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

Diagnosis: abdominal pain
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a female who presented to the emergency room (ER) with right upper quadrant (RUQ) pain and positive Murphy's sign, mild leukocytosis, and normal hepatic panel. A RUQ ultrasound (US) revealed large gallstone with borderline wall thickening and dilated common bile duct (CBD) 8 millimeter (mm). The patient was admitted, made nothing by mouth (NPO), provided intravenous fluids (IVF) and intravenous (IV) antibiotics (abx) without improvement in pain. Given persistent pain, a decision was made to proceed with laparoscopic cholecystectomy on 2/6/23. On postoperative day (POD)#1, the patient was able to tolerate oral intake, pain controlled with PO (by mouth) medications and discharged home.

The inpatient hospital admission was medically necessary. Although most cases of elective biliary colic/cholelithiasis can be managed in an ambulatory or elective fashion, this patient presented with early acute cholecystitis which was initially managed non-operatively. The patient did not respond to conservative management and a decision was made to proceed with surgical cholecystectomy. The procedure was uncomplicated and the postoperative course was routine and the patient was discharged home on POD#1. Given the initial equivocal findings on US, more than 5 days or pain prior to presentation and only mild leukocytosis with normal hepatic panel, trial of conservative management with IV antibiotics was not unreasonable. The patient did not clinically improve and a decision to proceed with surgical cholecystectomy was made. This treatment for acute cholecystitis was not able to be achieved at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: General Debility
Treatment: Increase Personal Care Aide (PCA) Services, Level 2: 12 hours per day -7 days per week - for a Total Amount of 84 Hours per Week
The insurer denied: Increase Personal Care Aide (PCA) Services, Level 2: 12 hours per day -7 days per week - for 
a Total Amount of 84 Hours per Week.
The denial is overturned.

The patient is an elderly female with history of general debility. The request is for Personal Care Assistance through Home Health care (Level 2) to be increased from 45.5 hours per week (6.5 hours per day, 7 days per week) based on UAS (Uniform Assessment System) of last year to 84 hours per week (12 hours per day, 7 days per week) based on UAS (Uniform Assessment System) of 3 months ago. The health plan denied the request, because the patient lives with spouse and daughter who are supportive and involved in her care. Also, that time has been allotted for meal preparation, laundry and housework, and the previously allocated PCA (personal care aide) hours of 45.5 per week are adequate for her current needs. The additional hours requested are for safety monitoring, bathing, dressing, meal preparation, errands, laundry, housework, medication management and attending medical appointments due to cardiac problems, hyperlipidemia, depression osteoarthritis, dementia, glaucoma, vitamin deficiencies, etc. A review of the records showed that patient has multiple medical conditions including hypertension, cardiac disease, hyperlipidemia, recurrent depressive disorders, osteoarthritis, dementia, glaucoma, vitamin B12 deficiency with anemia, Vitamin D deficiency, etc. The patient's evaluation of 3 months ago showed that she required extensive assistance with mobility, walking, locomotion, transfer toilet, toilet use and eating, required maximum assistance with upper/lower body dressing, bathing, etc., while totally dependent for meal preparation, medication management and housework. Her family support is very good with the presence of her spouse and the daughter.

The requested Increase Personal Care Aide (PCA) Services, Level 2: 12 hours per day - 7 days per week - for a Total Amount of 84 Hours per Week is medically necessary.

