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

Diagnosis: Alpha 1 Antitrypsin Deficiency, SS Allele Type, asthma-chronic obstructive pulmonary disease overlap syndrome

Treatment: Prolastin C

The insurer denied coverage for Prolastin C

The denial is upheld. 

The patient has a history of Alpha 1 Antitrypsin Deficiency, SS Allele Type, asthma-chronic obstructive pulmonary disease overlap syndrome, obstructive sleep apnea, and diabetes. 

As per the last medical doctor visit, the patient was afebrile and hemodynamically stable saturating well on room air. The patient had been off Prolastin C for 3 months.

Last pulmonary function test results included: forced vital capacity (FVC) 2.24 75% (percent), predicted forced expiratory volume (FEV1) 1.71 & 2 %, predicted Ratio 76% flow volume (FV) loop - normal. Total lung capacity was within normal limits.  DLCO (diffusing capacity of the lungs for carbon monoxide) was normal.

Alpha-1-Antitrypsin (AAT) levels 17 micro Mol /L (moles per liter) 96 milligrams per deciliter (mg/dL). Chest x-ray revealed (CXR) no acute pathology and no evidence of emphysema. Both of the levels reported are above the recommended thresholds for which replacement is indicated.

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

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

Diagnosis: Type two (T2) Diabetes Mellitis (DM). 
Treatment: Continuous Glucose Monitoring Device/Supplies. 
 
The insurer denied continuous glucose monitoring device/supplies.  The denial is overturned. 

This is a male diagnosed with type two (T2) diabetes mellitus (DM). This request is for Dexcom G6 continuous glucose monitor (CGM). As reported; he has been using a Tandem T-slim insulin pump which needs a Dexcom G6 CGM. He has been using a Dexcom G6 for at least a year. He is on Novolog via insulin pump; Metformin 1 gram (g) twice daily (BID); Steglatro 15 milligrams (mg); pioglitazone 15 mg daily.
His C-peptide was 0.40, 0.54, and 0.4. His glycated hemoglobin (HbA1C) was 6.9 %.
The subject under review is the medical necessity for continuous glucose monitoring device/supplies. 

The requested treatment is medically necessary for this patient. Continuous glucose monitoring systems including real-time systems have Food and Drug Administration (FDA) approval (1, 2). They are not the subject of Phase I-III clinical trials. The peer reviewed literature supports the long-term use of CGM systems in adult (greater than or equal to [>=] 25-year-old) patients. The American Diabetes Association (ADA) position statement on standards of medical care in diabetes published in January 2011(3), states, "Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults (age >=25 years) with type 1 diabetes." The ADA considers this to have a level of evidence of "A" which is "Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered." 

The use of continuous glucose monitoring in type II diabetes has been shown to be effective in patients who are on multiple daily injections of insulin or an insulin pump such as this patient. The patient has been on the requested service and has an A1c at goal. Continuation of the requested service is consistent with generally accepted standards of medical practice and discontinuation is expected to be harmful to this patient. The request is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immunologic Disorders-Cogan Syndrome
Treatment: Pharmacy/Prescription Drugs-Kineret
The health plan denied the prescription drug Kineret as not medically necessary. 
The reviewer has overturned in whole the health plan's determination.

The patient has atypical Cogan syndrome with presentation of bilateral sensorineural hearing loss, anterior uveitis, retinal hemorrhages, and vasculitis on nasal biopsy. The patient also had recurrent pericarditis treated with colchicine, steroids, and CellCept. According to the documents provided the patient also had recent episode of Guillain-Barre syndrome and does not qualify for anti-tumor necrosis factor (TNF) therapy. Patient had been previously admitted to the hospital for recurrent refractory pericarditis and was treated successfully in the hospital with anakinra/ Kineret with improvement in symptoms. The patient is currently in rehab and a request for approval of anakinra/Kineret 100 milligrams (MG) was denied.

The requested health service/treatment of Kineret 100 MG is medically necessary for this patient. Considering that the patient previously responded to Kineret in his previous hospital stay. Additionally, the patient had previously failed colchicine, and CellCept and has a contraindication for the use of anti TNF with his recent episode of Guillain-Barre syndrome.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pancreatic cancer, dementia, hypertension and atrial fibrillation

Treatment Home Care/Personal Care HHC (home health care) - Level 2 personal care services, per 15 minutes increase to 24 hour(s) per day (split shift); CDPAS (consumer directed personal assistance services).

