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

Diagnosis: Cardiac amyloidosis, diabetes and peripheral artery disease. 
Treatment: home care/personal care level 2 personal care services increase to 84 hours per week. 
The insurer denied coverage for home care/personal care level 2 personal care services increase to 84 hours per week. 
The denial is upheld. 

This is an elderly  male with chronic medical problems including cardiac amyloidosis, diabetes and peripheral artery disease. He lives with his wife in a private residence. The patient requested an increase of his home care/personal care level 2 personal care services from 65 to 84 hours per week (hours overlap with spouse), denied by the insurer and leading to an external review. 
 
According to the Uniform Assessment System (UAS) report, the patient's cognition is described as modified independent. He reportedly requires extensive assistance to total dependence for completing much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. He is also reportedly dependent for lower body dressing, locomotion and toilet use. The patient reportedly requires maximal assistance for bathing, personal hygiene, upper body dressing, bed mobility and eating. He is reportedly non-ambulatory. He is reportedly frequently incontinent of bladder and infrequently incontinent of bowel. There has been no reported change in the patient's activities of daily living (ADL) status or self-sufficiency over the prior 90 days. There have been no reported falls over the prior 90 days. His cognitive status and functional ability are much the same when compared to the prior UAS report. 

The progress notes, from the patient's nurse practitioner (NP), describing his clinical condition and (later note) treatment for a urinary tract infection with resolution of his altered mental status; described as fully alert and oriented. The treatment notes do not provide a functional assessment or clinical condition that requires the requested increase of personal care assistance (PCA) services to 84 hours/week. Based on the records reviewed, the patient's cognitive and functional ability are much the same. The patient's medical condition and physical limitations are not at a level or unpredictable as to require increasing PCA services to 84 hours/week. This physician would agree the patient may benefit from additional monitoring for safety; particularly due to his reported cognitive deficits and limited mobility. However, PCA service hours are approved primarily to provide hands-on assistance for completion of IADL/ADL tasks when no else is available to provide assistance; not primarily for safety monitoring. 

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 home care/personal care level 2 personal care services increase to 84 hours per week services is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma. 
Treatment: Ventolin HFA (hydrofluoroalkane) (albuterol). 
The insurer denied Ventolin HFA (albuterol). 
The determination is upheld. 

The patient is a female who is seeking approval for Ventolin Hydrofluoroalkane (HFA) for asthma treatment. This medication was denied by her health plan as it was not a formulary drug. 
A pulmonologist saw the patient for asthma on long standing Flovent. The patient had been more short of breath. The patient has failed Advair in the past. Prednisone burst was given at this visit. Symbicort was continued as well as albuterol as needed. Her provider noted the patient has tried three different brands of albuterol and found Ventolin HFA to be the most beneficial. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Ventolin HFA, or would have adverse effects. 

It appears the patient has trialed albuterol sulfate but not Levalbuterol for the treatment of asthma. It would be reasonable for the patient to trial Levalbuterol for the treatment of asthma. The standard of care for asthma is to have any form of a short acting beta agonist to use as needed. Levalbuterol would be able to serve this purpose.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Anorexia Nervosa
Treatment: Virtual Mental Health Partial Hospitalization Treatment Services
The insurer denied virtual mental health partial hospitalization treatment services.
The determination is overturned.

The patient was diagnosed with an eating disorder best characterized as anorexia nervosa, restricting type. She was referred by her outpatient clinician to a virtual telehealth partial hospital program (PHP) following completion of an in-person residential eating disorders program as a step down for continued intensive treatment while resuming work and living at home providing care for her children. The patient has a complicated history of eating disorder characterized by restricting intake and comorbid generalized anxiety disorder and major depressive disorder treated with therapy and medications including Zoloft and augmentation with Abilify and supplemental use of trazodone. Her eating disorder had worsened in the context of associated symptoms of anxiety, depression, and psychosocial stressors resulting in restricted intake prompting her referral for residential and PHP level treatment. The virtual telehealth PHP program provides services that include group and individual psychotherapy, nutritional counseling with meal plans and nutritional supports, as clinically appropriate, intuitive eating.

At issue is the medical necessity virtual PHP treatment of an eating disorder.
 
The requested health service/treatment of virtual mental health partial hospitalization treatment services is medically necessary for this patient.

The request for virtual PHP level services is reasonable, in the best interest of the patient, and reflects sound medical judgment with respect to the associated risk for relapse in this case, and the necessity for continued services and monitoring and structure that are necessary for the continued treatment of the eating disorder. The patient is capable of actively participating in treatment and making progress toward treatment goals that will likely be successfully provided with the clinically appropriate step down to lower-level care services with virtual PHP services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Intentional Overdose

Treatment: Skilled nursing facility subacute rehabilitation Level 2 admission

The insurer denied coverage for skilled nursing facility subacute rehabilitation Level 2 admission

The denial is upheld 

This is a patient who was admitted to the hospital "after the patient had taken a large overdose of their medications with suicidal intent." The patient has a history of depression, anxiety and alcohol use disorder.  Under review is the medical necessity for Skilled Nursing Facility (SNF) subacute rehabilitation Level 2 admission.

