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

Diagnosis: Left foot necrotizing infection

Treatment: Acute rehabilitation (inpatient medical rehabilitation)

The insurer denied coverage for acute rehabilitation (inpatient medical rehabilitation.)

The denial is overturned.

 
This patient is an adult male with a past medical history of asthma, diabetes, hyperlipidemia, hypertension. The patient was admitted with left foot necrotizing infection status post bedside, left foot incision and drainage, left open below-knee amputation (BKA), left below-knee amputation (BKA) revision and closure. The patient experienced undifferentiated shock during the closure. Course was complicated by anemia status post negative esophagogastroduodenoscopy (EGD) and colonoscopy which revealed one non-bleeding polyp.

This patient meets criteria for medical necessity of acute inpatient rehabilitation following a thorough evaluation during their acute hospital stay. The complexity and severity of their medical condition, which complicated BKA, necessitate an intensive, multidisciplinary approach to maximize recovery, prevent secondary complications, and facilitate a safe transition to the next level of care. The patient demonstrates significant functional impairments that require specialized rehabilitation interventions, which cannot be adequately provided in a less intensive setting. The anticipated goals of the acute inpatient rehabilitation include, but are not limited to, enhancing the patient's functional abilities, improving mobility, achieving a higher level of independence, and optimizing quality of life, all of which are crucial for their short-term recovery and long-term health outcomes. A coordinated team of rehabilitation professionals will address the patient's unique needs through a comprehensive and individualized treatment plan, ensuring a continuity of care that is paramount to achieving optimal recovery. The structured, supportive environment of an acute inpatient rehabilitation facility is imperative to manage and mitigate the risks associated with their condition, such as falls, deconditioning, and further functional decline, thereby safeguarding the patient's health and expediting their recovery trajectory.

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 of acute rehabilitation (inpatient medical rehabilitation) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic.
Pain management.

Diagnosis: chronic pain.
Treatment: pain management.
The insurer denied Oxycodone Tablet 30 mg - greater than 120 tablets every 30 days.
The health plan's determination is upheld.

This is a case review for a female being prescribed Oxycodone 30 milligrams (mg) tablets, greater than 120 tablets every 30 days, for the diagnosis of chronic pain. Coverage for this medication was denied by the health plan.

The requested Oxycodone Tablet 30 mg - greater than 120 tablets every 30 is not medically necessary for this patient.
The patient is currently prescribed 5 tablets per day of oxycodone 30mg. This is 225 MME (Morphine Milligram Equivalents) per day. She has been taking this medication at this dose for many years. The current guidelines for opioid prescribing in chronic, non-cancer pain recommend considering a taper to the minimum effective dose for any patient receiving greater than 50 MME per day. There was no documented attempt at tapering to a lower effective dose. There is no documentation regarding why the patient requires ongoing therapy with this high of a dose, rather than attempting to achieve pain control at a lower dose. This is based on evidence that there is limited benefit to higher-dose opioid therapy and that the harms may significantly outweigh the benefits. The physician has not provided any documentation regarding whether or not this is appropriate to consider for the patient. The patient states that treatment is appropriate for palliative care for her HIV; palliative treatment is typically reserved for those with a life expectancy of six months or less, and there is no physician documentation that the patient is terminal at this time. Therefore, the request to continue exceeding the maximum quantity limit for oxycodone is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left palatine tonsillar abscess measuring 3.4 centimeters.
Treatment: Inpatient admission.
The insurer denied coverage for Inpatient admission.
The denial is Upheld.

The patient is an adult with a past medical history significant for tonsillitis who presented to the emergency department (ED) for complaints of sore throat.

Vital signs on presentation included: Temperature -99.1 Fahrenheit, blood pressure 136/86, pulse - 96, respiratory rate -20, oxygen (O2) saturation - 98%. Laboratory results were remarkable for white blood cell count (WBC) -13.3k, hemoglobin (Hgb) -12.8, hematocrit (Hct) -37.4, creatinine -0.65, glucose-128.

The patient was admitted for throat and neck pain. The patient was empirically started on intravenous antibiotics (Clindamycin) and Solumedrol. A computed tomography (CT) scan of the neck showed a left palatine tonsillar abscess measuring 3.4 centimeters (cm) and narrowing of the adjacent pharynx. Ear nose throat (ENT) specialist evaluated a patient and recommended discharge on oral antibiotics (Augmentin) and Medrol-Pak. The patient remained afebrile, hemodynamically and clinically improved. The patient was discharged to continue oral antibiotics and follow-up as an outpatient.