The insurer denied coverage for Home Care/Personal Care HHC - Level 2 personal care services, per 15 minutes increase to 24 hour(s) per day (split shift); CDPAS

The denial is upheld

This is a patient with dementia, atrial fibrillation and history of pancreatic cancer.   She requires nasal oxygen.  She lives with her husband.  The patient's services were increased from 44 hours/week to 84 hours/week.  However, the patient, through her representatives requested an increase to 24 hour(s) per day (split shift); CDPAS which is under review.  

According to the Uniform Assessment System (UAS) report, the patient is totally dependent for ordinary housework, meal preparation and shopping.  She requires extensive assistance for bathing, lower body dressing and toilet use.  She is bladder and bowel incontinent.  She requires limited assistance for upper body dressing and supervision for ambulation.  The combination of the patient's limited functional ability and dementia supports the increase from 44 hours/week to 84 hours/week, in order for her to continue living safely at home. The patient's condition is progressive, and this physician recommends a follow-up assessment in six months.

From a physical medicine and rehabilitation perspective, the patient's service increased from 44 hours/week to 84 hours/week was clinically appropriate.  However, Home Care/Personal Care HHC - Level 2 personal care services, per 15 minutes increase to 24 hour(s) per day (split shift); consumer directed personal assistance services (CDPAS) is not supported as medically necessary at this time.  This physician recommends a 6-month follow-up assessment from the prior assessment. 

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

The insurer's denial of coverage for Home Care/Personal Care HHC - Level 2 personal care services, per 15 minutes increase to 24 hour(s) per day (split shift); consumer directed personal assistance services (CDPAS) is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opioid use disorder and polysubstance abuse.
Treatment: Suboxone sublingual (SL) 8-2MG film (FLM). 

The insurer denied Suboxone sublingual (SL) 8-2MG film (FLM). 
The denial is overturned. 

This is a male patient with severe Opioid use disorder and polysubstance abuse, who has been following up in an opioid treatment program. The physician documented that the patient is taking an extra 8 milligrams (MG) some days and hence the script runs out at the end of the month and the patient seeks out other drugs to self-treat the withdrawal. The urine drug screen is appropriately positive for buprenorphine and norbuprenorphine. The patient is also occasionally positive for cocaine in his urine.
At issue is the medical necessity of Suboxone sublingual (SL) 8-2MG film (FLM).

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Suboxone SL 8-2MG FLM is medically necessary for this patient.
The suboxone 8 MG three times per day (TID) is medically necessary. As shown in multiple studies, the harm reduction model is more effective than the goal of abstinence. The patient is using less illicit opioids with the help of suboxone 24 MG per day. Suboxone is safe at that dose, it is United States Food and Drug Administration (FDA) approved at a maximum dose of 32 MG per day. The practice is using a harm reduction model. The patient's urine drug screen and levels of buprenorphine and norbuprenorphine are appropriate and show that he is using the drug appropriately. It is not unusual for a patient to have intermittent withdrawal symptoms during their recovery. The patient is at risk of overdose from illicit opioids from the street if suboxone is not received.
Therefore, the requested health service/treatment of Suboxone SL, 8-2MG FLM is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Blood Disorder/Anemia.
Treatment: Pharmacy/Prescription Drugs/Aranesp.
The health plan denied the requested treatment with Aranesp.
The health plan's determination is overturned.

The patient is a female with a history of hypertension (HTN), gastroesophageal reflux disease (GERD), chronic kidney disease (CKD) stage 4 and anemia with CKD who presented for an outpatient evaluation of her CKD. She reported feeling tired. Her vital signs showed a blood pressure of 136/81 millimeters of mercury (mmHg), and a pulse of 72 beats per minute (bpm). Her exam showed trace edema.
The patient's labs showed a hemoglobin of 9.1, a creatinine of 3.75 and decreased iron saturation levels. She was started on oral iron (FeSO4 325mg (milligrams)) a day in addition to the Aranesp 60mcg (micrograms) subcutaneous injection. 
At issue is the medical necessity of the requested treatment with Aranesp.

I overturn, in whole, the health plan's determination of medical necessity.

