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

Diagnosis: Functional Impairment.
Treatment: Home Health Aid.
Insurer denial of Personal are services 12 hours/day, 7 days/week - 84 hours/week.
The denial was reversed.

This is an elderly patient with chronic medical conditions including hypertension, diverticulitis, and osteoarthritis.  She lives alone in a 3-bedroom apartment.  The patient's is currently approved for PCS 40 hours/week (8 hours/day, 5 days/week) and the request is for 84 hours/week (12 hours/day, 7 days/week), leading to an external review.  

The Uniform Assessment System (UAS) report was reviewed.  The patient's cognitive status is described as minimally impaired.  The patient reportedly requires extensive to maximal assistance for performing much of her Instrumental Activities of Daily Living (IADL) tasks including shopping, ordinary housework, and meal preparation.   She reportedly requires maximal assistance for lower body dressing.  Extensive assistance is reportedly needed for bathing, upper body dressing, bed mobility, locomotion, toilet transfer/use and ambulation.  Limited assistance is reportedly needed for personal hygiene and independent with eating.   She reports being occasionally incontinent of bladder and continent of bowel.  

The patient's ability to perform activities of daily living has reportedly declined over the prior 90 days.  There have been no reported falls or decrease in self-sufficiency over the prior 90 days.   The patient's cognitive (modified independent to minimally impaired) and functional (dressing and bed mobility) ability have modestly declined when compared to the prior UAS report.  The patient's medical condition, physical limitations and functional ability are not at the level or unpredictable as to require the requested PCS 12 hours/day, 7 days/week for a total of 84 hours/week.  

The letter from the patient's treating physician was reviewed.  The doctor describes the patient's underlying medical conditions including hip surgery, associated impairments, and reported need for "12hours per day, 7 days per week (84 hours/week) at a minimum."  This physician would further agree the patient has cognitive and functional impairments that have declined and warrant increasing PCS.  Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCS.  

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

Based on the above, the insurer's denial must be reversed. The medical necessity for personal care services (PCS), 12 hours a day, 7 days a week, for a total of 84 hours services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Benign prostatic hyperplasia
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay
The determination is upheld.

The patient is a male with a history of diabetes, hyperlipidemia, benign prostatic hyperplasia (BPH) who underwent transurethral resection of the prostate (TURP). His post operative course was complicated by hematuria requiring clot evacuation and fulguration. He presented to the emergency department (ED) with difficulty urinating. He was started on continuous bladder irrigation (CBI) and received 2 Units packed red blood cells (PRBC). The patient had an uneventful hospital course and was discharged.
At issue is the medical necessity of an inpatient stay.
A majority of patients who present with hematuria/retention can be discharged within 24-48hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status does not suggest the need for acute inpatient care. A lower level of care for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment: Dupixent 300mg (milligrams)/2 ml (milliliters) Pen Injector
The insurer denied: Dupixent 300mg (milligrams)/2 ml (milliliters) Pen Injector
The denial is overturned.

This is an adult female patient with atopic dermatitis. She has 20% body surface area (BSA) coverage. She has treated with topical steroids including betamethasone, triamcinolone, and hydrocortisone as well as Eucrisa and Elidel. The provider is requesting Dupixent (dupilumab). The health plan requires use of a topical calcineurin inhibitor for at least six weeks within the last 180 days. The medication was also denied as the patient is on Stelara for Crohn's disease, and Dupixent is not covered when used with other biologics.

The requested health service is medically necessary.

There are no known contraindications to Stelara and Dupixent. Dupixent is not immunosuppressive. The patient is well controlled on this medication, and it is generally medically necessary to continue a patient on a therapy to which they have favorably responded. The patient had over 20% body surface area (BSA), which makes topical therapy very difficult and topical calcineurin inhibitors would not be the most appropriate therapy. Therefore, the requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain
Treatment: Nerve Treatment (in the spine)
The insurer denied: Nerve Treatment (in the spine)
The denial is upheld.