According to documentation, the patient presented with throat pain. The patient was febrile and hemodynamically stable. Laboratory results were only notable for a mildly elevated WBC. The patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on the above findings, the patient met the criteria for observation level of 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 a full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation with rapid ventricular response. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for the inpatient hospital admission. 
The denial is overturned. 

This is the case of a patient with a past medical history of hypertension and diabetes that presented to the hospital complaining of shortness of breath, palpitations, fever, right leg swelling and lightheadedness. Upon arrival vital signs were stable (blood pressure (BP) 164/104, pulse irregular at 69) and room air oxygen saturation was noted to be 96% (percent). Physical examination revealed an irregularly irregular heart rhythm and bilateral lower extremity swelling with left leg swelling greater than right leg and left leg erythema. 12 lead electrocardiogram (ECG) revealed atrial fibrillation with rapid ventricular rates at 156. Serum blood testing was significant for elevated white blood cell count 15,000 and erythrocyte sedimentation rate (ESR) (88). The patient was admitted to the hospital for treatment of atrial fibrillation and left leg cellulitis. Intravenous (IV) Amiodarone and Cardizem were both administered for rhythm/rate control. Deep vein thrombosis (DVT) was ruled out and the patient was treated with intravenous (IV) antibiotics. 

Admission for monitoring and treatment was medically necessary. Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia (Reference 1). An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen year period demonstrated an average length of stay of 3 days (Reference 2). This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital.  The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. This patient presented to the hospital with palpitations, lightheadedness, fevers, cellulitis and atrial fibrillation with poor rate control. In conclusion, inpatient admission was medically necessary.

Based on the above, the insurer's denial must be reversed. 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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke, chronic obstructive pulmonary disease (COPD) and Alzheimer's dementia
Treatment: Increase Consumer and Self-Directed Personal Assistance Services 18 hours a day 7 days a week, total of 126 hours
The insurer denied coverage for: increase Consumer and Self-Directed Personal Assistance Services 18 hours a day 7 days a week, total of 126 hours.
The denial is: Upheld
This is an advanced age adult patient with chronic medical problems including stroke, chronic obstructive pulmonary disease (COPD) and Alzheimer's dementia.  The patient lives alone in a private residence.  The insurer approved consumer directed personal assistance services (CDPAS) 84 hours/week.  The request is for an increase to CDPAS 126 hours/week, which was denied by the insurer leading to an external review.   

Uniform Assessment System (UAS) report submitted for review.  The patient's cognition is described as minimally impaired, and the patient is "able to self-direct care."  The patient is reportedly total dependent for performing much of the Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is total dependent for locomotion. Maximal assistance is needed for bathing, dressing, toilet transfer/use and ambulation.  Extensive assistance is needed for personal hygiene.  Limited assistance is needed with eating and bed mobility.  The patient reports being frequently incontinent bladder and continent of bowel. There have been no reported falls over the prior 90 days.  

The letters, from the patient's treating physicians, describing her clinical condition and need for additional personal care aide (PCA) services were reviewed.  They do not include associated treatment notes to support their claim of the patient's reported functional incapacity. The patient's clinical condition and functional deficits are not at a level and unpredictable as to require increasing CDPAS 126 hours/week. This physician would agree the patent may benefit from monitoring for safety, particularly due to the reported progressive cognitive deficits and weakness.  However, patient activity scale (PAS) hours are approved primarily to provide hands-on assistance for completion of instrumental activities of daily living/activity of daily living  (IADL/ADL) tasks when no else is available to provide assistance. PAS services for companion care or safety supervision (e.g., dementia, wandering, falls risk)  without the direct provision of ADL task assistance is not a covered service.  A more recent UAS report would have also been helpful.  Based on the clinical records made available for review, attention to the patient's functional needs are appropriately provided and maintained by the recently increased  CDPAS of 84 hours/week.