The requested health service, treatment with Aranesp, for anemia with CKD is medically necessary for this patient. The NKF KDOQI (National Kidney Foundation Kidney Disease Outcomes) guidelines recommended that:
1. For adult CKD patients with anemia not on iron or erythropoietin stimulating agent (ESA) therapy we suggest a trial of intravenous (IV) iron (or in CKD (non-dialysis) ND patients alternatively a 1-3-month trial of oral iron therapy).
2. For adult patients on ESA therapy who are not receiving iron supplementation, we suggest a trial of IV iron (or in CKD ND patients alternatively a 1-3-month trial of oral iron therapy).
The health care plan will provide coverage for Aranesp in the setting of CKD in the setting of a low ferritin only if the patient is on iron repletion. The patient was started on oral FeSO4, and therefore meets the plan's criteria for receiving Aranesp therapy.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Atrial Fibrillation
Treatment: Eliquis
The insurer denied the Eliquis
The determination is upheld.

The patient has a diagnosis of "unspecified atrial fibrillation." Eliquis was prescribed. Per the health plan, Eliquis is approved for stroke prevention in atrial fibrillation or for deep vein thrombosis (DVT) prophylaxis for a patient who has undergone hip or knee replacement surgery if the patient cannot be switched to a formulary drug, Xarelto. At issue is whether the formulary drug Xarelto will be or has been ineffective, would not be as effective as the non-formulary drug Eliquis, or would have adverse effects.

There are no data provided that the patient had been previously treated with Xarelto and it was ineffective. There are some data showing a lower bleeding risk with Eliquis compared to Xarelto (reference 1, 2 below). However, these were not randomized, controlled trials and the difference in risk was small, though statistically significant. Both Eliquis and Xarelto are Food and Drug Administration (FDA) approved for cerebrovascular accident (CVA) prevention in atrial fibrillation (AF), with support from large scale, randomized controlled clinical trials. Xarelto is an appropriate therapy for stroke prevention in this patient with atrial fibrillation.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: pruritus.
Treatment: Doxepin 5% cream.
The insurer denied Doxepin 5% cream. 
The health plan's determination is upheld.

The patient is a male with pruritus. He has numerous excoriations papules on his body. No rash is noted. He has failed betamethasone and tacrolimus. The medication under review is Doxepin 5% (percent) cream.

A formulary exception is not indicated for this patient. While the cause of the pruritus is not provided, and the fact that doxepin cream is not Food and Drug Administration (FDA) approved for pruritus, it would be appropriate for the patient to try the formulary drugs prior to doxepin cream. The formulary medications, such as Eucrisa, have been shown to be very effective for pruritus. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred formulary therapies. Therefore, doxepin cream is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, hyperlipidemia, cerebrovascular accident (CVA), congestive heart failure (CHF), and peripheral artery disease (PAD). 
Treatment: PCA (personal care aide) level II; 24-hour continuous care, 7 days per week. 

The insurer denied coverage for PCA level II; 24-hour continuous care, 7 days per week. 

The denial is overturned. 
	
This patient has multiple medical problems including hypertension, stroke (cerebral vascular accident) and congestive heart failure.  She also has dementia.  She lives alone in the basement apartment of her daughter's home, never left alone and under video surveillance by her daughter.  The request is for personal care aide (PCA) level II; 24 hour continuous care, 7 days per week. 

According to the Uniform Assessment System (UAS) report, the patient is totally dependent for meal preparation, housework, managing medications and shopping.  She is totally dependent for activities of daily living such as bathing, personal hygiene, dressing and toilet use.  She has a PEG (percutaneous endoscopic gastrostomy) tube for feeding which is administered by her daughter.  She is incontinent of bowel and bladder.  The patient is also totally dependent for functional mobility. She requires a Hoyer lift for transfers from her bed and in non-ambulatory.  The patient's cognitive skills are described as "severely impaired."  The patient is totally dependent for all activities of daily living and mobility.  She requires 24 hour continuous care, 7 days per week in order to continue living safely at home.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for personal care aide (PCA) level II; 24 hour continuous care, 7 days per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Stroke
Treatment: Inpatient stay

The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with a past medical history significant for hypertension, hyperlipidemia insulin-dependent diabetes mellitus, hypothyroidism, and transient ischemic attack (TIA) who presented to the hospital with left-sided facial numbness. Reportedly, two days before the presentation, he lost a crown in the left upper tooth. The next morning, he noticed left-sided facial numbness. The patient stated that it felt like he had a Novocain injection. Subsequently, the patient was seen at an urgent care clinic and was started on penicillin.
On the day of admission, the patient woke up with left forearm and left hand numbness. For this reason, he presented to the emergency care center where he underwent an magnetic resonance imaging (MRI) of the brain, which demonstrated a focal acute infarct within the right thalamus. Due to an acute stroke, the patient was admitted to the hospital.

