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

Diagnosis: Abdominal pain. 
Treatment: Full hospital admission. 
The insurer denied the full hospital admission.  The health plan's determination is upheld. 

The patient is a man, who presented with complaints of abdominal pain and nausea of one-day duration. Past medical history includes a hypertension and obesity. He was admitted to the hospital. Vital signs included normal temperature, heart rate and respiratory rate and blood pressure at the time of presentation. He was tender in the right upper quadrant. The white blood cell (WBC) count was slightly elevated at 10.7. Lab data showed an aspartate aminotransferase (AST) of 33, alanine aminotransferase (ALT) of 63, and alkaline phosphatase of 56 with normal bilirubin. Ultrasound showed a gallbladder with stones and a common duct of 6.5- millimeter (mm). Magnetic resonance cholangiopancreatography (MRCP) showed gallstones with mild gallbladder wall thickening, but no common duct stones. 

An inpatient hospital admission was not medically necessary in this case. This patient presented to the hospital with complaints of abdominal pain. Imaging and surgical consultation was performed and established the diagnosis of cholelithiasis/cholecystitis. At the time of presentation, the patient had normal vital signs and was without fever. MRCP on day #2 did not show common duct stones. Surgery (cholecystectomy) was performed. The perioperative and early post-surgical recovery were uncomplicated, and the patient had normal vital signs and tolerated a diet on the first post-surgical day. He was deemed to be stable for discharge from the hospital. Acute inpatient care was not medically necessary for this patient, as the care and treatment provided could have been rendered with a lower level of care. 
A lower level of care would have provided for initial assessment, perioperative care and monitoring, provision of IV (intravenous) fluid, surgical consultation, performance of cholecystectomy, and overnight care. There were no peri-procedure complications or other clinical issues.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial droop and dizziness.
Treatment: Inpatient Hospital Stay.

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

This is a female patient with no past medical history (PMH) who was admitted with complaints of (c/o) facial droop and dizziness. The patient's vital signs were unremarkable. The physical exam was notable for facial asymmetry, National Institute of Health Stroke Scale (NIHSS) 3. Lab work was unremarkable. Imaging studies, including a chest x-ray (CXR) showed no acute disease, a computed tomography (CT) scan of the head showed no acute intracranial pathology, magnetic resonance imaging (MRI) showed no acute ischemia. An electrocardiogram (EKG) showed no evidence of ischemia. The patient was diagnosed with Bell's palsy and was treated with steroids. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) facial droop and dizziness. The patient's NIHSS score was 3, indicating that the patient on presentation, at most, had suffered a minor stroke, but was eventually found to have a negative computed tomography (CT) scan and magnetic resonance imaging (MRI) negative for acute findings. Further suggestion that this patient was appropriate for a lower level of care is that the patient did not have a crescendo transient ischemic attack (TIA), head CT/MRI was negative, there was no known extracranial embolic source such as atrial fibrillation or artificial heart valve, known carotid stenosis, disabling stroke, altered mental status, or hypertensive encephalopathy. The patient remained hemodynamically stable during the stay, was treated with standard medications for TIA, but was eventually diagnosed with Bell's palsy, not a TIA or cerebrovascular accident (CVA), and was discharged in stable condition after a good response from administration of steroids. Overall, this patient could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Other- Mobility issues.
Treatment: Directed Personal Assistance Services (CDPAS): 7 Days per Week, 24 Hours per Day, Continuous Care by More Than One Person - A total of 168 Hours per Week.
The insurer denied coverage for Directed Personal Assistance Services (CDPAS): 7 Days per Week, 24 Hours per Day, Continuous Care by More Than One Person - A total of 168 Hours per Week.
The health plan's determination is Overturned. 

The patient is a female with a past medical history notable for mobility issues, incontinence, dementia, and pressure ulcers. 