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 increase Consumer and Self-Directed Personal Assistance Services 18 hours a day 7 days a week, total of 126 hours is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease, laryngeal cancer, status post laryngectomy, osteoarthritis, anxiety, depression, hypertension, and schizophrenia
Treatment: Increase Personal Care Services for a Total of 98 Hours Per Week
The insurer denied: Increase Personal Care Services for a Total of 98 Hours Per Week
The denial is overturned.

The patient is an elderly male. His medical conditions that include Parkinson's disease, laryngeal cancer, status post laryngectomy, osteoarthritis, anxiety, depression, hypertension, and schizophrenia. Denial of increase personal care services for a total of 98 hours per week is being appealed. The health plan approved an increase to 63 from 56 hours per week. The patient's Uniform Assessment System (UAS) evaluation completed 6 months ago shows minimally impaired cognition and functional status: total dependence with housework, meal preparation, managing finances, stairs, and shopping; maximal assistance with bathing, personal hygiene, dressing, walking, location, and tolerating; extensive assistance with managing medications, phone use, and eating; and limited assistance with bed mobility. He has frequent bladder incontinence. An appeal statement notes that the patient needs significant weight bearing help with tasks throughout the day. A letter from the patient's provider notes that the patient needs assistance with ADLs (activities of daily living), including ambulation. He has urinary urgency and frequency and requires assistance standing for use of the urinal.

The requested Increase in Personal Care Services for a Total of 98 Hours Per Week is 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. Denial of increase personal care services for a total of 98 hours per week is being appealed. The health plan approved an increase to 63 from 56 hours per week. This patient has multiple chronic conditions. Uniform Assessment System evaluation completed 6 months ago, shows the patient requires assistance with all ADLs (activities of daily living). Appeal statements note support the need for assistance with ADLs (activities of daily living), including assistance with urination. He is unable to stand without assistance. The information provided show that this patient has significant limitations in functioning. The approved 63 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living) throughout the day. The requested increase to 96 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary/kidney
Inpatient hospital

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

This case involves a woman with multiple sclerosis (MS), hospitalized with fever and body aches. The patient complained of burning with urination and has a history of pyelonephritis. Vital signs in the emergency department showed a temperature of 102.5, pulse rate of 137, and respiration of 18. Examination showed a well-developed individual, not ill or toxic appearing. The cardiac exam showed tachycardia, and the lungs were clear. There was a pure wick catheter in place. Labs showed a white blood cell count of 11, normal hemoglobin, and platelets. Electrolytes and kidney function were normal. LFTs (liver function tests) were slightly elevated, including alanine aminotransferase (ALT) of 66, aspartate aminotransferase (AST) of 88, and total bilirubin of 1.3. Urinalysis showed positive white blood cells, leukocyte esterase, and nitrites. 

Based on the provided documentation, the inpatient hospital admission was medically necessary. The patient has signs of sepsis, with fever, tachycardia on admission, end-organ dysfunction as evidenced by elevated LFTs, and a source of infection from the urinary tract. Imaging identified an obstructing stone at the UV (ureterovesical) junction, and blood cultures were positive for E. coli (Escherichia coli). This is a severe infection requiring inpatient treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Wegovy 0.25mg (milligrams) /0.5mL (milliliter) SC (subcutaneously) SOAJ (Solution Auto-injector). 
The insurer denied: Wegovy 0.25mg/0.5mL SC SOAJ. 
The denial is upheld. 

The patient is an adult female and a diagnosis of obesity. The patient has a body mass index of 27.1 kilograms per meter squared (kg/m2) for a weight of 158 pounds. She has failed lifestyle modification for more than six months including a calorie restricted diet. The provider prescribed Wegovy (semaglutide) Solution Auto-Injector.

The requested health service is not medically necessary.