Based on the most recent UAS (Uniform Assessment System) evaluation of 3 months ago, the patient requires extensive assistance with mobility, walking, locomotion, transfer toilet, toilet use and eating, required maximum assistance with upper/lower body dressing, bathing, etc., while totally dependent for meal preparation, medication management and housework. The reason for denial by the health plan, as stated in the clinical information above, does not align with the patient's disability features as noted in the UAS (Uniform Assessment System) 
evaluation of 3 months ago. Therefore, the requested Personal Care Aide 84 hours per week (12 hours per day, 7 days per 
week) is medically necessary, based on UAS (Uniform Assessment System) of 3 months ago.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of hypertension (HTN) and diabetes mellitus (DM) who was recently hospitalized with back pain and needed a laminectomy. She was discharged to stay with her friend. However, she presented back as she had no place to live and she had right lower extremity pain that was worsening with activity. She has no systemic symptoms, and no trauma. She was afebrile with a systolic blood pressure (SBP) in 200s that improved to 160 soon after her admission. Her lab results were remarkable for a blood glucose of 390. She had negative straight leg raising test. She expressed that she had nowhere to go. She was admitted and a chest x-ray was performed that did not show any acute pathology. She was seen by physical therapy (PT) / occupational therapy (OT) and her pain medications were adjusted. Efforts were made for shelter placement. The patient was eventually discharged under safe conditions. At issue is the medical necessity of an inpatient stay.
Based on a review of medical records and the literature, the inpatient admission was not indicated or medically necessary as there was no clinical indication for that level of care. The patient needed shelter placement and that was the sole reason for her staying in the hospital. The patient had no clinical/medical indication for inpatient admission. She was hemodynamically stable. She had no trauma, fracture, severe infection, rapidly progressive cellulitis of the lower extremity, hardware infection, need for any intervention that would make her a candidate for inpatient admission [1,2]. She had hyperglycemia and an A1c of 11.4 due to poor compliance with her medications. She had no associated acidosis, ketosis, electrolyte derangements, acute kidney injury (AKI), severe dehydration, or any other acute condition making her a candidate for inpatient admission [3]. The care provided was suitable for a lower level of care with subsequent transition to the outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
Diagnostic testing

Diagnosis: Epigastric pain
treatment: Diagnostic testing
The insurer denied Esophagogastroduodenoscopy (EGD.)
The health plan's determination is upheld. 

The patient is a female who presented with epigastric pain, belching, and nausea for weeks. She had been on famotidine twice daily for two days with some improvement. She was started on an anti-reflux diet, and an endoscopy was planned if symptoms did not improve. An Esophagogastroduodenoscopy showed mild esophagitis, a small hiatal hernia, chronic gastritis, and mild duodenitis; biopsies showed chronic nonspecific gastritis, and mild chronic nonspecific duodenitis. She was started on lansoprazole.

The esophagogastroduodenoscopy is not medically necessary for this patient. Clinical guidelines (including the American College of Gastroenterology guidelines for the treatment of gastroesophageal reflux disease, and guidelines for dyspepsia) recommend endoscopy for investigation of upper gastrointestinal symptoms when those symptoms are refractory to proton pump inhibitor taken properly for 4-8 weeks without response. The most recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines for appropriate use of endoscopy state that endoscopy is warranted if an appropriate empirical trial of therapy for a suspected benign digestive disorder has been unsuccessful. The Current medical literature continues to support these recommendations. In this case, there is no documented proton pump inhibitor therapy for at least 4 weeks before the endoscopy. No other guideline-supported indication for esophagogastroduodenoscopy is documented. For these reasons, the esophagogastroduodenoscopy is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity (weight management)
Treatment: Saxenda (3mg [milligrams]/ 0.5ml [milliliter]) Pen Injector
The insurer denied: Saxenda (3mg [milligrams]/ 0.5ml [milliliter]) Pen Injector
The denial is overturned.

This is an adult female with a body mass index (BMI) of 30. The patient reports being on Saxenda (liraglutide) for the past year with excellent results. This was discontinued as there was a request for her to join Weight Watchers for at least three months. The patient joined Weight Watchers 4 months ago.

The requested health service is medically necessary.

This is an adult female with a body mass index (BMI) of 30. The patient reports being on Saxenda for the past year with excellent results. This was discontinued as there was a request for her to join Weight Watchers for at least three months. The patient joined Weight Watchers 4 months ago. Despite being on Weight Watchers, the patient's weight continued to increase, and her blood pressure worsened. The patient reported significant weight loss on Saxenda and has failed Weight Watchers; therefore, Saxenda is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD)
Treatment: Concerta
The insurer denied Concerta.
The determination is upheld.

