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

Diagnosis: Parkinson's Disease
Treatment: Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 90 hours per week 
The insurer denied Home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 90 hours per week.
The determination is overturned.

This is a male patient with a medical history notable for Parkinson's disease, end-stage renal disease on hemodialysis, incontinence of bladder and bowel, cognitive impairment, and seizure disorder status post subdural hematoma. The patient is approved for 42 hours per week of level 2 personal care services. The patient and his care team requested an increase to 90 hours per week, and this request was denied by the health plan.
The patient's neurologist provided a letter of support for this appeal. The letter states that an increase in home care services is medically necessary for the patient, and he recommends a minimum of 12 hours per day, 7 days per week. The patient requires assistance with transfers, locomotion, toileting, dressing, and bathing.
A Uniform Assessment System (UAS) was completed and was available for review. The patient was cognitively intact and able to direct his own care. For his Instrumental activities of daily living (IADLs), he requires total dependence for meal preparation and housework. He requires maximal assistance for shopping. He requires extensive assistance for all others. For his activities of daily living (ADLs), he requires extensive assistance for all (except for bed mobility and eating, for which he is higher functioning). He transfers and ambulates with hands on assistance. He is frequently incontinent of stool and urine. He had 3 falls in the 90 days preceding the assessment, including one that resulted in hospitalization. A task tool associated with the assessment recommended 40.67 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 90 hours per week.

The requested health service of home care/personal care HHC- level 2 personal care services, per 15 minutes increase to 90 hours per week is medically necessary for this patient.
The patient has multiple medical problems which are all expected to result in progressive functional decline. He currently requires assistance for all transfers, ambulation, and toileting. He had 3 falls recently including one that required hospitalization. He is incontinent of stool and urine. His personal care needs can be expected to be continuous and unscheduled in nature. It is not possible to use a task tool to determine care hours when patients require all-day care such as in this case. Failure to address his personal care needs could result in additional falls or other adverse health consequences.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Crohn's Disease
Treatment: Stelara 90 milligrams (MG)/ milliliter (ML) Syringe
The insurer denied: Stelara 90 milligrams (MG)/ milliliter (ML) Syringe
The denial is upheld.

The patient is an adult male with moderate to severe ulcerative colitis. He has failed Entyvio and Remicade, and has had some, but not a complete response to Rinvoq, with ongoing symptoms and elevated fecal calprotectin. The physician (MD) is requesting treatment with Stelara in addition to Rinvoq. Stelara was denied, as the plan does not allow dual therapy with Stelara and Rinvoq.

The proposed treatment is not medically necessary.

While there are small case reports, there are no randomized, case-controlled studies showing the safety and efficacy of dual therapy with a biologic agent such as Stelara and small molecule such as Rinvoq, and specifically no literature on the use of Stelara with Rinvoq, even just case reports. Therefore, the requested dual therapy with Stelara and Rinvoq is not clinically appropriate, accepted standard of care, and not medically necessary based on the plan definition and current medical literature, and Stelara is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: ovarian cyst
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who presented to the emergency room with left lower quadrant pain. She was found to have a 5-centimeter left ovarian cyst on imaging with suspected torsion. She was not pregnant. She was admitted and went to surgery the same evening for a laparoscopic cystectomy.

Inpatient admission was not medically necessary. The patient was in the hospital less than 12 hours. The laparoscopic surgery she underwent is routinely performed at a lower level of care. Observation after the procedure was reasonable, since the procedure ended late at night with discharge from the post-anesthesia care unit (PACU) not occurring until about 02:00. However, there was no need for serial labs, multiple physician evaluations, or further interventions. She was voiding, ambulating, and taking oral pain medications by the morning after her surgery - therefore meeting discharge criteria. The patient displayed a routine postoperative course, and a lower level of care would be appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations and Chest Pain
Treatment: Transthoracic Echocardiogram
The insurer denied the transthoracic echocardiogram.
The determination is overturned.