The patient has a body mass index (BMI) of 27.1 with no weight-related comorbidities such as hypertension, hyperlipidemia, or obstructive sleep apnea. The presence of weight-related complications are needed as this was part of the original study design that led to the approval of semaglutide. According to the United States Food and Drug Administration (FDA) prescribing guidelines: "WEGOVY is a glucagon-like peptide-1 (GLP-1) receptor agonist indicated as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in: 
. adult patients with an initial body mass index (BMI) of 
. 30 kg/m2 or greater (obesity) or 
. 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, or dyslipidemia)." (1) 
"A double-blind trial enrolled 1961 adults with a body mass index (the weight in kilograms divided by the square of the height in meters) of 30 or greater (greater than or equal to 27 in persons with one or more weight-related coexisting condition) and who did not have diabetes and randomly assigned them, in a 2:1 ratio, to 68 weeks of treatment with once-weekly subcutaneous semaglutide (at a dose of 2.4mg) or placebo, plus lifestyle intervention. The coprimary end points were the percentage change in body weight and weight reduction of at least 5%." (2) 
"To compare continued once-weekly treatment with subcutaneous semaglutide 2.4mg with switch to placebo for weight maintenance (both with lifestyle intervention) in adults with overweight or obesity after a 20-week run-in with subcutaneous semaglutide titrated to 2.4mg weekly." 
"Design, setting, and participants: Randomized, double-blind, 68-week phase 3a withdrawal study conducted at 73 sites in 10 countries from June 2018 to March 2020 in adults with body mass index of at least 30 (or greater than or equal to 27 with at least one weight-related comorbidity) and without diabetes." (3)
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intracranial Bleed
Treatment: Inpatient Rehabilitation
The insurer denied Inpatient Rehabilitation.
The determination is overturned.

This is a male patient with a history of a fall with an intracranial bleed (ICB) who was hospitalized. He was stabilized and transferred to an acute rehabilitation facility. He was transferred from there to the hospital for possible sepsis and was found to have coronavirus disease (COVID) without pneumonia. Transfer back to the rehabilitation facility to complete rehabilitation has been denied. At issue is the medical necessity of acute rehabilitation admission.
The acute rehabilitation admission is medically necessary.
This patient requires three hours daily of physical therapy (PT), occupational therapy (OT), and speech therapy (ST). He requires nursing and physician supervision for safety, medication management, nutrition, bowel and bladder function and skin care. He is cooperative and can tolerate the required therapy. He has achievable goals. The rehabilitation goal is modified independence with mobility and activities of daily living (ADLs) with discharge to home.
Appeal type: Medical necessity
Decision: Upheld

Cardiac
Inpatient hospital

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

This case involves a man with multiple myeloma, admitted to the hospital with hypotension. Blood pressure was 70/33 measured in the hematology clinic, but the patient denied any dizziness or fatigue. He was undergoing treatment with chemotherapy for multiple myeloma. There were no reported fevers, chills, or body aches. Assessment in the emergency department showed a blood pressure of 71/39. The patient was given 3 L (liters) of saline. 

The inpatient hospital stay was not medically necessary. The patient was transiently hypotensive in the hematology clinic and emergency department, responding very well to intravenous (IV) fluid treatment. Subsequent vital signs remained stable. The patient has no evidence of systemic infection. The urinalysis had increased squamous epithelial cells and, therefore, needed repeating to determine if, indeed, there was an infection. Criteria for urinary tract infection (UTI) with sepsis are not satisfied based on normal white blood cell count, no dysuria symptoms, normal lactic acid level, and negative blood cultures. The infectious disease specialist evaluated the patient and concurred with this assessment. Additional work-ups, including adrenal insufficiency or cardiogenic hypotension, were ruled out. The ultimate conclusion as the patient was suffering from intravascular depletion, which was rapidly corrected with fluid boluses in the emergency department. There is no evidence of severe end-organ damage. The acute kidney injury improved rapidly to a baseline of chronic kidney disease stage III. There was no indication for renal replacement therapy based on lack of severe electrolyte derangements, uremia, or hypoxemia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: varicose veins
Treatment: of Saphenous Vein Ablation, Radiofrequency 
The insurer denied of Saphenous Vein Ablation, Radiofrequency 
The health plan's determination is overturned. 

The patient is a man with symptomatic lower extremity varicose veins and venous insufficiency. The patient has had VNUS (radiofrequency ablation) closure on the left greater saphenous vein (GSV). The patient has complaints of (c/o) intense pruritus at the right medial malleolus and is bothered by the appearance of the varicose veins.

The requested Saphenous Vein Ablation, Radiofrequency is medically necessary for this patient. The patient has had VNUS (radiofrequency ablation) closure on the left greater saphenous vein (GSV) several years ago. The patient has complaints of (c/o) intense pruritus at the right medial malleolus and is bothered by the appearance of the varicose veins. The patient has venous insufficiency of the right lower extremity requiring treatment. The recommended radiofrequency ablation is medically necessary and is the standard of care for the treatment of venous insufficiency.