This is a male patient being prescribed Concerta for the treatment of attention-deficit hyperactivity disorder (ADHD). Coverage for this medication was denied by the health plan.
They require a trial of at least three formulary alternatives before considering the non-formulary medication. Formulary alternatives available to treat the patient's condition include amphetamine-dextroamphetamine mixed salts extended release (XR), dexmethylphenidate XR, dextroamphetamine XR, methylphenidate XR, and Azstarys.
Medical records and pharmacy benefit records were provided for review. Notes stated that the patient is on Concerta 36 milligrams (mg) XR daily. He was diagnosed with attention deficit hyperactivity disorder (ADHD) several years ago and has been on medication on and off since then. No side effects were noted. There was no previous medication trial noted. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The requested non-formulary drug would not be considered to be more effective than all other covered formulary drugs on any tier. Clinical guidelines for the management of attention-deficit hyperactivity disorder recommend consideration of stimulants as pharmacologic options, but they do not place preference for the requested medication over the available formulary alternatives.
Not all covered formulary drugs would have adverse effects. The covered formulary drugs available for use in treating the patient's attention-deficit hyperactivity disorder have the potential to cause palpitations and decreased appetite, but these can be minimized by starting at low doses and working closely with the prescribing physician.
The plan formulary contains multiple medications that would be acceptable treatment alternatives for the patient. These medications include the generic for the requested medication. There is no evidence in the documentation provided that the patient would not tolerate the generic version of the medication.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Brain abscess. 
Treatment: Continued care in Skilled Nursing Facility (SNF). 
The insurer denied coverage for continued care in Skilled Nursing Facility (SNF). 
The denial is overturned. 

According to the medical records, the patient is an adult female with history of deep vein thrombosis (DVT), pulmonary embolism (PE), neurofibromatosis, chronic obstructive pulmonary disease (COPD), hyperlipidemia (HLD), breast cancer, squamous cell carcinoma (SCC), craniotomy for tumor removal (pathology was SCC) who returns to rehab with increased lethargy. Diagnosis by magnetic resonance imaging (MRI) was brain abscess. The peripherally inserted central catheter (PICC line) was placed for intravenous (IV) Antibiotics. 

This patient, following a meticulous evaluation during their acute hospital stay, has been determined to meet the criteria for medical necessity for continued care at a skilled nursing facility. 

The patient's medical condition, specifically severe brain injury after a craniotomy, presents with a complexity and severity that demands a structured, skilled, and sustained level of nursing care and rehabilitation. The patient exhibits substantial functional limitations and medical needs that necessitate continuous skilled nursing attention and rehabilitative services to prevent deterioration, manage chronic symptoms, and promote optimal recovery and safety. The skilled nursing facility is pivotal in providing a level of care that encompasses regular monitoring, management of medical needs, and the provision of therapeutic interventions, which are not feasible in a less intensive or home setting. 

The primary goals of the skilled nursing facility admission include, but are not limited to, stabilizing the patient's medical condition, enhancing functional capabilities, managing pain, preventing potential complications, and facilitating gradual improvement towards the highest possible level of independence and quality of life. A multidisciplinary team of healthcare professionals in the skilled nursing facility will devise and implement a comprehensive, individualized care plan that addresses the patient's multifaceted needs, ensuring a seamless continuum of care that is vital for achieving the best possible recovery and maintaining health stability. The skilled nursing facility will provide a supportive and adaptive environment, crucial for managing the risks associated with the patient's condition, such as medication mismanagement, safety concerns, and potential for rehospitalization, thereby ensuring the patient's wellbeing and paving the way towards a sustainable recovery trajectory. 

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 continued care in the Skilled Nursing Facility (SNF) is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Dry eyes. 
Treatment: Miebo. 
The insurer denied Miebo. 
The health plan's determination is overturned. 

This is a female patient with dry eyes for whom coverage of Miebo is the subject of review. Coverage was previously denied as it was not identified that the patient had an allergy, an adverse reaction, or failure to the preferred formulary medications, cyclosporine 0.05 percent (%), Xiidra, Eysuvis, and Restasis. Upon appeal, the patient has tried Eysuvis, Xiidra, Systane, and cyclosporine. 
The Preferred Practice Patterns of the American Academy of Ophthalmology recommends the use of topical cyclosporine (Restasis) or lifitegrast (Xiidra) for patients with dry eyes who have demonstrated an inadequate response to ocular lubricants. Topical corticosteroids such as Eysuvis are recommended for a limited time only, as long-term use places the patient at risk of elevated intraocular pressures and cataracts. In this case, the patient has reportedly tried and failed Xiidra, Eysuvis, and generic cyclosporine but not branded Restasis (cyclosporine) 0.05%. A review of the peer-reviewed medical literature found it to be safer or more effective than its generic, which the patient has already failed. Miebo was recently Food and Drug Administration (FDA) approved for the treatment of dry eyes in May 2023. It has a different mechanism of action than those formulary alternatives that the patient has already tried and failed. Therefore, as the patient has already failed generic cyclosporine, the remaining formulary alternative, Restasis, would likely be less effective than the requested Miebo.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decreased mobility. 
Treatment: Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week. 
The insurer denied Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week. 
The health plan's determination is overturned. 

