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

Diagnosis: Osteoarthritis, hypertension, low back pain,
insomnia, poor vision, breast cancer, heart disease, and unsteady gait.
Treatment: Increase Personal Care Assistance Services from 35 Hours per Week to Eight Hours per Day, Five Days per Week and Six Hours per Day, Two Days per Week, for a Total of 52 Hours per Week
The insurer denied the Increase Personal Care Assistance Services from 35 Hours per Week TO Eight Hours per Day, Five Days per Week and Six Hours per Day, Two Days per Week, for a Total of 52 Hours per Week
The denial is upheld

This female has medical conditions including osteoarthritis, hypertension, low back pain, insomnia, poor vision, breast cancer, heart disease, and unsteady gait.  She is appealing denial of increase Personal Care Assistance Services from 35 hours per week to 52 hours per week.  Uniform Assessment System (UAS) evaluation shows modified independent cognition and functional status: maximal assistance with meal preparation, housework, stair, shopping, and transportation; extensive assistance with managing finances and medications, bathing, dressing, and toilet transfer; limited assistance with personal hygiene, walking, locomotion, and toilet use; and independent with bed mobility and eating.  She is continent of bowel and bladder.  

The daughter states increase hours of care are needed because the patient is diabetic and unable to see properly due to macular degeneration and effects from chemo.  She has had numerous falls.  She is unable to cook for herself and uses the microwave improperly.  The patient has risk of hypo and hyperglycemia.  She has increased pain and weakness due to femur fracture.

No, the proposed treatment is not medically necessary.
Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  

The patient has several chronic conditions.  She is appealing denial of increase Personal Care Assistance Services from 35 hours per week to 52 hours per week.  Uniform Assessment System evaluation completed shows the patient needs assistance with meal preparation, housework, stair, shopping, transportation, managing finances and medications, bathing, dressing, toilet transfer, personal hygiene, walking, locomotion, and toilet use.  The appeal statement notes the patient needs assistance with management of insulin and cooking.  Personal care aide (PCA) services are not indicated for management of medical conditions or safety supervision.  The approved 35 hours per week is appropriate to meets the patient's needs for assistance with activities of daily living (ADLs) / instrumental activities of daily living (IADLs) as noted above.  The proposed increase in personal care aide (PCA) services to 52 per week is not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Breast cancer in remission, hypothyroidism, gastroesophageal reflux disease, pre-diabetes, constipation, nocturia, gastric ulcer, hyperlipidemia, irritable bowel syndrome, chronic kidney disease and chronic pain

Treatment: personal care assistance services of 8 hours per day, 7 days per week for a total of 56 hours per week

The insurer denied coverage for personal care assistance services of 8 hours per day, 7 days per week for a total of 56 hours per week.

The denial is overturned.

This case involves a female who was seen after being in the hospital for 8 days. She was hospitalized for a fall and left ankle edema. She was accompanied by a home health aide. The patient was initially admitted for syncope. She does utilize multiple medications and upon physical examination she was in no acute distress. The documentation detailed there was an area of ecchymosis noted to the right medial tibial aspect an area of ecchymosis on the right antecubital fossa with multiple intravenous (IV) scars and venous stasis changes distally. The recommendation was made to soak her leg in warm water and elevate when possible. The documentation indicated she was also requesting an increase in home health care to 8 hours. It is noted that she lives in a private home alone and does have evidence of memory issues. She was alert and oriented per assessment. She does require maximal assistance with meal preparation in addition to ordinary housework. She also requires extensive assistance with bathing in addition to dressing. She does utilize an assistive device with ambulation and is frequently incontinent. The request has been received for personal care assistance service hours and 8 hours a day for 7 days a week for 56 hours a week.

The patient has recently been admitted for a syncopal episode. Though she does not have significant cognitive impairment, the medical records indicate that she has declined with respect to her ability to care for herself and she requires help with activities of daily living (ADLs) including toileting. She is also on multiple medications which places her at increased risk of adverse events including medication errors, increased falls, and toileting needs and increased risk of hospitalization. Due to her increased frailty and advanced age, she is appropriate for 8 hours 7 days a week. 

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

The insurer's denial of coverage for the requested Personal Care Assistance Services of 8 hours per day, 7 days per week for a total of 56 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: diplegic cerebral palsy.

Treatment: personal care assistance (PCA) services of 84 hours per week.

The insurer is denied coverage for personal care assistance (PCA) services of 84 hours per week.

The denial is upheld. 

This female patient has a history of diplegic cerebral palsy, paralysis due to cerebral palsy, a fractured foot and emergency hernia surgery.