The inpatient hospital admission was not medically necessary.
Based on the nationally accepted standards of care, admission at the acute inpatient level of care is usually indicated for patients with acute ischemic stroke with neurologic findings whose National Institute of Health Stroke Scale (NIHSS) score is greater than two, also when there is evidence of hemorrhagic transformation, altered mental status, significant dysphasia, aphasia, gait impairment. This was not present in this clinical case. The brain imaging studies did not demonstrate evidence of edema, large acute infarction. According to the consultation note from the neurologist, the NIHSS score was 1.
Furthermore, there was no evidence of hemodynamic instability, cardiac arrhythmias of immediate concern. The echocardiogram was unremarkable, ruling out severe valvular disease, atrial myxoma. There was no evidence that the patient had respiratory abnormalities associated with acute stroke. There were no reports of severe controlled hypertension requiring any intervention. The patient did not need prolonged cardiac telemetry monitoring beyond 24 hours. There was no need for any urgent procedures such as thrombectomy or thrombolysis. There was no need for parenteral anticoagulation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: cancer 
Treatment: inpatient hospital. 
The insurer denied inpatient admission. 
The denial is upheld in whole.

The patient is a female who presented to the emergency department (ED) for evaluation of complete wound dehiscence of her right breast with exposure of the breast implant. Her history is significant for breast cancer treated with mastectomy, chemotherapy and radiation, and an eventual breast reconstruction. Her treatment was complicated by chemotherapy induced cardiomyopathy with a significantly decreased ejection fraction (EF) of 30%.
She was admitted to the surgical service for definitive treatment. She was started on intravenous (IV) antibiotic Cefazolin every 8 hours. She required Cardiology clearance prior to surgical intervention, and although she was found to be at increased risk, she was cleared for surgery. She also was hypokalemic and received IV potassium chloride (KCL) x 3 doses. The operative procedure was performed  with the implant removal, irrigation of the wound and Jackson-Pratt (JP) drain placement. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The patient presented to the hospital with an exposed breast implant. Per the notes, she was not sick, and her wounds were not infected. Exam showed no pus or erythema in the wound. Cardiology clearance was completed. Potassium replacement was accomplished. Surgery was performed to remove the expander and wash out the wound. The patient had an uneventful postoperative course and was discharged.
She had an exposed breast implant that was not clinically infected. She was not septic. She required preoperative clearance from cardiology and potassium replacement. Both were accomplished. She could have been managed at a lower level of care status. This patient was medically stable. Consultation and potassium replacement were accomplished within 24 hours of presentation. Her breast procedure is generally performed at a lower level of care. She could have been safely managed at a lower level of care status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: possible seizure

Treatment: inpatient hospital admission

The insurer is denied coverage for inpatient hospital admission

The denial is overturned. 

This female patient has a history of possible seizure.


The patient was admitted for BRUE (brief resolved unexplained event). The history and physical noted that a previous event happened when the patient's mother was at an appointment, and she brought him into the clinic, and he went limp and was foaming at the mouth with blue color. A pediatric attending provider stimulated the patient and he subsequently returned to baseline with the event lasting less than a minute. Vitals included 98.3 degrees temperature, 115 beats per minute (bpm) heart rate, 32 breaths/min respiration, 100% oxygen saturation, and blood pressure of 101/68. Physical examination reported the patient was active and alert with normal skin color and reflexes intact.  The patient's white blood cell count was not elevated, there was no electrolyte abnormalities, the carbon dioxide (CO2) level was decreased, urine analysis revealed no signs of infection, and influenza and Covid were negative. Chest x-ray revealed normal cardiac shape and no consolidation. Electrocardiogram (EKG) revealed normal sinus rhythm. The patient was given a normal saline bolus. Febrile seizure was considered unlikely as was infectious etiology as the patient was afebrile. Progress notes reported there were no events or abnormal movements overnight. Progress notes reported the EEG was normal with no seizure-like activity noted. The patient was discharged.

In this case the patient had a brief resolved unexplained event that was witnessed by a medical provider. Signs included cyanosis, marked change in tone, and altered level of responsiveness. The infant did recover fully to baseline state of health after the event and the event remained unexplained after the history and physical examination. A febrile seizure was unlikely as was infectious etiology as the patient was afebrile and the patient's white blood cell count was normal.

The health plan did not act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the inpatient hospital admission is overturned.  The medical necessity is substantiated.