The patient is an elderly male with low back pain which began over 7 years ago. Past treatments include chiropractor, physical therapy, lumbar laminectomy, medial branch block, aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), and Tylenol. The pain prevents the patient from sitting or standing for more than five minutes. Magnetic resonance image (MRI) of the lumbar spine from 6 months ago shows post-operative L3-L5 laminectomies, paraspinal muscle edema/atrophy of the surgical site, facet arthropathy, a 2 millimeter (mm) nodule involving the 
cauda equina (likely nerve sheath tumor), and Modic type 1 changes from L1 to L3. Request for Intracept was denied as not medically necessary.

The requested health service is not medically necessary.

Review of the literature shows moderate-quality evidence that suggests this procedure is effective in reducing pain and disability in patients with chronic back pain who are selected based on Type I or Type II Modic changes as well as other inclusion and exclusion criteria used in published literature to date. However, non-industry funded high-quality, large prospective studies are needed to confirm these findings. At this time there is not enough valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment, or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments; and that generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable. There is a lack of sufficient (enough) peer reviewed literature and data regarding the long-term outcomes of the procedure. As such the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, atrial fibrillation, pre-diabetes mellitus, glaucoma, arthritis, current memory changes and strokes
Treatment: Increase Personal Care Aid (PCA) Services for a Total Amount of 168 Hours Per Week (split shift)
The insurer denied Increase Personal Care Aid (PCA) Services for a Total Amount of 168 Hours Per Week (split shift).
The denial is overturned.

The patient is an elderly female. She has a history of hypertension, atrial fibrillation, pre-diabetes mellitus, glaucoma, arthritis, current memory changes and strokes. She was admitted 4 months ago with a stroke. The request is for Increase Personal Care Aid (PCA) Services for a Total Amount of 168 Hours Per Week (split shift), from 12 hours per day - 7 day(s) per week -a total of 84 hours per week.

The request to increase Personal Care Aid (PCA) Services for a Total Amount of 168 Hours Per Week (split shift) is medically necessary.

Per the patient's assessment, the patient is oriented x (times) 1 (to person), and she has dementia with history of strokes. The patient is confused, disoriented with recent falls. The patient's son reports that the patient wanders aimlessly at night within the home, gets restless and fidgety in the legs. The patient's son reports that there is a camera for patient's safety, but the patient is alone at night. The son fears that the patient will fall down again, and the son lives out of state. The patient refuses to use a bedside commode, and does not remember to use the cane due to cognitive barrier. The patient is dependent on personal care aide for toilet care, and bathing due to physical debility and cognitive barrier. The patient is now totally dependent on caregivers for weight bearing assistance. Personal Care Aid (PCA) now provides all perineal care. Due to confusion, poor coordination, poor balance, and poor motor skills, the patient needs significant weight bearing support around the waist, under arms then behind the knees during bed mobility. Personal care aid feeds the patient and does all meal preparations, all shopping, all housekeeping tasks. They also administer all medications. Per the appeal letter that was reviewed, this patient had multiple strokes that has left her with cognitive decline, some degree of receptive aphasia and generalized weakness. The patient is more confused at night, and she sustained a fall while trying to sit down in the kitchen, striking her head. The patient is depressed and anxious, she is not sleeping, and she wanders in the house during the night. The patient needs monitoring at all times due to disorientation and needs to be monitored at all times. Her mental status has changed drastically ever since she had the stroke and her physical status too. Assistance is being requested for her daily activities to go to the bathroom and ADLs (activities of daily living) during the day and assistance during the night. Based upon this information, the request for an increase in Personal Care Aid (PCA) Services for a Total Amount of 168 Hours Per Week (split shift) is considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld



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

This case involves a male admitted to the hospital with vertigo. The patient described a spinning sensation in the room, with nausea and diaphoresis, exacerbated when he lays on the left side. Temperature, heart rate, and blood pressure were normal. Examination showed a well-developed man, not in distress, lying comfortably. The neurologic exam showed alert and oriented x 3, with no focal deficits. The cardiopulmonary exam was unremarkable.

