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

Diagnosis: Aneurysm 
Treatment: Continued acute rehabilitation
The insurer denied coverage for continued acute rehabilitation
The denial is upheld

This is an adult patient who developed a subarachnoid and intraventricular hemorrhage due to a ruptured aneurysm. The patient was eventually admitted to the acute rehabilitation unit. Under review is the medical necessity of continued acute rehabilitation.

Based on the clinical records submitted for review, the patient was no longer appropriate for acute inpatient rehabilitation. The patient was medically stable and could have been safely transferred to a lower level of care (such as outpatient or home with skilled therapy services). According to the Team Conference note, the patient was already ambulating with a rolling walker and contact guard-supervision. The patient was also at the contact guard-supervision level for activities of daily living (ADL) such as dressing and toileting. The patient "ambulated 3 times around the hallway (300 x 3) without an assistive device and with close supervision with no instances of loss of balance." The patient also "ambulated outdoors for 40 minutes with close supervision and occasional contact guard assistance." Performing ADL tasks such as ambulatory toilet transfers, toileting hygiene and clothing management required only "distant supervision." The patient was ambulating, "to/from therapy spaces with distant supervision using a rolling walker." In addition, there were no acute medical or complicated skilled nursing issues that required continued acute rehabilitation.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Considerations include the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendations and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and/or associations. All decisions are evidence-based. From a physical medical and rehabilitation perspective, acute rehabilitation was no longer medically necessary.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for continued acute rehabilitation is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Daily Tension Headaches, Jaw Clenching (bruxism).
Treatment:  Nurtec ODT (oral dissolving tablet) 75mg (milligram) tablet.

The insurer denied: Nurtec ODT (oral dissolving tablet) 75mg (milligram) tablet.  The denial is upheld.

The patient is an adult female with tension headaches and bruxism. She has tried and failed Ubrelvy and sumatriptan. The provider has requested Nurtec. The requested medication was denied coverage because she does not have a diagnosis of migraine headache disorder, and she has not tried and failed or does not have a contraindication to the use of two triptan medications.

The requested health service is not medically necessary.

Based on the medical records, the patient has some headaches with some features of migraine to support that Nurtec is appropriate here. However, she has only tried one triptan. There is no documented reason the patient cannot be treated with another triptan. There is no contraindication to triptan use. Triptans are FDA (Food and Drug Administration) approved for the acute treatment of migraine headaches and are considered first line, standard of care, abortive agents (Tepper, 2019). There are no high-quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Nurtec relative to triptans.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis
Treatment: Home care/personal care HHC (home health care)- level 2 personal care services, per 15 minutes increase to 50 hours per week.
The insurer denied Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week.
The determination is upheld.

This is a male patient with a medical history notable for diabetes, hypertension, and osteoarthritis. The patient is approved for 40 hours per week of level 2 personal care services. The patient and his care team requested an increase to 50 hours per week, and this request was denied by the health plan.

The patient's physician provided a letter for this appeal. The letter states that "he requires increasing assistance at home. He may benefit from increasing home care hours." No further detail was provided. There was no discussion of unmet personal care needs.

A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with his wife (mutual case), daughter, and son-in-law. The patient's cognition was minimally impaired. He is able to make his needs known and direct care in simple situations. For his Instrumental activities of daily living (IADLs), he requires total dependence for meal preparation, housework, and finances. He requires maximal assistance for stairs, shopping, and transportation. For his activities of daily living (ADLs), he requires maximal assistance for bathing, dressing lower body, and toilet use. He requires extensive assistance for hygiene, dressing upper body, walking, locomotion, and toilet transfer. He is independent for bed mobility and eating. He is frequently incontinent of bowel and bladder and wears pullups for 4-5 episodes per day of incontinence. Compared with a prior assessment, the patient showed a slight decline in ADL functioning but was otherwise largely unchanged. A task tool associated with the prior assessment recommended 38 hours per week to address his personal care needs. At issue is the medical necessity of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week.

The requested health service of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 50 hours per week has not been demonstrated to be medically necessary for this patient.

There is no documentation regarding unmet personal care needs for the patient. His condition is largely unchanged from the prior assessment. He has consumer directed personal care hours and can use them as needed to meet his needs. The physician did not document any unmet personal needs. There is no demonstrated medical necessity for an increase in hours.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Entyvio (vedolizumab)
The insurer denied Entyvio (vedolizumab). 
The health plan's determination is overturned.

