurer denied Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day, Live-In.
The health plan's determination is overturned. 

The patient is a female with a medical history notable for dementia, partial blindness, and mobility issues. The patient's son provided a letter of support for this appeal. The letter states that the patient has had 2 falls in the last three months. She has had progressive difficulty with ambulation and unsteady gait. She requires assistance with all activities of daily living including bathing, toileting, hygiene, and ambulation. She is unable to direct her care or call for help in an emergency.

The requested Personal Care Worker (PCW) Services: 7 Days per Week, 24 Hours per Day, Live-In is medically necessary for this patient.
The patient requires hands-on assistance with all personal care needs. The Uniform Assessment System (UAS) may be underestimating her true level of assistance required for activities of daily living (ADL) given that she has had multiple falls recently. Her falls while attempting ADLs independently are evidence of unmet personal care needs. Her physician also attested that her level of assistance for ADLs is greater than reflected by the assessment. The patient has dementia and is not able to direct her care. She has incontinence and will require assistance with managing toileting and incontinence care. The patient's personal care needs will therefore be continuous and unscheduled throughout the day and occasionally at night as well. Therefore, the requested services are medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Viral syndrome. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

The patient is a male child born via emergent Cesarean section with a history of an umbilical hernia and speech delay who was taken to the emergency department (ED) via Emergency Medical Services (EMS) with a several-day history of cough, rhinorrhea, and nasal congestion. The shelter contacted EMS for evaluation of both cold symptoms and general wellness. The examination was significant for an active playful appearance, clean and well-dressed, non-toxic, moist mucous membranes, erythematous left tympanic membrane, edematous nasal mucosa with rhinorrhea, thick mucopurulent nasal congestion, no tonsillar exudate or pharyngeal erythema, clear lungs, benign abdomen, and non-focal neurologic exam. He was diagnosed with otitis media, prescribed high-dose amoxicillin and outpatient pediatrician follow-up, with plans to discharge home with his mother. 
An Administration for Children's Services (ACS) worker subsequently spoke with the mother. As a result, the child was admitted along with the siblings because the mother was being admitted to the neurology unit for evaluation of possible pseudotumor cerebri and there were no other caregivers available. Admission diagnoses included viral syndrome, acute otitis media, and complex social situation. Admission orders included regular diet for age, continued amoxicillin, nebulized saline as needed, Tylenol/Motrin as needed, and Social Services/ACS clearance prior to discharge. 
He remained stable overnight, afebrile, tolerating his antibiotics and diet. He was cleared for discharge with paternal grandparents and the father of the twins while the mother was readmitted, to complete a ten-day course of antibiotics for acute otitis media. At issue is the medical necessity of an inpatient admission. 
This young male child presented to the ED via EMS with ACS following for evaluation of cough and congestion. He was diagnosed with acute otitis media and viral syndrome and treated with high-dose amoxicillin. Complicating the situation, his mother required admission following an unwitnessed fall for evaluation of possible pseudotumor cerebri. There were no available caregivers initially identified, so the child and his infant siblings were monitored overnight. Grandparents were identified as appropriate caregivers, so the child was discharged the following day to complete his course of antibiotics. 
Safe discharge includes identification of appropriate caregivers and shelter. In this case, appropriate caregivers were not initially identified. As soon as a safe discharge situation was identified, he was discharged home to complete his course of antibiotics. However, he was overall hemodynamically stable and did not require acute inpatient admission. He could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient admission
The insurer denied: Inpatient admission.
The denial is overturned.

The patient is an adult female with a history of asthma. She presented to the emergency room with shortness of breath (SOB). She did not improve on home bronchodilation. She has a history of non-compliance. There is a history of prior intubation. Prior to arrival at the emergency room, emergency medical services treated her with DuoNebs, intravenous dexamethasone, intravenous magnesium, and subcutaneous epi. The patient improved with this treatment. In the emergency room, the patient's temperature was 98; heart rate was 120; blood pressure was 124/69; and SpO2 (pulse oximetry) was 100%. There was no acute finding on chest X-ray. She was treated with two treatments of albuterol and ipratropium Nebs, and two treatments of albuterol and intravenous solumedrol. Her peak flow in the emergency room was 150 (baseline 300) as reported in the history/physical note. The treatments did not improve the patient's wheezing with shortness of breath, and she was admitted. Following admission, she continued to have bilateral wheezing. She required DuoNebs every six hours and intravenous Solumedrol 60 milligrams every eight hours. On day #3, the patient's wheezing resolved, and peak flow was close to 300 per note. She was discharged on a course of prednisone, Symbicort and as-needed albuterol. Inpatient hospital admission was denied coverage by the health plan. This denial is being appealed. 

The inpatient admission was medically necessary.

The patient had peak flow less than 50% (baseline 300). There is documentation that patient peak flow in the emergency room was 150. The patient had persistent respiratory findings requiring frequent bronchodilation and intravenous systemic steroids until her respiratory symptoms improved. Identifying patients who should be kept for observation or hospital admission versus discharged to home remains largely a matter of clinical judgement of the patient response to therapy and patient signs and symptoms of respiratory distress from airflow obstruction. The patient in this case was in respiratory distress, with persistent wheezing with poor peak flow. This suggests acute bronchospasm that did not improve in the emergency room and during admission. She required frequent bronchodilation nebulizer and systemic steroids to improve her bronchospasm. The purpose of hospitalization during an asthma exacerbation is close observation and availability of aggressive intervention in the event of worsening asthma. Hospitalization also serves to remove the patient from stimuli in the home environment that potentially aggravates asthma, ensure medication compliance, and permit inactivity during recovery from the illness. In this patient, her breathing problem started at home despite bronchodilation. She has a history of near fatal asthma as indicated by intubations in the past. Her symptoms 
persisted until she was discharged. She also has a history of medication non-compliance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraines
Treatment: Qulipta 60mg (milligram) Tablet
The insurer denied: Qulipta 60mg (milligram) Tablet
The denial is overturned.

The patient is an adult male with migraines. He is currently on Qulipta (atogepant). He has not had any migraines since starting treatment. His provider wishes to continue Qulipta. The request was previously denied coverage by the health plan, as he had not tried the health plan's preferred alternatives, including other anti-calcitonin gene-related peptides (CGRPs). The denial 
is being appealed.

The requested Qulipta is medically necessary.

Qulipta is continuation of care in this case. The patient has not had migraines, which indicates that Qulipta is effective. Switching him to one of the health plan's preferred alternatives could result in adverse side effects and decreased efficacy. Furthermore, research indicates that insurance-driven medication adjustments lead to decreased patient health outcomes. Lastly, the American Headache Society anti-calcitonin gene-related peptide (CGRP) guidelines do not differentiate between the different anti-calcitonin gene-related peptides. Therefore, the requested 
health service is medically necessary.