This is a female patient who was evaluated for complaints of intermittent palpitations and non-exertional chest pain. Her medical history was pertinent for hyperlipidemia. Her cardiac exam and electrocardiogram were unremarkable. An exercise stress myocardial perfusion imaging showed no evidence of ischemia. The medical necessity for a transthoracic echocardiogram is at issue.

Based on the documentation provided, a transthoracic echocardiogram (TTE) was medically necessary.

This patient presented with atypical chest pain and palpitations. The potential causes of palpitations are myriad, ranging from benign to malignant conditions. They are often associated with structural heart disease including chamber enlargement, valvular disease, and cardiomyopathy. Transthoracic echocardiography (TTE) is useful in assessing chamber size and function and valvular function. Per the American College of Cardiology Foundation (ACCF)/American Society of Echocardiography (ASE)/American Heart Association (AHA)/American Society of Nuclear Cardiology (ASNC)/Heart Failure Society of America (HFSA)/Heart Rhythm Society (HRS)/Society for Cardiovascular Angiography and Interventions (SCAI)/Society of Critical Care Medicine (SCCM)/Society of Cardiovascular Computed Tomography (SCCT)/Society for Cardiovascular Magnetic Resonance (SCMR) 2011 Appropriate Use Criteria for Echocardiography, TTE is indicated (with an appropriateness score of 9) for patients with symptoms or conditions potentially related to suspected cardiac etiology including but not limited to chest pain, shortness of breath, palpitations, transient ischemic attack (TIA), stroke, or peripheral embolic event.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Prediabetes
Treatment: Rybelsus
The insurer denied: Rybelsus
The denial is upheld.

The patient is an adult female with prediabetes and metabolic syndrome. The request for Rybelsus (semaglutide) is under review. The patient has tried and was intolerant to Wegovy and 
Saxenda. She has tried metformin. The prior request was denied coverage by the health plan, as the patient does not have a diagnosis of type 2 diabetes. The provider is appealing this determination, as the patient is at very high risk of developing type 2 diabetes due to metabolic syndrome and insulin resistance. She has tolerated Rybelsus 3 milligram samples.

The requested Rybelsus is not medically necessary.

This request is for Rybelsus to treat a patient with prediabetes, metabolic syndrome, and insulin resistance. The prior request was denied coverage by the health plan, as the patient does not have a diagnosis of type 2 diabetes. Rybelsus is not indicated by the United States Food and Drug Administration (FDA) for the treatment of prediabetes, metabolic syndrome, weight loss, or insulin resistance (1). The American Diabetes Association clinical guidelines do not support the use of Rybelsus for the treatment of prediabetes or for the treatment of patients that are very high risk of developing type 2 diabetes to prevent or delay the development of type 2 diabetes (2). Rybelsus has risks, including nausea and vomiting. Therefore, no, the requested Rybelsus is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult male. He was hospitalized 4 months ago for pulmonary embolism. The patient presented to the emergency department for evaluation of right-sided chest pain and elevated D-dimer done at an urgent care center. His past medical history was significant for ulcerative colitis treated with the immune suppressor Humira and recent Salmonella bacteremia. The patient's vital signs were stable. His chest computed tomography (CT) scan confirmed pulmonary embolism involving the right lower lobe. Ultrasound of the patient's legs was negative for deep vein thrombosis (DVT). Treatment included anticoagulation with Lovenox with transition to Eliquis. The patient remained asymptomatic and was discharged to home. The requested coverage for Inpatient Hospital Admission was denied based on the patient's policy, and the patient is appealing the decision.

The proposed treatment was not medically necessary.

