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

Orthopedic/Musculoskeletal
Inpatient Rehabilitation

Diagnosis: Septic arthritis and osteomyelitis
Treatment: Subacute rehab stay
The insurer denied Subacute rehab stay.
The determination is overturned.

This a male patient who was admitted to subacute rehabilitation for septic arthritis and osteomyelitis. The treating facility provided a letter of support for this appeal. He was admitted following treatment for septic arthritis of the left ankle and osteomyelitis of the distal tibia. He required a left ankle incision and drainage and hardware removal. The letter states that the patient would benefit from continued skilled services. He is continuing to receive physical and occupational therapy with a goal of increasing his lower extremity range of motion and strength. Further rehabilitation (rehab) will help him to improve his activities of daily living participation and require less help from others. They would like an extension of inpatient rehab care.
Therapy notes were provided as part of this review. They demonstrate that the patient showed continued improvement with ongoing therapy. His bed mobility progressed to set up assistance only from a baseline of caregiver assist. His trunk strength improved from 3-/5 to 4-/5. Dynamic standing improved from poor to fair. His wheelchair mobility improved from moderate to supervised and distance increased from 150 feet to 250 feet. He showed improvements across multiple domains.
The health plan denied coverage for an ongoing rehab stay. They stated that the patient requires a small amount of help with daily activities and walking. His pressure ulcer is getting smaller and does not require complex care. They stated that 10 additional days were authorized to help with continued improvement. At issue is the medical necessity of the subacute rehab stay.

The requested treatment is medically necessary for the patient.
The patient is being treated for rehabilitation following a surgical procedure and infection of the leg. Rehabilitation in an inpatient setting is typically continued until patients reach their maximum therapeutic potential as outcomes are maximized with intensive early interventions. The patient had a substantial decline in functional status as a result of his infection and surgery. Given his favorable prognosis for meaningful recovery of function, ongoing therapy services were recommended as medically necessary by his treating team. They were correct in this assessment, as the patient did show improvement in functional status with ongoing therapy support. The continued rehabilitation was medically necessary and reasonable for the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diabetes

Treatment: Ozempic 2 milligram (mg) / 3 milliliter (ml) pen

The insurer denied coverage for Ozempic 2 milligram (mg) / 3 milliliter (ml) pen

The denial is upheld

 
This is a patient diagnosed with Type 2 Diabetes. This request is for Ozempic. As reported he experienced tinnitus with covered alternative Trulicity. As per visit note he is on Trulicity and Jardiance. He was on Januvia and Jardiance. He has hypertension (HTN) and hyperlipidemia (HLD).
Ozempic is a glucagon like peptide 1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type 2 diabetes (2-7). There are no studies showing superiority of the requested medication over the formulary alternatives. The patient has failed the formulary alternative Trulicity due to side effects. The patient's A1c is not at goal based on the American Association of clinical endocrinologists guidelines recommending a goal A1c less than 6.5%. the patient can try the formulary alternative Victoza. The request is not consistent with generally accepted standards of medical practice. 
Case summary details

The formulary drug, Victoza, is not expected to cause adverse effects. 

The formulary drug, Victoza, was not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The non- formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Ozempic 2 milligram (mg) / 3 milliliter (ml) pen to treat diabetes is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hyperlipidemia, coronary artery disease (CAD), anemia, benign prostatic hypertrophy (BPH), and kidney calculus (stone).

Treatment: home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week

The insurer denied coverage for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week

The denial is overturned

 
The patient has been diagnosed with a history of diabetes, hyperlipidemia, coronary artery disease (CAD), anemia, benign prostatic hypertrophy (BPH), and kidney calculus (stone). Home health assistance increase is requested, due to cognitive decline, dizziness, heart disease, an unsteady gait, and other comorbidities. The request is for home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week, which is under review.

Uniform Assessment System (UAS) indicates patient lives with wife; however, wife died since and now lives alone. A son lives upstairs and visits in evening. Daughter is out of town -calls often. His cognition is modified independence. Noted as alert and oriented X3. He is maximum assist for meals, total dependent for housework, limited assist for medications. Phone use is help on some occasions. Transport is extensive assistance. Activities of daily living (ADLs) reported were limited assist for personal hygiene and dressing upper body, He is extensive  assist for lower body. He is supervision for walking, locomotion and transfer toilet. Extensive assist for toilet use. Independent for bed mobility and eating. He is continent of bladder/bowel.

As per prior UAS  dressing lower body, toilet use were all limited assistance indicating some level of deterioration over time. Physician notes were reviewed but provided minimal information regarding ADL and instrumental activities of daily living (IADL) needs.  A clinical note did indicate cognition is abnormal with no details.