The patient's physician provided a letter of support stating that the patient has a history of chronic obstructive pulmonary disease (COPD), a prior joint replacement, an aortic valve replacement, urinary and fecal incontinence, an overactive bladder, prior hip fractures, cognitive decline, and bed sores. She currently has a stage 3 pressure ulcer on the buttock and a new pressure ulcer on her right leg. She is required to be repositioned every 2 hours throughout the day and night. The patient does not have support from family. Due to these personal care needs, the physician requests 24-hour split-shift personal care for the patient.


The requested health service of Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 24 Hours per Day, Continuous Care by More Than One Person - A total of 168 Hours per Week is medically necessary for this patient.

The patient's personal care needs are extensive. The UAS appears to underestimate her current level of functional need; two pressure ulcers, including a stage 3 pressure ulcer of the buttocks, have developed since the time of that assessment. Her personal care needs are continuous and unscheduled throughout the day and night. A live-in personal care aide would not be able to receive sufficient rest. Therefore, continuous personal care by more than one person, 24 hours per day, is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Home health care

Diagnosis: Decreased mobility
Treatment: Home health care
The insurer denied Personal Care Aide (PCA) Services: 24 Hours (Split Shift) per Day, 7 Days per Week.
The health plan's determination is upheld.

This is a case review for a female with medical history notable for end stage renal disease on dialysis, urinary incontinence, and mobility issues.
Per a letter from the patient's physician, the patient's condition has deteriorated and she now requires total assistance with all activities of daily living including transfers, ambulating, and toileting. She requires frequent assistance in the night time and uses the commode frequently due to medication side effects. She needs to be cleaned and changed frequently during the night due to incontinence as well. The physician recommends split shift care.

The requested Personal Care Aide (PCA) Services: 24 Hours (Split Shift) per Day, 7 Days per Week is not medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5 hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, the question at hand is whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
Based on the documentation provided, there is insufficient evidence that the patient requires split shift personal care. There is no documentation of a pressure ulcer or a requirement for turning and repositioning every two to three hours overnight. There were no night time care logs provided to demonstrate that the patient has toileting or other care needs of such frequency overnight that a live-in care aide would not be able to receive at least 5 hours of uninterrupted rest. Therefore, the requested services are not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II Diabetes Mellitus.

Treatment: Mounjaro 2.5 milligrams (mg) / 0.5 milliliters (ml).

The insurer denied coverage for Mounjaro 2.5 milligrams (mg) / 0.5 milliliter (ml).

The denial is upheld. 


This patient is diagnosed with type II diabetes mellitus (T2DM). This request is for Mounjaro. As reported, the patient had tried and failed Trulicity and metformin (due to headache and diarrhea). As per visit notes, the patient is on Mounjaro and Jardiance. The patient tried and stopped Januvia with no side effects. 

The patient's most recent hemoglobin A1C's were 6.7%, 7%, and 7.6%.

The formulary alternative Victoza is not likely to cause an adverse reaction. 

The patient is reported to have only failed Trulicity due to adverse side effects. 

The requested drug will not be more effective than the formulary alternative.

The requested medication Mounjaro (Trizepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes.  It is a glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonist.  It has been shown in clinical trials to lead to improvement in hemoglobin A1c as well as weight loss (1-3). There are no studies demonstrating the superiority of the requested medication over the formulary alternatives. The most recent American Diabetes Association guidelines recommend using GLP-1 receptor agonists as a 1st line agent. There is no preference for the requested medication over GLP-1 receptor agonists (4). 

The available formulary drugs are not all expected to cause adverse effects. 

The formulary drug available and required to be tried were not all tried as indicated above, and the patient did not have an adverse reaction or contraindication to an additional formulary drug (Victoza).

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 Mounjaro 2.5 milligrams (mg) / 0.5 milliliter (ml) pen to treat Type 2 Diabetes is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back pain
treatment: Magnetic Resonance Imaging (MRI) of the Lumbar Spine
The insurer denied the MRI of the lumbar spine.
The health plan's determination is overturned. 

The patient is a male who has a long-standing history of low back pain. His other significant medical history includes prostate cancer and atrial fibrillation. He fell off a ladder 9 years ago, which aggravated his back pain. His prior treatments include physical therapy (PT), chiropractic manipulation, and non-steroidal anti-inflammatory drugs (NSAIDs). He has increased pain with physical activities such as walking and lawn work. His pain level is 7/10. Lumbar x-rays revealed anterolisthesis.