Based on the documentation, a full inpatient hospital admission was not medically necessary. The patient has clear positional symptoms consistent with peripheral vestibular vertigo. Head CT and brain MRI are both negative for central causes of vertigo. The recommendation for permissive hypertension and performing a 2D echocardiogram are outside the clinical guidelines for evaluating TIA and stroke. Permissive hypertension is indicated for 24 hours when there is evidence of an acute stroke on imaging. A 2D echocardiogram is typically obtained when a stroke is detected to rule out intracardiac sources such as a thrombus, which could have resulted in an acute stroke. With a negative brain MRI, there was no indication for either 1 of these. Even if there is suspicion of transient ischemic attack (TIA), these are routinely managed under an observation level of care for 24 hours in the neurology unit. If there is no recurrence of symptoms, the patients are routinely discharged home, with outpatient follow-up.
Appeal type: Medical necessity
Decision: Upheld



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

In this case, the patient is a female admitted at twenty and three-sevenths (20-3/7) weeks gestational age with a plan of admission due to documentation of fetal demise on the date prior based upon ultrasound. The patient was noted to have a history of pregnancy loss and leiomyomas of the uterus. The patient was afebrile with stable vitals at presentation. She denied any bleeding, cramping, nausea or vomiting, urinary symptoms, or discharge. 

An inpatient hospital admission was not medically necessary for a 20-3/7-week stillbirth that was lagging in gestational age. Given this presentation, this would be considered a missed abortion, and the patient would be offered induction or dilation and evacuation (D&E). She opted for induction with Cytotec, and this was completed in an uncomplicated fashion after the removal of the McDonald's cerclage. In this case, the patient was noted to have no symptoms, stable vital signs, no bleeding, and no abdominal pain. She had been previously diagnosed with the stillbirth. She presented a plan of delivery on this date. The patient underwent Cytotec without complications and delivered the fetus and placenta. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder. 
Treatment: Braces, monthly visits, and retainer. 
The insurer denied braces, monthly visits, and retainer. 
The determination is overturned. 

The patient a male with a buccal (reverse) crossbite on tooth number (#) 5. He has moderate maxillary and mandibular crowding. He presents with a Class II malocclusion with 2-millimeter (mm) overjet and 5 mm overbite. He is treatment planned for 30-36 months of orthodontics to correct the malocclusion. At issue is the medical necessity of braces, monthly visits, and retainer. 

Because tooth 5 is in buccal crossbite, it has no antagonist. As a result, it is extremely likely that these teeth will overerupt. Once this overeruption occurs, it is very difficult to treat. (1) Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance. (2) 
If left untreated the damage that will likely occur to the patient's teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For these reasons, the requested treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Kidney Stone.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient is a male, who presented with intermittent flank pain; the associated symptoms included vomiting. He was afebrile and hemodynamically stable. The exam suggested costovertebral angle (CVA) tenderness. The white blood cell count (WBC) was 10.5, and creatinine was 1.56. A nephrostomy was placed, and he underwent a ureteroscopy with stone treatment. He was discharged. At issue is the medical necessity of an inpatient stay.
A full hospital admission was not medically necessary. A majority of patients who present with renal colic can be discharged within 24 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. The procedure was not done on an emergent basis. The procedure performed is considered a minimally invasive outpatient procedure and as such in the absence of a "high risk surgical patient" does not warrant acute inpatient care. The information provided and the patient's perioperative clinical status does not suggest the need for acute inpatient care. Observation status for this patient's clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Heart failure.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is an adult with a history of hypertension, hepatitis C virus and polysubstance abuse who presented to the hospital with lethargy and pedal edema.  She was unable to provide any history.  Physical examination revealed vital signs that were stable (161/89, Pulse 65). The patient was lethargic and responsive to pain. 2+ (1-4 scale) pedal edema was also noted.  12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm with a prolonged QT (heart wave) interval. Serum blood testing revealed an elevated Brain natriuretic peptide (BNP) level, elevated creatinine and an elevated troponin level. Toxicology screen was positive for cocaine, fentanyl, methadone, and benzodiazapines. The patient was admitted to the hospital for treatment of systolic congestive heart failure and withdrawal from cocaine and opiate use. Echocardiogram revealed a dilated right ventricle and normal left ventricular ejection fraction (65% percent). She was treated with guideline directed medical therapy and cardiac catheterization was recommended. She was ultimately discharged on medical therapy.

This patient presented with lethargy and examination findings of heart failure in the setting of active cocaine, opiate and benzodiazepine use. There was echocardiography determined right ventricular dysfunction. The patient's pretest probability of coronary artery disease is moderate. 