This man is now living alone, has cognitive issues and has shown deterioration is some areas as per the UAS.

Bursack, C.B. (2021), "The ability to perform ADLs is often used to determine what types of care and senior living settings are suitable for an elder. For example, independent living facilities do not provide any assistance with ADLs. This type of unskilled care is usually referred to as personal care or custodial care. If a resident requires this kind of help, he or she will have to get it from a family caregiver, hire in-home care or move to a higher level of care where ADL support is provided (e.g., an assisted living facility, a memory care unit, a nursing home)."

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 home care / personal care HHC - level 2 personal care services, per 15 minutes increase to 60 hours per week is substantiated.
Appeal type: Formulary Exception
Decision: Overturned



Diagnosis: chronic kidney disease and proteinuria 
Treatment: Filspari.
The insurer denied Filspari. 
The health plan's determination is overturned. 

The patient is a male with chronic kidney disease and proteinuria secondary to IgA (immunoglobulin A) nephropathy on kidney biopsy and the treating physician requested Filspari. 

The formulary drug would not be as effective as the non-formulary drug.
The patient is currently being treated with angiotensin receptor blocker (Losartan) with progression of chronic kidney disease. The Formulary alternatives (systemic steroids) are an option for IgA nephropathy, however, they are not Food and Drug Administration (FDA) approved for this indication.
Filspari (Sparsentan) is FDA approved for IgA nephropathy to slow down progression of chronic kidney disease and reduce proteinuria.
Sparsentan is an oral, single-molecule, selective antagonist of the angiotensin II receptor (AT1) and endothelin 1 (ET-1) receptor (ETA). ET-1, primarily through activation of ETA, has been implicated in podocyte injury, proteinuria, fibrosis, and progression of chronic kidney disease. Sparsentan has received approval by the FDA for reduction of proteinuria in patients with IgAN (IgA nephropathy) at risk of rapid disease progression.
The efficacy and safety of sparsentan are being evaluated in a phase III trial that randomly assigned 404 adults with biopsy-proven IgAN, an estimated glomerular filtration rate (eGFR) >= (greater than or equal to) 30 , and persistent proteinuria > (greater than)1 g/day (gram/day) in spite of three months of optimized supportive care (including maximally tolerated ACE (Angiotensin-converting-enzyme inhibitors) or angiotensin II receptor blockers (ARB) therapy) to sparsentan 400 milligrams (mg) once daily or irbesartan 300 mg once daily.
Therefore, a formulary exception is indicated in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: multiple psychiatric issues, diabetes mellitus, with end stage complications including neuropathy and vision loss in her left eye.

Treatment: personal care assistance (PCA) services, 5 hours per day, 7 days per week, (Monday through Sunday), a total of 35 hours per week

The insurer denied coverage for personal care assistance (PCA) services, 5 hours per day, 7 days per week, (Monday through Sunday), a total of 35 hours per week

The denial is upheld 

This patient has multiple psychiatric issues, diabetes mellitus, with end stage complications including neuropathy and vision loss in her left eye and recent laparoscopic band surgery. She has multiple children. She also has a brother. 

The patient is alert and oriented x 4. She has easy onset fatigue and shortness of breath (SOB) and leg pain due to neuropathy. She can walk at home unassisted with no device but with daily contact guard, supervision, and surface reliance. She is independent in bed mobility and self toilets, showers, and dresses with safety supervision for transfers. No falls were reported in the past 90 days.

Depression and anxiety are addressed with psychiatric appointments and a therapist every other week and medications.

Family does routine housework, shopping, finances, and medication management including filling insulin pump. She assists with cooking as able.

The patient does not live alone and has multiple older age and adult children living with her. Further, she has the physical capabilities to make meals. The medical records provided for review do not support that her current hours per week are not sufficient enough to support her current activities of daily living.