The Uniform Assessment System (UAS) states patient is currently at Riverside Premier center. The patient is able to manage finances and medications with some assistance. She is self-directing, able to make a decisions, and can be left home alone. She can describe an emergency plan, activate PERS (Personal Emergency Response System) or call 911. The patient's sister is involved and supportive. Primary mode of locomotion indoors include wheelchair, scooter. Durable medical equipment include walker, transfer bench, grabber, and wheelchair. The patient reports currently in skilled nursing facility (SNF) and doing physical therapy/occupational therapy and was able to walk 3 feet with the walker and 1 person assisting her. She needs assistance with transferring from wheelchair to bed and vice versa, and bed mobility at times. She needs extensive assist with personal hygiene, dressing, and walking. She is frequently incontinent of bladder but some control present, and continent of bowel. She uses adult incontinence products and also sleeps on an incontinence pad during the night. The patient lives in the building with elevator and handicapped access. Her sister visits daily but has her own medical problem.

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

The carrier's denial of coverage for the personal care assistance (PCA) services of 84 hours per week is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma.
Treatment: Formulary exception for Albuterol Inhaler.
The insurer denied the Formulary exception for Albuterol Inhaler.
The denial is upheld.

The patient is a female with asthma who is prescribed albuterol inhaler. This request is denied as the patient has not tried and failed or has contraindication to the formulary alternatives. This denial is being appealed.

No. The health plan should not cover the proposed treatment.
This patient with asthma is prescribed albuterol inhaler. This request is denied since patient has not tried and failed or has contraindication to formulary alternatives: Proair HFA (hydrofluoroalkane inhalers), generic ProAir HFA (hydrofluoroalkane inhalers), Proair respiclick. The main ingredients in formulary alternatives and prescribed albuterol inhalers are the same and provides asthma relief in a similar manner. The prescribed albuterol inhaler is not superior to the formulary alternatives. The formulary drug would not be ineffective for this patient. It would be as effective as the requested non-formulary drug, It would not have adverse effects for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Traumatic Brain Injury
Treatment: Continued Inpatient Acute Rehabilitation
The insurer denied the continued inpatient acute rehabilitation.
The denial is upheld.

The patient is a male with history of alcohol abuse who was involved in a dirt bike accident sustaining severe Traumatic Brain Injury (TBI) with initial Glasgow Coma Scale (GCS) of seven and requiring intubation. Computed tomography (CT) scan of the head showed a subdural hematoma, subarachnoid hemorrhage, bitemporal cerebral contusion, and right vertebral artery dissection. In addition, he sustained left pneumothorax, L2-L6 (second lumbar spinal vertebra to sixth lumbar spinal vertebra) transverse fractures, multiple left rib fractures, complex calvarial and skull base fractures, and so forth.

Prior to admission, the patient was independent with all activities of daily living (ADLs) and living with his dad and sister in a house with two steps to enter. The patient was admitted to acute inpatient rehabilitation.

No, the proposed acute inpatient rehabilitation stay is not medically necessary.

The proposed acute inpatient rehabilitation stay is not medically necessary because the patient has not met all the criteria for acute rehabilitation care INTERQUAL Criteria 2021 for Acute Rehabilitation in a patient with central nervous system (CNS)/TBI. The patient did not meet criteria because as of the date of service in question, he was medically stable without any current clinical issues, aphasic, able to ambulate 1000 feet with supervision and requiring supervision for most ADLs while on mechanical soft with liquid diet. He was unresponsive and non-compliant with instructions.

Based on not meeting the INTERQUAL requirements for acute inpatient rehabilitation, it is not medically necessary for the patient to continue to stay in an acute inpatient rehabilitation as he is unable to follow commands/instructions while also aphasic, while also requiring mostly supervision for most of his ADLs. The patient does not require acute inpatient rehabilitation; a lower level of care is more appropriate.

Yes, the health plan has acted reasonably in this instance and its decision has sound medical judgment which is in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara 90 milligrams every four weeks, Pre-service
The insurer denied the Stelara 90 milligrams every four weeks, pre-service.
The denial is overturned.

This patient is a female. She has had moderate to severe Crohn's disease (CD). She failed conventional therapy. She then failed Entyvio. She has been on Stelara 90 milligrams (mg) for several years, initially every eight weeks and then changed to every four weeks due to symptoms and low drug level. Her doctor requested to continue Stelara 90 milligrams every four weeks. 

The reason for prior denial was that the requested dosing is more frequent than Food and Drug Administration (FDA) approved frequency.

Yes, the proposed treatment with Stelara is medically necessary.