Utilizing the HEART (scale to assess cardiac event risk) score she was considered moderate of major adverse cardiac events (defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death) in the six weeks following presentation. 

Utilizing the TIMI (score of risk of heart problems and death) risk score she also had a moderate risk of developing major adverse cardiac events in the subsequent 30 days. In addition to his moderate risk for major adverse cardiac events, this patient was actively using cocaine.  Investigators studying more than 300,000 hospital admissions for chest pain in the setting of cocaine abuse found that patients over age 50 with concomitant heart failure had the highest risk of major adverse cardiac events and mortality. They concluded that such patients did require hospital admission. 

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

Diagnosis: Uterine Fibroids.
Treatment: Inpatient Hospital.
The insurer denied Inpatient Hospital.  The determination is upheld.
 
This is a female patient with uterine fibroids. She had a total laparoscopic hysterectomy with bilateral salpingectomy. She was admitted after surgery as an inpatient. She progressed well without complications and was discharged the following day. The inpatient admission is under review for medical necessity.

The requested health service/treatment of inpatient admission is not medically necessary for this patient.
The patient is a healthy female without significant comorbidities. She had a laparoscopic surgery without complications. There were no pulmonary or anesthesia complications. Her vital signs were normal. She progressed well and was discharged in less than 24 hours. There were no renal, hepatic or gastrointestinal concerns. She had no postoperative complications such as hemorrhage, infection, nor poor healing. She could have been observed after surgery in the post-anesthesia care unit (PACU) or at a lower level of care, as she was discharged less than 24 hours later. There was no need for acute, inpatient monitoring as there was no complications after surgery.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraine
Treatment: Aimovig
The insurer denied Aimovig
The health plan's determination is upheld. 

The patient is a male diagnosed with migraines. For prevention of migraine, the patient has tried and failed multiple therapies, including a calcium channel blocker, an anticonvulsant, and botulinum toxin. Treatment with Aimovig is the subject of this review. The drug was denied because the patient has not tried and failed formulary alternatives of Ajovy and Emgality.

A formulary exception is not indicated in this case. The formulary alternatives for this patient are Ajovy and Emgality. The patient is diagnosed with migraine. These drugs are Food and Drug Administration (FDA) approved for treatment of both episodic and chronic migraine. There is no reason to believe that these formulary alternatives would not be as effective as the non-formulary drug or would have adverse side effects. All of these drugs are CGRP (Calcitonin gene-related peptide) inhibitors. All of these drugs have been shown to be safe and effective for prevention of migraine and randomized controlled trials. There is no documentation to suggest that the patient has tried and failed both of the formulary alternatives, or would have an absolute contraindication to the use of these drugs. The efficacy is expected to be similar to that of Aimovig.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stage 4 squamous cell nasopharyngeal tumor

Treatment: Radiation Therapy for Metastases

The insurer denied coverage for Radiation Therapy for Metastases

The denial is overturned

This is the case of a patient who presented with stage 4 squamous cell nasopharyngeal tumor that is Epstein Barr Virus positive (EBV+). The patient was treated with neoadjuvant chemotherapy followed by chemotherapy and radiation therapy (RT) with 7000 centigray (cGy) with good response. The patient was treated with stereotactic body radiotherapy (SBRT) to metastatic lesions in the pelvis and spine with SBRT. This is the subject of review.

Oligometastatic cancer, typically defined as the presence of 1-5 metastases, represents an intermediate state between locally advanced and widely metastatic disease. Emerging research suggests that oligometastatic cancer has a unique molecular signature distinct from widely metastatic disease, and that it carries a superior prognosis. Owing to its more limited capacity for widespread progression, oligometastatic disease may benefit from aggressive ablative therapy to known metastases. Options for ablation include surgical excision, radiofrequency ablation, and hypofractionated image-guided radiotherapy (HIGRT). The phase II Stereotactic Ablative Radiotherapy for the Comprehensive Treatment of Oligometastases (SABR-COMET) trial, which enrolled patients with oligometastatic disease of multiple histologies and randomized them to HIGRT vs. standard of care, found a notable survival advantage in favor of HIGRT.

There are several published data to support this treatment for oligometastatic disease.

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 Radiation Therapy for Metastases is substantiated.