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

Diagnosis: Pseudobulbar affect and post-traumatic stress disorder (PTSD).
Treatment is personal care aid (PCA) services 35 hours per week.
The insurer denied coverage for personal care aid (PCA) services 35 hours per week.
The denial is overturned.

This is a young adult with diagnoses that include pseudobulbar affect and post-traumatic stress disorder (PTSD). His mother is his personal care aide. According to the case notes, "the patient has declined to participate in monthly calls. These calls are part of the agreement with the insurer. Therefore, the insurer made the decision to stop personal care aide services." The patient is requesting the resumption of coverage for personal care aid (PCA) services 35 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "minimally impaired." He requires extensive assistance for bathing. Limited assistance is required for personal hygiene, dressing and toilet use. He is occasionally incontinent of bladder and continent of bowel. He requires supervision for eating, toilet transfers and ambulation. The combination of his medical condition and functional impairments supports the medical necessity for the previously approved PCA services 35 hours per week. The patient's underlying mental health and behavioral conditions may have contributed to his lack of compliance with insurer required monthly calls. Since his clinical/functional needs have not changed, this physician recommends the resumption of the PCA services and also instructs the patient's mother (who is the PCA), to encourage him to participate in the monthly calls.  

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 the Personal Care Aide services 35 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral neuritis and migraine
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is upheld.

This is a case of an adult female who presented with vertigo. A CT (computed tomography) of the head was normal. The patient had normal vital signs and blood work. She was unable to walk due to vertigo. She was evaluated by neurology and a central cause of vertigo was ruled out. She was admitted due to the inability to walk with a diagnosis of peripheral neuritis and migraine. She was treated with IV (intravenous) steroids and anti-emetics. She was discharged after being seen by an ENT (ear nose and throat) physician and recommendation of an outpatient MRI (magnetic resonance imaging) and vestibular testing.

In this case, stabilizing the patient's symptoms and ruling out any central cerebral etiologies with an observation status would have been appropriate. The remaining work up, treatment with steroids and anti-emetics, and evaluation by ENT could have been done as an outpatient.

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

The insurer's denial of coverage for full hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The denial is upheld.

The patient is a female with atopic dermatitis, 70% (percent) body surface area (BSA), treated with hydrocortisone, mometasone, triamcinolone, and prednisone. Her provider is recommending Dupixent. The health plan requires use of Tacrolimus, phototherapy, or systemic therapy.

At issue is the medical necessity of Dupixent 300 milligrams (MG)/2 milliliters (ML) subcutaneous (SC) solution prefilled syringe (SOSY).

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

No, the requested health service/treatment of Dupixent 300MG/2ML SC SOSY is not medically necessary for this patient.

This patient has not demonstrated an adequate trial and failure to all other standard of care measures for atopic dermatitis. The documentation does not support aggressive topical measures with topical calcineurin inhibitors, emollients and wet-to-dry wraps, bleach baths, and phototherapy, which are considered first and second line therapies for eczema.

According to the recommendations provided by Simpson, et al (2017), steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy.

Therefore, the requested health service/treatment of Dupixent 300MG/2ML SC SOSY is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This is a young adult male patient. He has been diagnosed with eosinophilic esophagitis based on initial endoscopy and biopsy. The patient was treated with omeprazole, and repeat biopsies showed persistent eosinophilic esophagitis. He was then treated with Flovent. Repeat biopsies showed persistent eosinophilic esophagitis. The patient's doctor requested Dupixent 300 milligrams (mg) every week. 
The reason for prior denial was that the patient has not failed preferred medications (Flovent and budesonide) for a trial of at least 12 weeks.

The proposed treatment with Dupixent is not medically necessary.
Current eosinophilic esophagitis treatment guidelines strongly recommend topical glucocorticosteroids (budesonide and fluticasone) and dietary therapy (elimination diet). The guidelines stated that "We found low or very low certainty in the effects of multiple other medical treatments for EoE: antiIL-5 therapy, anti-IL13 therapy, anti-IgE therapy, montelukast, cromolyn, and anti-TNF therapy" (1). 

Dupilumab (Dupixent) was recently approved by the Food and Drug Administration (FDA) for eosinophilic esophagitis in children 12 years of age or older with weight at least 40 kilograms (kg). Current medical literature support the use of dupilumab in children with refractory eosinophilic esophagitis (2-3).