A multi-center cohort study evaluated the response to ustekinumab in children with moderate to severe Crohn's disease (Chavannes, et al). At 12 months, 38.6% (percent) of the 44 patients achieved clinical remission and 47.8% achieved clinical response. They concluded that "Subcutaneous Ustekinumab should be considered a viable therapeutic option for paediatric patients who are refractory to other biologic agents". 

Recently, Dayan, et al published their real-world experience with ustekinumab at a tertiary care pediatric inflammatory bowel disease (IBD) center. Fifty-two children and young adults initiating ustekinumab were analyzed. Most patients (81%) failed greater than one anti-tumor necrosis factor (TNF), and 37% failed anti-TNF and vedolizumab;  ten patients were biologic-naive. At week 52, 75% were still on ustekinumab, and 50% (bio-exposed) and 90% (bio-naive) were in steroid-free remission. Their results suggested that ustekinumab is efficacious and safe in pediatric patients with inflammatory bowel disease (IBD). 

In summary, current medical evidence shows that ustekinumab is reasonably safe and effective in children with severe Crohn's disease. The standard maintenance dose for Crohn's disease is 90 milligrams (mg) every eight weeks. For patients who responded to Stelara initially and then lost response due to low drug concentration and/or antibody formation, shortening the interval to every four weeks is recommended (1-5). 

As documented, this patient has moderate to severe Crohn's disease and was on Stelara at standard dosing of 90 milligrams every eight weeks. The patient still had symptoms with low drug level. The dosing was increased to 90 milligrams every four weeks. Thus, the treatment option would be to continue Stelara 90 milligrams every four weeks, as supported by current medical literature and treatment guidelines.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 
The insurer denied personal care aide level 2: 12 hrs. per day 7 days a week split shift for a total of 168 hours per week.  
The denial is overturned.

There is documentation from the patient's primary care provider and son that the patient has had a decline in functional status. Although there was no significant change in assistance needs when comparing the 3/1/2021 and 6/8/2021 assessment tools, the patient requires at least some assistance with all tasks except for eating. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The patient has overnight ADL assistance needs at least every 2-3 hours which would not allow a PCA to obtain 5 hours of uninterrupted sleep. The plan assumed the patient had informal help outside of the 7 hours/day that she current had PCA services. The patient's care needs cannot be met with adaptive equipment and medical supplies alone. The request to increase PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 x 12 hours/day, split shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems-Other-Syncope. 
Treatment: Inpatient Hospital Stay. 

The health plan denied the inpatient stay as not medically necessary. 
The reviewer has overturned in whole the health plan's determination. 

This is a case of a patient with hypertension, hyperlipidemia, and is status/post (s/p) craniotomy for resection of a meningioma who was brought in by Emergency Medical Services (EMS) in the early morning after a syncopal ground level fall when he got out of bed in the middle of the night to go to the bathroom because he felt nauseous. He did strike his head and his wife who witnessed the fall described a brief loss of consciousness and called 911. The EMS providers described pre-hospital disorientation. Upon arrival to the emergency department (ED), he was alert and oriented x 2, did not remember the event, and complained of left-sided chest pain. He was hypertensive to 192/107, tachycardic to 107, tachypneic to 20, hyperglycemic at 180 and saturating normally at 98% on room air. An electrocardiogram (EKG) showed a trifasicular bundle branch block. A computed tomography (CT) scan of his head showed a small left frontal traumatic subarachnoid hemorrhage. He was admitted to the Trauma Telemetry Unit for Neurochecks, blood pressure control, as well as for cardiac and neurologic syncope workups. Neurosurgery recommendations were syncope work up, repeat CT scan in 6 hours, control of blood pressure to less than 150 and never over 160 and hold anti-platelet medications. A repeat CT head 6 hours later was unchanged and so Neurosurgery signed off. Several blood pressure measurements were greater than 150 and even greater than 160 at 164/98. The medical record notes that the "patient wanted to go home." He was discharged to home the same day in the afternoon with instructions for outpatient follow-up with neurosurgery, trauma, and his primary care physician (PCP). 

The inpatient level of care was medically necessary for this patient. 

This patient was concussed, as manifested by loss of consciousness and amnesia to the event, with a traumatic subarachnoid hemorrhage in the setting of significant co-morbid conditions related to traumatic brain injury, specifically, previous craniotomy, uncontrolled hypertension, and unknown anti-platelet use. In addition, he had a potentially significant syncope risk with a tri-fascicular block seen on his EKG. Standard of care for this patient would have been at least a 24-hour admission for hourly neurochecks by trained and experienced intensive care unit (ICU) nurses who can recognize subtle neurologic changes, blood pressure control, and annotation of anti-platelet medication use. 