The patient has jejunoileal and perianal Crohn's disease status post small bowel resection and perianal abscess drainage. The patient has failed 6-mercaptopurine, methotrexate, Humira, Remicade 20 milligrams (mg) per kilogram (kg) every 4 weeks, and high-dose Stelara. The patient started Entyvio, and it was increased to every 4 weeks due to breakthrough symptoms at 4 weeks after Entyvio infusions. 

The patient presented after receiving 3 Skyrizi infusions, with subsequent improvement in symptoms, but has had bowel urgency, accidents, and blood in stool. The coverage is requested to continue Entyvio 300 milligrams (mg) every 4 weeks for the treatment of Crohn's disease. At issue is the medical necessity of the requested health service/treatment of Entyvio (vedolizumab).

Entyvio (vedolizumab) is medically necessary for this patient. Current medical literature supports the request for Entyvio 300 milligrams (mg) every 4 weeks (to be used as dual biologic therapy with Skyrizi) for the treatment of Crohn's disease. The patient's disease is severe and anatomically extensive, with history of complications requiring surgical resection, and they have failed all recommended primary therapeutic medication classes recommended by guidelines for the treatment of Crohn's disease; the patient is already on dose escalated Entyvio. Several studies have assessed the use of Stelara (which shares a mechanism of action with Skyrizi) with Entyvio, including both used at dosing every 4 weeks. In aggregate, no significant safety issues were attributed to dual biologic therapy, and the therapy was broadly successful in improving response in patients who had failed biologic therapy.

In this case, the patient had improvement after Skyrizi was added to Entyvio, although they have had ongoing symptoms despite the use of both medications. Therefore, discontinuation of Entyvio, or reduction of the current Entyvio dose could result in additional complications of uncontrolled disease, flare, hospitalization, need for surgery, fistula, and stricture. Alternative options are limited given failure of 6-mercaptopurine, methotrexate, Humira, high-dose Remicade, high-dose Stelara, and the standard and high doses of Entyvio. Therefore, the request to continue Entyvio is supported as medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations
Treatment: Inpatient Hospital Admission
The health plan denied Inpatient Hospital Admission.
The determination is Overturned.

The patient is a female who was sent to the emergency department (ED) from her oncologist's office secondary to tachycardia. She was transfused with a unit of blood and developed palpitations as well as tachycardia. She has a medical history of ovarian cancer, breast cancer, and lumpectomy. On admission, she was noted to have a heart rate of 131 beats per minute (bpm). She was saturating 98 percent (%) on room air. She had imaging performed on admission that revealed multiple pulmonary thromboemboli as well as evidence of peritoneal carcinomatosis that has worsened since previously completed imaging. She was started on Lovenox stat due to her pulmonary embolism. Due to fevers, she was placed on intravenous (IV) antibiotics due to concerns for infection, as the patient is on chemotherapy for her cancer. She also required an urgent ophthalmology consult due to the need for evaluation secondary to chemotherapy.

At issue is the medical necessity of the inpatient hospital admission. The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of inpatient admission was medically necessary for this patient. The patient in this case did not just have tachycardia, which is the rationale provided to deny this admission. The patient had tachycardia, new onset pulmonary embolism in the setting of malignancy, anemia requiring transfusion of packed red blood cells (PRBCs) and was treated with blood thinners. An echocardiogram was ordered as well. She did not demonstrate hypotension, but the tachycardia was concerning as it was found in the setting of acute pulmonary embolism. The patient was placed on IV Lovenox with plans to bridge to an oral anticoagulant. She had several factors biochemically that demonstrated evidence of the severity of her disease (elevated liver function tests [LFT]). She did not show evidence of hypoxemic respiratory failure. Given the severe issues noted with this patient on admission, an inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.
treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female with a past medical history of mitral regurgitation, iron deficiency anemia secondary to endometriosis, and chronic back pain and anxiety due to multiple motor vehicle accidents who presented with complaints of intermittent substernal chest pressure associated with shortness of breath and diaphoresis that had been ongoing for a week.

She denied palpitations, dizziness, or syncope. She had seen her PCP (primary care provider), who performed an electrocardiogram (EKG) that was normal. She had a routine follow-up with cardiology for mitral regurgitation but was told before the COVID (Coronavirus disease) pandemic that she did not need to be seen for ten years.

The inpatient hospital admission was not medically necessary.