In clinical practice, children with eosinophilic esophagitis may be treated with one medication (proton pump inhibitors [PPIs], fluticasone or budesonide) for three months (12 weeks) and get repeat endoscopy and biopsies to determine treatment response. As documented, this patient was treated with a proton pump inhibitor (omeprazole) for about ten weeks and Flovent (fluticasone) for about six weeks before repeat endoscopy and biopsies. The patient has not tried and failed another topical steroid, budesonide. Thus, there is not enough documentation to show that the patient failed all recommended treatments. There is not enough documentation to show that the patient has a refractory eosinophilic esophagitis. The proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung problems and hypertension
Treatment: Increase in personal care aide (PCA) hours to 40 hours/week
The health plan denied the requested increase in PCA hours to 40 hours/week. 
The health plan's determination is upheld.

This is a case review for a female with a medical history notable for type 2 diabetes, hypertension, shortness of breath on exertion, and functional deficit due to chronic pain. The health plan had previously approved 24.5 hours/week of consumer directed personal care services (PCS). The patient's care team requested an increase to 40 hours/week. The health plan did increase PCS to 30 hours/week.

Recent office visit notes were reviewed. The patient was being seen for chest pain and shortness of breath and had a negative cardiac workup. It was thought to be of pulmonary origin, and she was started on appropriate treatment with inhalers. The office visit note states that "patient requires help with activities of daily living" but does not elaborate on any specific needs that are or are not being met.

A Uniform Assessment System (UAS) was completed and was available for review. This was completed via video teleconference. Cognition was noted to be minimally impaired. She lives with her son and daughter-in-law who provide supervision. For her functional status, she requires maximal assistance for meal preparation, housework, and finances. She requires extensive assistance for medications. Regarding her activities of daily living (ADLs), she requires extensive assistance for bathing, toilet use, dressing upper body, and dressing lower body. She requires limited assistance for hygiene, walking, locomotion, and toilet transfer. She is independent with bed mobility and eating. She is able to ambulate with a walker and non-weight bearing assistance. No nighttime care needs were reported. She is frequently incontinent of urine and continent of stool. She uses 2-4 adult diapers per day. An associated task tool recommended 23.8 hours/week to assist with these functional needs.

At issue is the medical necessity for the requested increase in personal care aide (PCA) hours to 40 hours/week.

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

The requested health service/treatment of PCA; 40 hours/week, Consumer Direct, 1 Client is not medically necessary for this patient.

This appeal was requested on the basis of needing more help due to lung problems and hypertension. The functional deficits covered on the UAS were evaluated by the tasking tool which recommended about 24 hours/week to help the patient. The health plan agreed to cover 30 hours, an increase of 25% (percent) over the recommendation. Furthermore, her assistance is consumer directed and can thus be called upon when needed. There is no established medical necessity in the documentation regarding functional needs that are not currently being met at the 30 hours/week level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia and cerebral vascular accident (CVA)
with residual hemiplegia and hemiparesis
Treatment: Personal care aide services - 24 hours per day, 7 days per week (two Shifts of 12 hours of aide service)
The insurer denied the Personal care aide services - 24 hours per day, 7 days per week (two Shifts of 12 hours of aide service)
The denial is overturned

This female patient has medical conditions including dementia and cerebral vascular accident (CVA) with residual hemiplegia and hemiparesis.  She lives in a skilled nursing facility (SNF).  The patient is appealing denial of increase personal care aide (PCA) services to 24 hours per day, seven days per week, split shift.  

Uniform Assessment Systems (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with locomotion; and maximal assistance with managing medications, bathing personal hygiene, dressing, toileting, bed mobility and eating.  She has bowel and bladder incontinence. 

A letter notes the patient was admitted to the nursing hone.  Since that time, the patient has had significant decline in medical, functional, and cognitive status. The patient requires maximal assistance with activities of daily living (ADLs) as well as hourly turning/repositioning.

Yes, the proposed treatment is medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift.