There was an annotation that the patient wanted to go home and may be the over-riding reason for the shortened stay and abbreviated evaluation while in the hospital. Nonetheless, the severity of illness and intensity of service warranted acute inpatient level of care; a lower level of care would not have met standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Short Stature.
Treatment: Growth Hormone.
The insurer denied Lupron Depot. 
The health plan's determination is upheld. 

The patient is a female who has been diagnosed with Crohn's disease and seeking treatment with gonadotropin releasing hormone analogue (GnRHa) to suppress puberty. Her mother's height is 64 inches and father's height is 71 inches. Her growth chart shows her weight below 3rd percentile since 4 years ago while her growth chart for height is not available.

Lupron Depot is not medically necessary.
The rationale of GnRH treatment in this patient is to increase adult height by slowing down the pubertal development which is not precocious. However, treatment with GnRHa therapy not only suppresses puberty, but also decreases growth velocity which can be the limiting factor in term of height gain and is not warranted in this patient.
This patient's bone age is as more than 1 year delayed and her height prediction is about 60''(inch) which, although is slightly less than 2 SD (standard deviation) below her midparental height, seems reasonable considering the diagnosis of Crohn's disease which is known to affect growth.
Although review of medical literature shows that combined GH with GnRH analogue treatment can improve height of some children by delaying puberty; it is not the standard of care and at best considered experimental or investigational. This patient's current height is at -2.5 SD(negative) while her weight is at -3.0 SD. Improving nutrition and weight gain would probably help her more in terms of height gain with the progression of puberty rather than suppressing pubertal development.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Renal Disease
Treatment: Jynarque
The insurer denied Jynarque.
The health plan's determination is upheld. 

The patient has a history of chronic kidney disease (CKD) stage 2 due to autosomal dominant polycystic kidney disease (ADPKD). The provider wishes to place the patient on Jynarque to slow down disease progression. The report indication is that the patient has a PKD1 or PKD2 gene mutation and is at risk for rapidly progressing disease. The report states that the patient is Mayo Clinic class 1C, which is the highest risk for disease progression and the clinical notes with labs and renal scan would be included. The heath care plan has denied the request due to missing clinical information including, but not limited to: the patient's laboratory report confirming presence of gene mutation and imaging related to, or chard notes used for confirmation of rapidly progressing disease.

The materials provided with the request for Jynarque do not provide the necessary documentation including a report of documented a gene mutation for either PKD1 or PKD2 and lack documentation to confirm the patient is at risk for progression. However, Jynarque is recommended for use in patient with confirmed ADPKD with risk of disease progression. There is not a comparison non-formulary drug with similar efficacy. Jynarque can cause liver toxicity and liver function tests need to monitor closely.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cirrhosis, abdominal pain.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient has cirrhosis and presented with right upper quadrant (RUQ) abdominal pain and lower extremity edema. In the Emergency Room (ER), she had a possible seizure, but her symptoms returned to baseline within 10 minutes. She had a previous negative video electroencephalogram (vEEG) but her neurologist had placed her on Keppra. She was afebrile and the vital signs were stable. The oxygen saturation was 100% (percent) on room air. She had abdominal distention but no peritoneal signs. Her neurologic exam was noted to be alert and oriented. The international normalized ratio (INR) was 1.4. An abdominal computed tomography (CT) scan showed cirrhosis and a non-occlusive thrombosis of the portal vein. The Model for End-Stage Liver Disease (MELD) score was 13. She was given Lactulose and Rifaximin. She did not have ascites or required a paracentesis at this time. 

Clinical indications for admission for Liver Disease Complications (MCG [Milliman Care Guidelines] M-5570) include moderate to severe hepatic encephalopathy, hemodynamic instability, infected ascites, INR(International Normalized Ratio) over 2, hepatorenal syndrome, severe metabolic abnormalities, severe pain, severe vomiting or dehydration, and an inability to maintain oral hydration after observation care. The patient did not have these conditions.

The patient has cirrhosis. However, she was not in acute liver failure. She did not have a moderate to severe encephalopathy and could have been given Lactulose and Rifaximin as an outpatient. Her coagulation profile was also acceptable for outpatient care. She did not have spontaneous bacterial peritonitis (SBP). The neurology consult, and continuation of Keppra could have been done as an outpatient. 

The health care plan acted reasonably with sound medical judgement. An inpatient admission was not medically necessary. 	

The insurer's denial of coverage for the inpatient admission is upheld. Medical Necessity is not substantiated.