Indications for admission at the acute inpatient level of care for patients with chest pain can vary based on individual patient characteristics, comorbidities, and presenting symptoms. In general, patients with chest pain who present to the emergency department may be admitted to the hospital for further evaluation and management if they meet any of the following criteria:
1) High-risk features: Patients with high-risk features such as ongoing or severe chest pain, evidence of myocardial ischemia on electrocardiogram, elevated cardiac biomarkers such as troponin, hemodynamic instability, or cardiogenic shock.
2) Unstable angina: Patients with unstable angina, defined as new or worsening chest pain or angina at rest or with minimal exertion, may require hospital admission for further evaluation and treatment.
3) Non-cardiac causes: Patients with chest pain due to non-cardiac causes, such as pulmonary embolism, aortic dissection, or pneumonia, may require hospital admission for further evaluation and treatment.

The review of the medical records demonstrated that the patient in this case had none of the features listed above. During the hospital stay, the patient remained afebrile and hemodynamically stable. He did not require any interventions that would require admission at the acute inpatient level of care. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rheumatoid Arthritis
Treatment: Inpatient Stay
The insurer denied the inpatient stay.
The health plan's determination is overturned.

The patient is a female with a past medical history (PMH) significant for rheumatoid arthritis (RA), hypertension, and heart murmur. Her past surgical history is significant for lumbar vertebrae (L)3/4 anterior and posterior fusion at an outside hospital 2 years prior. She presented with a history of balance issues, lower back pain and bilateral lower extremity pain (right greater than left) with right leg weakness.

The pre-operative physical examination was notable for a right foot drop with 3 out of 5 right psoas, 3 out of 5 right hamstrings, 2 out of 5 right tibia anterior, 3 out of 5 right gastrocsoleus and 3 out of 5 right extensor hallucis longus (EHL). The patient presented for elective L4 (lumbar)-sacral vertebrae (S)1 decompression. No intraoperative complications occurred. A drain was placed sub-fascially. Post-operatively the patient received pain control, anti-hypertensives, bowel regimen, and home medications. The hospitalist was consulted for medical management. The surgical drain was removed on post operative day number 2.

Physical therapy was consulted for rehabilitative purposes. Physical therapy (PT) was poorly tolerated due to pain control and pre-operative strength deficits. The patient required ongoing PT until she was able to ambulate 10 to 15 feet with a rolling walker and transfer with supervision. She was safely discharged home with 24 hour supervised care.

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

Inpatient medical treatment was medically necessary for this patient due to her underlying medical complexity and pre-operative neurologic deficits. Due to her medical comorbidities and baseline weakness, she was slow to progress with PT post-operatively. Therefore, the patient remained in the hospital receiving ongoing care until she was safe to be discharged home. Given the patient's diagnosis of RA (rheumatoid arthritis) and preexisting neurologic deficits, she was most appropriately cared for at the inpatient level. While this surgery is normally performed as an outpatient, the patient required care until her discharge. The patient could not have been cared for at a lower level of care.

The health plan's determination is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope
Treatment is an inpatient admission 
The insurer denied coverage for an inpatient admission 
The denial is upheld

This adult female with history of hypertension and gastroesophageal reflux disease presented to the emergency room complaining of near syncope after dizziness. Her blood sugar was 126 mg (milligrams)/dL (deciliter) and she reported on and off palpitations. An Electrocardiogram (EKG) showed sinus rhythm, but with flattening T waves (interval on an EKG).  The patient claimed that she was in a hot shower when she felt dizzy and fell. She stated that she was held by her son and then passed out or nearly passed out again. She was not taking blood thinners or aspirin on a daily basis.  She reported a history of multiple syncopal episodes. Exam findings noted blood pressure 152/91 mmHg (millimeters of mercury) with a pulse of 73 bpm (beats per minute) and a stable temperature at 98.4 degrees F (Fahrenheit). The patient was otherwise normal for cardiovascular and pulmonary assessment. She was alert and oriented to person, place and time, had clear speech, and denied any head or neck trauma. The patient was admitted to telemetry for syncope and prolonged QT (interval on an EKG) waves. 

Laboratory testing did not identify any significant abnormalities. A Computed tomography (CT) scan of the head without contrast was unremarkable. A transthoracic echocardiogram (TTE) was conducted with findings showing mild mitral valve thickening and minimal mitral valve regurgitation. Her Ejection Fraction was 56.0% (percent). 