The magnetic resonance imaging (MRI) of the lumbar spine is medically necessary for this patient.

This patient has had low back pain for more than 10 years. X-rays of the lumbar spine indicated anterolisthesis. His pain is severe despite prior treatments including NSAIDs, PT, and chiropractic manipulation. X-rays of lumbar spine indicated anterolisthesis. Given this clinical scenario, the MRI is medically necessary to clarify the etiology of his pain. Further therapeutic interventions will be determined by the MRI findings.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Falls
Treatment: Personal Care Worker (PCW) service of 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person
The insurer denied Personal Care Worker (PCW) service of 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person.
The determination is overturned.

This is a female patient with a medical history notable for heart disease, incontinence, and a history of falls. The patient was residing at a long-term care facility, and her care team requested a discharge with 24 hours per day, 7 days per week for a total of 168 hours per week of personal care worker services. The health plan approved 8 hours per day, 7 days per week for a total of 56 hours per week. The denied request for 24-hour split shift continuous care is the subject under review.
A Uniform Assessment System was completed. The assessment was conducted in person. The patient's cognition was severely impaired. She was alert and oriented to person only. For her instrumental activities of daily living, she requires maximal assistance or total dependence for all. For her activities of daily living, she requires maximal assistance for hygiene. She requires extensive assistance for all others. She was unable to ambulate during the evaluation and requires weight bearing support for ambulation. She is frequently incontinent of both stool and urine. There were no falls in the previous 90 days. There was no pressure ulcer present.
Night time personal Care logs were available for review. The care logs demonstrate that the patient requires assistance with personal care tasks every 2 to 3 hours throughout the night. She has frequent requests for using the bathroom. She also requires cleaning after episodes of incontinence. She occasionally requires assistance with repositioning using a booster. At issue is the medical necessity of Personal Care Worker (PCW) service of 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person.
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The requested health service of Personal Care Worker (PCW) service of 7 days per week, 24 hours per day; 168 hours per week, continuous care by more than one person is medically necessary for this patient.
The patient requires personal care assistance for all activities of daily living. She is not able to ambulate, transfer, toilet, or manage incontinence care products on her own. Furthermore, due to her advanced dementia, she is unable to direct her own care. The patient's care needs are expected to be continuous and unscheduled throughout the day and night. The night time care logs demonstrate that the patient's care needs are of such frequency that a live-in personal care aide would not be able to receive adequate rest at night. Therefore, the requested increase to 24-hour continuous care by more than one person is medically necessary for the patient. Failure to address her personal care needs could result in falls, injury, skin breakdown, and/or infection.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraine Headache
Treatment: Vyepti
The insurer denied: Vyepti
The denial is upheld.

This patient is an adult female with migraines. The patient was previously treated with Emgality and Depakote. The patient's provider wishes to start Vyepti. The request was previously denied as the patient has not tried formulary alternatives, including Ajovy and Emgality. This denial is under review. 

The requested health service of Vyepti, is not considered medically necessary. 

While this patient has reportedly tried formulary alternative Emgality, there is no indication that she has tried Ajovy. The American Headache Society anti-CGRP (calcitonin gene-related peptide) guidelines do not indicate that any one anti-CGRP is more effective than the other. As such, the requested health service of Vyepti would not be considered medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Carious lesions encroaching on the pulp spaces #14
Treatment: Endodontic therapy: cleaning inside roots of a back tooth (root canal) for tooth #14
The insurer denied coverage for: Endodontic therapy: cleaning inside roots of a back tooth (root canal) for tooth #14
The denial is: Overturned
Based on the submitted documentation which includes copies pre-endodontic therapy periapical radiographs, dental treatment record and insurer correspondence, it appears that this patient presented to the dentist for evaluation and comprehensive dental treatment. Endodontic therapy was recommended on #14 due to carious lesions encroaching on the pulp spaces, failing restorations and periapical pathology #14. The insurer has denied these services stating that the services are not medically necessary as the clinical circumstance does not meet their stipulated criteria for approval. The patient is appealing the decision.