Based on the above, the insurer's denial must be upheld. The medical necessity for personal care assistance (PCA) services, 5 hours per day, 7 days per week, (Monday through Sunday), a total of 35 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult previously healthy male who presented to the emergency department with complaints of diarrhea and abdominal pain of two-days duration. On presentation, the patient's vital signs included a normal temperature, a heart rate of 60 beats per minute, and blood pressure of 162/72 millimeters of mercury (mmHg). Oxygen saturation was 99 percent. The white blood cell (WBC) count was 10.5 thousand. Serum electrolytes and renal parameters were normal. Imaging with computed tomography scan identified findings that suggested small bowel obstruction or ileus. The patient was admitted to the hospital. Initial treatment included nothing by mouth (NPO) status, antiemetic medication, pain medication, and monitoring for emesis. 
On day # (number) 2 an abdominal x-ray showed progression of oral contrast into the colon consistent with partial obstruction or ileus. The patient's diet was advanced. On day #3, the patient's vital signs were normal. The patient remained hemodynamically stable throughout the period of monitoring. He was passing flatus. The white blood cell (WBC) count and serum electrolytes were normal on day #2. The patient was considered to be stable for discharge home on day #3. The health plan rationale for denial is that the documentation does not show that the requirements for an inpatient level of care have been met. Per this letter there is no documentation of abnormal vital signs, persistently abnormal blood tests, complete obstruction on imaging, or failure to improve with observation care.

The medical record does not support that inpatient admission was medically necessary.

This patient presented to the hospital with abdominal complaints. 
At the time of presentation, he was without fever and was hemodynamically stable. He had findings that suggested ileus or partial small bowel obstruction on computed tomography scan on day #2. He was monitored overnight, and his symptoms improved such that a diet was initiated on day #2. Lab data and vital signs remained normal throughout the period of monitoring. The patient was discharged from the hospital on day #3 with planned outpatient follow up. The patient did not require acute surgical intervention or intensive monitoring and he responded favorably to the treatment provided. A lower level of care would have satisfied this patient's clinical needs with subsequent care provided in the outpatient setting.
Appeal type: Medical necessity
Decision: Overturned

Genitourinary /Kidney Disorder
Radiology Services (including ultrasound)

Diagnosis: Benign Prostatic Hypertorphy
Treatment: Magnetic Resonance Imaging (MRI) of the Pelvis
The insurer denied the Magnetic Resonance Imaging (MRI) of the Pelvis.
The health plan's determination is overturned.

The patient is a male with a rising prostate-specific antigen (PSA). Review of his chart notes indicate a biopsy is planned; fusion biopsy would be performed if magnetic resonance imaging (MRI) were suggestive of a target lesion. He is biopsy naive.

The requested health service/treatment of Pelvis Magnetic Resonance Imaging (MRI) is medically necessary for this patient. The applicable plan notes that prostate MRI is endorsed when a patient has suspected prostate cancer and a biopsy is planned.
Current guidelines of the American Urological Association (AUA) note "Studies have demonstrated the clinical value of multiparametric MRI (mpMRI) and using this to guide biopsy decision-making can increase the likelihood of detecting clinically significant prostate cancer while lowering detection of insignificant disease." 
National Comprehensive Cancer Network (NCCN) guidelines state, "At this time, the panel believes that the multiparametric MRI should be considered prior to Transrectal ultrasound guided biopsy (TRUS-guided biopsy) to inform biopsy decisions and to help identify regions of the prostate that may harbor cancer."

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

Diagnosis: Family history of cancer
Treatment: Integrated BRACAnalysis with MyRisk Update 
Test (81479)
The insurer denied: Integrated BRACAnalysis with MyRisk Update Test (81479)
The denial is upheld.

The patient is an adult female who underwent BRACAnalysis with MyRisk Update Test for evaluation of breast cancer risk. The test was reported last year. The test denied as not medically necessary because of insufficient genetic risk documented in the family to support this testing.

The proposed treatment was not medically necessary.

The policy, which is consistent with the position from the American Society of Clinical Oncology and the United States Preventative Service Task Force recommendations states that testing should be performed on family members first who are at risk of carrying the BRCA gene before obtaining this test on the individual who is unaffected with cancer. This was not done and no reason has been given as to why this testing could not be performed on the patient's uncle with pancreatic cancer.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a female who presented to the hospital with chest pain that woke her up from sleep. She described the pain as an elephant sitting on her chest. Her pain was pressure-like, non-radiating, and without associated symptoms. The patient was given intravenous fluids (IVF) bolus, and intravenous (IV) Lopressor. The patient was admitted to the telemetry unit. 

The requested inpatient hospital stay was not medically necessary for this patient. The patient had chest pain at rest, with an unremarkable ECG (electrocardiogram) and normal cardiac enzymes. Her vital signs were stable, and she did not have evidence of heart failure, serious arrhythmia, unstable blood pressure. The patient's stress test was abnormal, and she underwent coronary angiography. However, there was no acute coronary syndrome, non-ST elevation myocardial infarction (NSTEMI) or ST-Elevation Myocardial Infarction (STEMI), based on her normal troponin, non-ischemic ECG and patent coronary arteries. 
The patient's care could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizures
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult female with a history of epilepsy. She presented to the ER (emergency room) following a seizure. She had been found in the bathroom seizing. She had back pain, 
abdominal pain nausea and vomiting. The patient was noted to be extremely uncomfortable, in acute distress, restless, walking back and forth. She was found to have leukocytosis and elevated CPK (creatine phosphokinase). She was given Keppra as well as other IV (intravenous) medications. Inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient admission was medically necessary. 