This patient has several chronic conditions.  She is currently in a nursing home.  She is appealing denial of increase in personal care aide (PCA) services to 24 hours per day, seven days per week, split shift.  Uniform Assessment Systems (UAS) evaluation completed shows the patient requires assistance with all activities of daily living (ADLs).  She has bowel and bladder incontinence.  The appeal letter notes the patient's condition has deteriorated and she requires maximal assistance with activities of daily living as well as hourly turning/repositioning.  This patient has significant physical impairments.  She requires assistance with all activities of daily living, including frequent turning/repositioning.  Based on the need for continuous care, the proposed increase in personal care aide (PCA) to 24 hours per day, seven days per week, split shift, is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Failure
Treatment: Hospital Admission
The health plan denied the requested Hospital Admission as not medically necessary. 
The health plan's determination is upheld.

This case involves a male with a history of chronic systolic heart failure due to ischemic cardiomyopathy, left bundle branch block (LBBB), hypertension (HTN), and hyperlipidemia. The patient underwent elective cardiac resynchronization therapy-defibrillator (CRT-D) implantation for the primary prevention of sudden death and the symptomatic improvement of heart failure. The patient did well post-operatively and there were no complications. The patient remained stable from a cardiovascular standpoint and a post procedure chest x-ray was clear without pneumothorax. The patient was discharged home the following day in stable condition.
At issue is the medical necessity for the inpatient stay.

I recommend that the health plan's determination of medical necessity be upheld, in whole.

No, inpatient level of care was not medically necessary in this case, given the patient's procedure was elective, occurred without complications, and he remained stable throughout his hospital stay. For this reason, an alternate level of care would have been medically appropriate in this case.
The patient underwent an elective CRT-D implantation without complications for improvement in his symptomatic heart failure and to reduce the risk of death per 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) guideline for the management of heart failure [1]. The patient remained stable post-procedure, was asymptomatic, monitored on telemetry overnight then discharged home the following day. Given that the patient's procedure was elective, uncomplicated, the patient did not require inpatient admission in this situation. Rather, overnight monitoring under an alternate level of care would have been medically appropriate and safe for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Headache and weakness
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.  
The denial is overturned. 

The proposed inpatient hospital admission was medically necessary.
The patient is a female who presented with headache and left sided numbness and weakness. She was noted to be positive for COVID. Computed tomography (CT) of the head and computed tomography angiogram were done and the patient was admitted for stroke workup and neurologic monitoring.
The patient presented with acute neurological change with focal deficits of left sided numbness and weakness. According to Milliman Care Guidelines (MCG) for neurology, inpatient
admission is warranted for new onset neurological symptoms that are severe including weakness which this patient had as part of her presentation.
The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Any person who comes in for a focal neurologic deficit, particularly in the setting of COVID, warrants admission as COVID can result in various neurologic complications which warrant monitoring that cannot be done in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Finger infection
Treatment inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned.

This is a patient with past medical history significant for hypertension, diabetes mellitus, and s/p (status post) amputation of the left third toe who presented to the emergency room with complaints of left middle finger swelling. Vitals on presentation included: Temperature- 98.2 Fahrenheit, blood pressure- 189/99, pulse- 77, respiratory rate- 17, oxygen saturation- 99% (percent) on room air. Laboratory results included the following: white blood count- 7.3, hemoglobin- 13.1, hematocrit test- 40.3,
creatinine- 0.41, glucose- 192.

The patient was started empirically on intravenous antibiotics (Unasyn) for a left third finger infection. X-ray revealed extensive soft tissue swelling of the third finger with erosion of distal tuft and soft tissue. The patient had irrigation and debridement of the finger; she tolerated the procedure well without complications. The patient remained afebrile, hemodynamically stable, and clinically improved. She was discharged to continue oral antibiotics as an outpatient.

According to documentation, the patient was admitted with a left third finger infection. Although the patient was afebrile, she remained hypertensive. Imaging studies showed extensive soft tissues swelling with bone erosion concerning for osteomyelitis. Intravenous vancomycin was added to IV (intravenous) Unasyn. The patient required irrigation and debridement of the finger under general anesthesia.

Based on above findings, the patient met criteria for acute hospitalization. Prior determination of denial of coverage for inpatient hospital services is overturned.
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 inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems - Mild and moderate crowding.
Treatment: Braces and monthly visits .
The insurer denied  braces and monthly visits as not medically necessary.
The health plan's determination is upheld in whole.