Based on the peer-reviewed medical literature, including the 2019 European Society of Cardiology (ESC) Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism (PE), the Milliman Care Guidelines (MCG) criteria for pulmonary embolism, and InterQual (I/Q) level of care (LOC) Criteria: Acute adult criteria "pulmonary embolism," criteria for inpatient admission are not met, including hemodynamic instability; respiratory distress; contraindications such as recent bleeding, severe renal or liver disease, or severe thrombocytopenia; abnormal troponin; abnormal N-terminal pro-brain natriuretic peptide; heparin-induced thrombocytopenia, suspected or by history; age over 80 years; heart rate 110-120 beats per minute, sustained; chronic lung disease; and heart failure requiring treatment or malignancy with active cancer treatment or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required inpatient hospital stay. The care the patient received, including providing anticoagulation (AC) to treat pulmonary embolism in a hemodynamically stable patient, is routinely provided safely and effectively at a lower level of care. Anticoagulation therapy in a low-risk patient can be continued at a lower level of care and does not require inpatient level of 
care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a male child who presented to the emergency department (ED) with a one-day history of subjective fevers, a cough, and congestion. He was not eating well and was having difficulty sleeping. His sister was also sick with a cold. The examination was significant for congestion, erythematous tympanic membranes bilaterally, moist mucous membranes, congestion, tachycardia, tachypnea with intercostal retractions and belly breathing, transmitted upper respiratory sounds on auscultation, and non-focal neurologic exam. With suctioning, the oxygen saturation improved to 98 percent (%) with continued retractions and belly breathing. He received three albuterol treatments and one Atrovent treatment with some improvement in the retractions but continued belly breathing. He was given an oral dose of dexamethasone but vomited shortly after administration, so was given an intramuscular (IM) dose. He was also given a dose of amoxicillin for bilateral otitis media. A chest x-ray was obtained revealing bilateral increased interstitial markings consistent with small airways inflammation or viral infection.

He was admitted for ongoing management of viral bronchiolitis with possible reactive airways disease. Admission orders included albuterol every four hours as needed, Tylenol as needed, Amoxicillin for total ten days, and a regular infant diet. He did well overnight with no need for supplemental oxygen. He was eating well and had no increased work of breathing. He was deemed stable for discharge to complete his ten-day course of Amoxicillin. At issue is the medical necessity of an inpatient stay.

Acute inpatient admission was not medically necessary.

This male infant presented with respiratory symptoms and increased work of breathing. He responded to bronchodilators while in the ED but continued to exhibit signs of respiratory distress. He was also diagnosed with bilateral otitis media. While it was reasonable to monitor him in the hospital for improvement versus decompensation, he was overall hemodynamically stable with adequate oral intake, no need for supplemental oxygen, no evidence of impending respiratory failure. He did not require acute inpatient admission and could have been safely managed at lower level of care.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: vitiligo.
Treatment: Tacrolimus.
The insurer denied Tacrolimus.
The health plan's determination is upheld. 

The patient is a female with vitiligo, for which the patient has previously been treated with topical corticosteroids and tacrolimus. Tacrolimus ointment has been denied coverage by the health plan because vitiligo is deemed a cosmetic condition. A recent clinic notes that the patient's vitiligo is located on the patient's hips, groin, and proximal medial thighs, as well as the epigastric skin and lower back.

Tacrolimus ointment is not medically necessary for this patient.
No functional impairment exists from the patient's vitiligo, such as decreased movement, increased itch, increased risk of infection, or any significant risk of skin cancer. The current medical literature notes that the face/neck and hands (particularly the former region) are the regions with the most psychosocial impacts, and might affect employment and personal relationships, for vitiligo patients. Accordingly, the use of tacrolimus is primarily for appearance, and not for any significant medical or even quality of life impacts or impairment and is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Leg Cellulitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient has a past medical history significant for peripheral vascular disease, cerebellar stroke, bilateral lower extremity deep vein thrombosis, chronic venous stasis, lymphedema, hypertension, hyperlipidemia, hypothyroidism, and morbid obesity who presented to the emergency department (ED) with complaints of bilateral leg pain and swelling.

Vitals on presentation included: Temperature 98.1 (degree) Fahrenheit, Blood Pressure (BP) 101/60, Pulse 68, Respiratory Rate 18, oxygen (O2) saturation 98% (percent) on Room Air. Laboratory results included the following: white blood cell count (WBC) 12.0, hemoglobin (HGB) 12.6, hematocrit (HCT) 55.0, creatinine 0.86, glucose 110, c-reactive protein (CRP) 8.7, and lactate 2.2. 