The patient had a seizure, which was supported by leukocytosis and elevated CPK (creatine phosphokinase). Her restless state with vomiting can be due to a prolonged postictal state. This 
warranted admission, as she was not back to her baseline. MCG (Milliman Care Guidelines) guidelines 26th edition Seizure recommend admission when one has not returned back to baseline. Furthermore, a lack of return to baseline can be concerning for non-convulsive status epilepticus, which can result in morbidity and mortality.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion. 
Treatment: Adjustment of braces and insertion of braces. 
The insurer denied: Adjustment of braces and insertion of braces. 
The denial is overturned. 

The patient is an adolescent male. The request is for orthodontic benefits. The patient has a Class I malocclusion with mild upper and moderate lower crowding. He has a deep bite and crossbite on the left side. The prior denial was due to a handicapping index score of 18. 

The proposed treatment is medically necessary. 

The patient has a deep bite with gingival impingement of the palatal gum tissues. This is an automatic qualifier according to the handicapping index scale. Orthodontic treatment is needed to correct this malocclusion and the case has medical necessity. Therefore, the proposed treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class II malocclusion
Treatment: Full braces and monthly brace adjustment visits.
The insurer denied: Full braces and monthly brace adjustment visits.
The denial is overturned.

The patient is a teenage female. The request is for orthodontic benefits and monthly visits. The prior denial was due to there being no need to "fix serious head or facial problems".

The proposed treatment is medically necessary.

The patient has a Class II malocclusion with severe upper and lower jaw crowding of her teeth. Tooth number 10, her upper left lateral incisor, is sticking out way too far from the other teeth. 
This tooth will be traumatized over time and there is the likelihood of it fracturing and/or loosening. The patient also has a very deep bite with her lower front teeth biting the gum tissue behind her upper front teeth. This will cause damage to the gums over time. Her retruded lower jaw will increase her possibly of developing a temporomandibular joint issue with its associated pain and discomfort. This case has medical necessity and orthodontic treatment is needed to correct the malocclusion. The monthly visits are needed to make sure the treatment is progressing properly.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Miscarriage
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is overturned.
 
The patient with a diagnosis of miscarriage presented to the Emergency Department (ED) with complaint of ongoing bleeding and fatigue. Curetting of the uterine cavity was performed. However, the patient kept bleeding necessitating Hemabate, rectal Cytotec, tranexamic acid, and insertion of a intrauterine balloon.

The patient stabilized and she was discharged home the next day.

Dilation and curettage (D&Cs) are done in offices and surgery centers.  Dilation and curettage can be performed safely in the office or other outpatient setting using manual vacuum aspiration or sharp curettage. However, this patient had an obstetrical hemorrhage necessitating active management. Including serious medications and a procedure (insertion of a balloon). Managing an obstetrical hemorrhage requires hospital admission for close monitoring, possible surgery. Insertion of a balloon to stop heavy bleeding requires hospital admission for close monitoring of the patient and rapid treatment in case the bleeding is still uncontrolled. 

Admission to an acute level of care for management of an obstetrical hemorrhage is standard of care.

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 hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Teeth Spacing Problem. 
Treatment: D8020 braces. 
The insurer denied the D8020 braces. 
The health plan's determination is overturned. 

The patient is a male with maxillary and mandibular crowding and several unerupted permanent teeth. Number (#) 7 and #10 are delayed in their eruption and are potentially impacted. The patient has treatment planned for phase one (I) orthodontics with rapid palatal expansion and possible exposure of the maxillary laterals. 
At issue is the medical necessity of braces. 

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

The requested health service/treatment of braces is medically necessary for this patient.
Impacted teeth indicate a strong medical need for orthodontic treatment. Many studies have shown that early intervention with rapid palatal expansion can lead to spontaneous eruption of previously impacted maxillary canines. [2,3,4] It is a generally accepted practice guideline to treat patients with impacted teeth, because if not handled properly it can lead to poor results for the patient. [5] Intervention now will likely lead to favorable eruption of the maxillary canines leading to less invasive treatment in the future. There is not currently enough space for the lateral incisors to erupt. This is almost universally indicative of a future lack of space for the permanent maxillary canines to erupt as well, which can lead to many complications. [1]