This is a case review for a male with medical history notable for mobility issues, incontinence, and end stage renal disease. The patient and his care team requested Personal Care Services. 

The Personal Care Services Level 2: 11 Hours per day, 7 Days per Week - Total of 77 Hours per Week service is medically necessary for this patient. 
The patient requires personal care assistance for nearly all activities of daily living, including ambulating, toileting, and transfers. Given that some of these personal care needs will be unscheduled throughout the day, the requested increase from 7 to 11 hours per day is reasonable and appropriate to meet the patient's functional needs. The most recent Uniform Assessment System (UAS) functional assessment reports that there was no significant functional decline, however in the text of the assessment it does report that his functional status has been worsening and that he does require personal care assistance with all activities of daily living. The increase in hours is therefore medically necessary and appropriate for the patient. His fall in the previous 30 days before the assessment is evidence of unmet personal care needs, as he requires assistance with ambulation and further attempts to do so without assistance could result in additional injuries.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: weakness
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is a female with a medical history significant for Chronic Myeloid Leukemia (CML) on Dasatinib, follicular lymphoma, and Primary central nervous system (CNS) Lymphoma. She presented with worsening weakness and an unsteady gait, along with difficulty walking. She reported feeling better after a transplant but noted a recent regression in her condition, prompting her request for inpatient rehabilitation. She denied fevers, chills, chest pain, shortness of breath, or cough. She complained of headaches and some nausea but denied any falls. Both of her legs were equally weak.

The inpatient hospital admission was medically necessary.
The patient developed new clinical conditions during her hospital stay, notably acute respiratory failure with hypoxia, which was directly attributed to bilateral pleural effusions. This condition necessitated a thoracentesis procedure for resolution, indicating the need for continuous monitoring and treatment.
The patient exhibited persistent nausea and vomiting, indicating a need for endoscopic evaluation. However, the inherent risk associated with her unstable respiratory status led to a careful decision to prioritize addressing her respiratory needs first, ensuring her safety throughout the process.
Following the successful thoracentesis and the patient's subsequent weaned off supplemental oxygen, an esophagogastroduodenoscopy (EGD) was performed.
Her persistent nausea and severely diminished oral intake put her at a high risk of dehydration and malnutrition. Furthermore, given her history of malignancies and the treatments received, there was a notable risk of graft-versus-host disease that warranted further evaluation and management.
The patient's ongoing weakness necessitated continued physical therapy to ensure her safe and optimal discharge.
Considering these comprehensive factors, including the severity of her new clinical conditions, the complexity of care required, and the specific timeframe for the services provided, it is evident that the level of care surpassed what observation status could accommodate. Admission at the acute inpatient level of care was imperative to ensure the patient's well-being and address her intricate medical needs effectively.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary Retention
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with atrial fibrillation (afib) status/post (s/p) ablation, who presented to the emergency room (ER) with urinary retention and pain following a prostate Aqua-ablation and cystoscopy and palpitations. The patient removed his Foley catheter without any improvement in the symptoms and then he was not able to get it back in. The vital signs were remarkable for a heart rate of 112. Lab results were remarkable for a hemoglobin of 8.2 (previously 11.9). The patient received a unit of red blood cells and intravenous fluids. He was admitted and his urine remained light pink and did not show active bleeding. The patient resumed use of aspirin. He was discharged. At issue is the medical necessity of an inpatient stay.

The admission was not medically necessary for a full hospital admission. The patient presented with bleeding post Aqua TURP which is a known complication of the procedure (1). His presentation did not align with an infection and sepsis which would be another common clinical syndrome with a similar presentation (2). The patient's Foley was replaced in the ER and he was having light pink urine. He had presumed post procedure bleeding. His hemoglobin had declined but was still greater than 7 grams per deciliter (g/dl) which is the commonly accepted threshold for transfusion, not indicating a need for transfusions (3). Given the patient's drop in hemoglobin, monitoring to assure acute bleeding has ceased is reasonable. Given standards set by the Centers for Medicare and Medicaid Services, this monitoring would not meet medical necessity for a full inpatient admission as the patient would not be expected to stay greater than (>) 2 midnights and management is not medically complex (CMS guidelines). If the patient had a clinical change necessitating a longer stay, then a full admission would be indicated at that time. The patient was monitored overnight with light pink urine and was able to be discharged the day after admission, thus not aligning with a full admission.