The patient was started empirically on intravenous (IV) antibiotics (vancomycin and cefepime) for bilateral lower extremity cellulitis. Duplex of lower extremity was negative for thrombosis. Infectious Diseases consulted and adjusted antibiotics. The patient received local wound care. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics as outpatient.

According to documentation, the patient presented with chronic lymphedema and leg cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results except for a mildly elevated WBC. The patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management. 

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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type II Diabetes Mellitus

Treatment: Mounjaro 5 milligram (mg) / 0.5 milliliter (ml) pen injector

The insurer denied coverage for Mounjaro 5 milligram (mg) / 0.5 milliliter (ml) pen injector

The denial is overturned.

This is a patient diagnosed with type II diabetes mellitus (T2DM). This request is for Mounjaro. As reported, the patient tried and failed Ozempic due to persistent nausea with vomiting. The patient has been doing well on Mounjaro; the patient has lost 40 pounds, their headaches and neuropathy have improved and their Hemoglobin A1C was improved from 6.8 % (percent) to 5.5%. The patient started on Mounjaro 5 milligrams (mg). As per the visit note, the patient had been on Ozempic but was unable to tolerate and then switched to Mounjaro 2.5 mg and then Mounjaro 5 mg. 

The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient as the request is medically necessary as described below.

The requested medication Mounjaro (Trizepatide) is a 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 gastric inhibitory 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). The patient has already failed one formulary alternative in the form of Ozempic due to side effects.  The patient has benefited greatly from the requested medication with a 40-pound weight loss and improvement in their hemoglobin A1C.  Continuation of the requested medication is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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 Mounjaro 5 milligram (mg) / 0.5 milliliter (ml) pen injector is substantiated.
Appeal type: Medical necessity
Decision: Upheld



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

The patient is an adult male who was admitted to inpatient rehabilitation for substance use disorder treatment of stimulant (cocaine and methamphetamine), alcohol, and cannabis (marijuana) use disorders. The patient was using cocaine intermittently with intranasal administration with daily use of marijuana (one to two blunts), and intermittent use of alcohol and methamphetamine. The patient was also tobacco-dependent with light use. He had a history of multiple past substance use disorder treatment episodes with relapses. His substance uses primarily involved cocaine and cannabis.

The Inpatient Hospital Admission was not medically necessary for this patient.
The Inpatient substance use disorder rehabilitation services in this case scenario were amenable to treatment at a lower level of care. The patient was motivated and was capable of effectively receiving substance use disorder treatment in a less restrictive treatment setting with sober support and/or housing. The patient did not need the structure of an inpatient setting to effectively participate in rehabilitation substance abuse treatment.
There were no biomedical or psychiatric complications, or severe psychiatric symptoms/disorders in this case that would have warranted the admission and the continued inpatient-level services and treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cavities

Treatment: Outpatient Dental services (cavities fixed and teeth removed)

The insurer denied coverage for Outpatient Dental services (cavities fixed and teeth removed)

The denial is overturned

Based on the submitted clinical documentation including narrative letters from the child's dentist and clinical notes/dental charting, it appears this child with dental anxiety presented for dental treatment and would require multiple and extensive dental services. Due to anxiety contributing to poor compliance in the outpatient setting, it was recommended that all dental treatment be performed under deep sedation in an outpatient ambulatory operating room setting. The insurer has denied services as not being necessary as the situation does not meet their stipulated criteria. The patient's dentist is appealing the denial on behalf of the patient.

Upon review of the documentation submitted and as enumerated above, this patient had dental needs that would be difficult to provide in the outpatient setting due to age of the patient and poor compliance/anxiety. Therefore, it was recommended that treatment be performed in a controlled setting under deep sedation/general anesthesia. This provides the benefit of completing dental needs and anesthesia assures patient compliance. This is a standard of care treatment for this clinical situation when dealing with pediatric patients. This treatment is supported in the literature (see below). Further, the treatment plan as recommended fulfills and meets all of the insurer's medical necessity criteria. As such the services recommended are considered medically necessary. 

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 Outpatient Dental services (cavities fixed and teeth removed) is substantiated.