The patient presented with Class I posterior occlusion on the right and left, mild crowding on upper and moderate crowding on lower, with estimated overjet of 7 millimeter (mm) and estimated overbite of 2 mm. The patient has a single tooth crossbite of the maxillary left 2nd molar.
At issue is the medial necessity of the braces and monthly visits.

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

The requested health service/treatment of braces and monthly visits is not medically necessary for this patient.
A handicapping labiolingual deviation index (HLD) that typically requires a total of 26 points to deem an orthodontic case medically necessary reveals the patient's malocclusion generates a total of 18 points in the HLD index and does not comprise any of the automatic medical qualifiers used to denote a significant discrepancy. This furthermore confirms that medical necessity cannot be established. To address the treating doctor's statement regarding the crossbite score, the HLD index only scores points for crossbite if two or more adjacent teeth are involved, and in this patient's case, the crossbite is a single tooth only (number [#]15).
Additionally, the Salzmann index is used as a tool to determine if the patient's tooth alignment will be handicapping or has the potential to adversely affect the patient's condition. The Salzmann index looks at rotation, crowding, alignment, and spacing of teeth, and accounts for any missing teeth. A score of 25 is a generally accepted assessment of a claimant's malocclusion and is therefore needed to establish medical necessity. In this patient's case, a Salzmann index score of 11 was attained. While the patient does have moderate dental protrusion with increased overjet, there is no evidence of trauma to the surrounding tissues clinically, nor defined by the Salzmann scoring index. Additionally, the patient does not meet any of the criteria for allowable automatic qualifiers or medical-exception conditions.
Orthodontic treatment (braces upper and lower teeth) is not medically necessary for this patient in order to address eating, speech, breathing difficulties, or to prevent permanent damage to the teeth and/or supporting oral structures (temporomandibular joint(s), bones, soft tissues, intra and/or extra oral muscles). There does not appear to be a severe handicapping malocclusion as a result of the existing relationship between the maxillary (upper) and mandibular (lower) dental arches and/or teeth. 
Therefore, requested health service/treatment of braces and monthly visits is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Excessive perspiration and sweating. 
Treatment: Chemodenervation of eccrine glands. 

The insurer denied chemodenervation of eccrine glands. 
The denial is overturned. 

The proposed treatment with chemodenervation is medically necessary. 
The patient is a male with hyperhidrosis, treated with Drysol, Robinul, and Botox. The patient is well controlled on Botox injections; the provider is requesting continuation. The
health plan requires a trial and failure to Drysol. 
It is generally accepted as national standards of care that Botox treatment for hyperhidrosis is medically necessary, and is far superior in efficacy to other treatment modalities. Hyperhidrosis treatments have undergone major improvements in the 21st century. The 2004 Food and Drug Administration (FDA) approval of Botox injections for the treatment of axillary hyperhidrosis has helped to transform the lives of many thousands of sufferers. By "turning off" the process that leads to sweating excessively, Botox treatments allow sufferers to lead more normal lives, free, at least temporarily, from the overwhelming symptoms of hyperhidrosis. 

It is the position of the International Hyperhidrosis Society that treatment of this condition with Botox injections is the gold standard and considered medically necessary.
The health plan act did not reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoporosis.
Treatment: Prolia.
The health plan denied: Prolia.
The denial is: Upheld.

The patient is a female with osteoarthritis and osteoporosis. The issue, in this case, is that Prolia is being denied by the health plan. The reason for denial is not medically necessary as there is a lack of medical records justifying the use of this medication. Per the denial, Prolia is covered if there is documentation of a diagnosis of osteoporosis, a specific T-score, a history of a pathologic fracture and the patient has tried and failed or has a contraindication to oral and intravenous (IV) bisphosphonates. A bone density scan was reviewed and shows osteoporosis. T-score of the right (R) femoral neck is -2.6 and Ward's is -2.9.

The requested health service/treatment of Prolia is not medically necessary for this patient. The medical records do not support the necessity for treatment with Prolia. Indeed, the patient has osteoporosis as seen on a bone density but there is no documentation of a pathologic fracture or treatment with or a contraindication to oral and IV bisphosphonates.