Upon review of radiographs, they support the recommended treatment. Tooth #14 has carious lesion involving the pulp chambers radiographically and exhibits periapical radiolucency consistent with periapical pathogenesis secondary to caries. This would require endodontic therapy as recommended by the dentist. The standard of care in general dental practice would be endodontic therapy for this tooth which would have an excellent long-term prognosis with the recommended treatment.

Reverse denial and approve coverage for cleaning inside roots of a back tooth (root canal) for tooth #14 as medically necessary as the clinical and radiographic documentation support this service, and this service would be a standard of care in general dental practice.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for cleaning inside roots of a back tooth (root canal) for tooth #14 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left leg pain
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This patient is an adult female who presented with ischemic rest pain of the left leg. She was admitted for angiogram and possible intervention. She was found to have peroneal occlusion, which was successfully treated by atherectomy. The procedure was uneventful. The patient was treated post-procedure with intravenous hydration for six hours. She was admitted overnight and discharged the following day. Her post-procedure course was uneventful.

The requested health service was not medically necessary.

Patients who undergo percutaneous lower extremity arterial interventions are not generally admitted to the hospital. They are typically discharged the same day or after an extended period of observation. Inpatient admission is reserved for patients who have complications. This patient's procedure and post-procedure course were entirely uneventful. The record does not demonstrate any reason for inpatient hospitalization. Such reasons would include bleeding, ischemia, or coronary symptoms. No such issues occurred in this case. The appeal letter does not offer any reason for the patient's inpatient admission. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Perforated sigmoid diverticulitis. 
Treatment: Inpatient Hospital Stay. 
The insurer denied Inpatient Hospital Stay. 
The determination is upheld. 

This patient is a male who presented to the hospital with the diagnosis of perforated sigmoid diverticulitis and a nonfunctional intravenous (IV) catheter. 
He initially presented to the hospital with complicated diverticulitis and had been treated with percutaneous drainage of an abdominal abscess and IV antibiotics via a peripherally inserted central catheter (PICC). He was receiving ongoing IV antibiotics in the outpatient setting until the IV catheter failed to function normally. He was instructed to present to the emergency department (ED). 
At the time of ED presentation, he was without a fever and the vital signs were normal. The patient reported feeling well and was without abdominal pain or tenderness. The white blood cell count (WBC) count was 11.3 thousand (K). Attempts were made to flush the peripherally inserted central catheter (PICC) without success and this catheter was removed. He was admitted to the hospital and treated with IV antibiotics. The plan was for replacement of the PICC line at the earliest possibility. He was started on a diet and tolerated oral intake. The patient was reported to be feeling well and was without complaint. 
A computed tomography (CT) scan performed showed a persistent abscess in the deep pelvis (4.8 x 3.7-centimeter (cm)). A new PICC line was placed. An infectious disease consultation was obtained. He was discharged from the hospital with continuation of IV antibiotic therapy in the outpatient setting. At issue is the medical necessity of an inpatient stay. 
Inpatient care was not medically necessary. The records indicate that there was a delay in performance of replacement of the PICC that prolonged this patient's hospitalization.
The patient was being treated in the outpatient setting for complicated diverticulitis. He had a percutaneous drain in place and was receiving IV antibiotics via PICC. He presented to the hospital due to occlusion / malfunction of the PICC. He was clinically stable at the time of the presentation. The stated reason for hospital admission was for replacement of the PICC. This was not performed until day 4. Upon completion of the PICC replacement, the patient was deemed stable for discharge from the inpatient setting. 
There were no clinical issues that mandated ongoing inpatient stay. He was tolerating a diet. He was without significant abdominal pain. He had been receiving antibiotics intravenously in the outpatient setting prior to. 
There was an alternative, less intensive setting, in which to manage this patient's ongoing need for IV access other than inpatient hospital admission.