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

According to the Milliman Care Guidelines, inpatient hospital care is indicated for those individuals who have documented hemodynamic instability, altered mental status that is severe or persistent, has a cardiac disease or finding that indicates necessity of immediate intervention, when a patient has pacemaker or AICD (Automated Implantable Cardioverter Defibrillator) malfunction, has an inheritable cardiovascular condition predisposing them to arrhythmias diagnosed or suspected, when they have severe or persistent dehydration, and syncope causing injury that requires hospitalization. While it was noted that the patient reported dizziness while taking a shower causing her to fall, hit her nose on the wall during the fall, and lose consciousness, the evidence provided for review did not suggest that she did not satisfy the criteria for inpatient admission. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Dehydration.
Treatment:  Inpatient Stay.

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

The patient is an autistic male who was brought to the emergency department with vomiting for four days and progressively decreased oral intake and number of wet diapers. The patient's vital signs were normal. The patient appeared tired. The patient's mucus membranes were dry. The patient's throat appeared red and intravenous (IV) fluids were given to hydrate, because the patient was "refusing fluids".
The patient's bicarbonate level was 16. The patient's urine specific gravity was more than 1.030. His glucose was 58. The patient was given a Normal Saline bolus in the emergency room. The patient's glucose increased to 86. He was admitted to the hospital. On arrival to the pediatric floor, the patient had normal vital signs, and was described as well appearing and sleeping comfortably. He had no vomiting or diarrhea while hospitalized and by the next day, he was starting to drink and improving. 

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

This patient was dehydrated based on his history (vomiting, no intake, no urine output for about 12 hours prior to arrival in the emergency department (ED)); physical findings (dry mucus membranes); and laboratory studies (bicarbonate 16, very concentrated urine). He was refusing oral fluids in the emergency department both before and after his Normal Saline IV bolus, so it was appropriate to admit him to the hospital for further IV therapy until he started to take fluids orally. His progress was likely complicated by his autism. The one day hospitalization was medically necessary, and he was appropriately discharged when he started to take oral fluids. The rest of the inpatient days were not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: ESRD (End Stage Renal Disease), colostomy, suprapubic catheter, sacrum, and foot pressure ulcers.
Treatment: Continued Long Term Acute Care (LTACH) admission.
The insurer denied: Continued Long Term Acute Care (LTACH) admission.
The denial is upheld.

The patient is an adult paraplegic male with a history of ESRD (end-stage renal disease), colostomy, suprapubic catheter, sacrum, and foot pressure ulcers. He was admitted to hospital after a transfer from the previous health system for continued and supportive care of the above. Nephrology had initiated hemodialysis and provided Aranesp and iron for anemia. It is unclear why he had a prolonged hospitalization. He is wheelchair bound. Since admission, the patient's wounds were treated with Dakin's solution. A progress note on Day #2 indicated he continued to receive offloading, nutritional support, and local care for his wounds. He was restarted on oral antibiotics for a tooth abscess and continued to receive physical and occupational therapy.
A progress note on Day #4 indicated he received ongoing wound care, therapy, and monitoring of his chronic anemia. He was transfused with 1 unit of blood on Day #4. Since Gay #3, the case management team had difficulty placing the patient in an outpatient setting or skilled nursing facility. A nutrition note on Day #4 indicated he had a good appetite and appropriate nutrition was provided for wound healing. His hemoglobin ranged from 7.2-8.4. A wound progress note on Day #5 indicated he had a sacral unstageable pressure ulcer (with 100%"hypogranulation"), left hip unstageable pressure ulcers, a right foot stage 3 pressure ulcer that had resolved, a left heel stage 3 pressure ulcer that resolved, and a right dorsal foot wound that resolved. Offloading, repositioning and A&D (Vitamin A and D) ointment were recommended. A wound progress note on Day #14 indicated he had a sacral unstageable pressure ulcer and left hip unstageable pressure ulcers. Offloading, repositioning and A&D (Vitamin A and D) ointment were recommended. From Day #5 to Day #17, he continued to receive similar care for his wounds and general health.

The Continued Long Term Acute Care (LTACH) admission was not medically necessary.

In this case, the patient was anemic and had several wounds. The wounds improved and the anemia stabilized after the Day #4 blood transfusion. The care was repetitious without any acute 
escalation of his medical conditions. There were no interventions provided that could have not been performed in a lower acuity setting. Furthermore, renal disease was managed via dialysis and the wounds did not continue to exhibit any significant necrosis. The patient was eating well, and did not require isolation, pain control, or other cardiopulmonary support. There was no indication that anemia management and wound care could not have been provided in a skilled nursing facility.