The clinical records submitted for review do not support the claim that the patient is an appropriate candidate for the SNF subacute rehabilitation Level 2 care for the time period under review (1, 2, 3).  The patient does not have any specific mental or physical impairment that are appropriate for subacute rehabilitation Level 2 services.  For example, the patient was seen by a psychiatrist.  The psychiatrist indicated the patient "is psychiatrically stable.  Awaiting placement to nursing home."  The Diagnostic Impression was "Major Depressive Disorder, in full remission."  According to the clinical notes the patient is reportedly wheelchair dependent as well as bowel/bladder incontinent, which are insufficient to support the medical necessity of subacute rehabilitation Level 2 care.  Furthermore, with regard to documentation provided for this review, there is a single occupational therapy (OT) evaluation recommending OT. A physical therapy (PT) reevaluation note stated that bed mobility is independent and sitting balance is good. The patient used a walker for 14 feet with a slow pace. The patient was independent propelling their wheelchair 100 feet. The goal was to increase to 100 feet with the walker.  No other physical or occupational therapy notes were submitted for review to support the need for subacute rehab.  Also, as noted, the patient's reported depression is "in full remission."  In addition, there are no acute medical or complicated nursing issues to support subacute rehabilitation Level 2 care.

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, Skilled Nursing Facility (SNF) subacute rehabilitation Level 2 admission is not medically necessary.  

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

The medical necessity for skilled nursing facility subacute rehabilitation Level 2 admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, lymphedema, pyoderma gangrenosum, asthma, anemia, polyneuropathy, 
spondylolisthesis, and lumbago
Treatment: Increase Home/Personal Care HHC Level 2 To 50 Hours Per Week
The insurer denied: Increase Home/Personal Care HHC Level 2 To 50 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her medical conditions include chronic obstructive pulmonary disease, lymphedema, pyoderma gangrenosum, asthma, anemia, polyneuropathy, spondylolisthesis, and lumbago. Denial of Increase personal care services (PCS) to 50 hours per week is being appealed. The health plan approved 40 hour per week. The Uniform Assessment System (UAS) evaluation completed 4 months ago shows modified independent cognition and functional status: total dependence with meal preparation, housework, and stairs; maximal assistance with shopping, bathing, lower body dressing, walking, locomotion, and toilet transfer; extensive assistant with managing medications, personal hygiene upper body dressing, and toilet use; and limited assistance with bed mobility and eating. She has occasional bladder incontinence. There has been improvement with bed mobility and toilet use compared to UAS (Uniform Assessment System) evaluation completed 8 months ago. An appeal statement reports the patient lives alone and does not have informal support. Due to conditions affecting lower extremity, she requires hands-on assistance and use of rollator for standing and locomotion. She is dependent on all aspects of care. Splitting her hours would result in unmet needs at different times. Another appeal letter reports that lymphedema affects the patient's ability to lift herself and get up from couch without assistance.

The requested Increase in Home/Personal Care to 50 Hours Per Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of Increase personal care services (PCS) to 50 hours per week is being appealed. The health plan approved 40 hour per week. This patient has multiple chronic conditions. Uniform Assessment System evaluation completed 4 months ago, shows she requires assistance with all ADLs (activities of daily living). Appeal statements note the patient's mobility is significantly limited due to severe lower extremity lymphedema. The statements support her needs for assistance with all ADLs (activities of daily living). She lives alone and does not have informal support. The information provided shows that this patient has significant limitations in functioning. Meeting her need for assistance cannot be met with the approved PCS (personal care service) 40 hours per week or splitting hours, as she will be left without care. The approved PCS (personal care service) 40 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase to 50 hours per week is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned


Diagnosis: Gastroesophageal Reflux Disease/GERD.
Treatment: Dexlansoprazole Delayed-Release.
The health plan denied: Dexlansoprazole Delayed-Release.
The determination is: Overturned.

The patient is a female with a history of eosinophilic esophagitis and gastroesophageal reflux disease (GERD) currently on chronic acid reflux therapy with Dexilant. This has been prescribed after the failure of esomeprazole, lansoprazole, omeprazole, and pantoprazole. At issue is the nonformulary drug Dexlansoprazole Delayed-Release (Dexilant).
The health plan's determination is overturned in whole.
The formulary drug has been ineffective. A review of the medical records indicates the patient has tried and failed the formulary alternative drug choices (esomeprazole, lansoprazole, omeprazole, and pantoprazole). Furthermore, the patient has been on chronic successful acid suppression therapy with Dexilant. Therefore, it is clinically prudent to continue with Dexilant. If treatment is interrupted, this may result in adverse outcomes.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: psoriasis

Treatment: Cosentyx 150mg/ml (milligram per milliliter)
Syringe

The insurer denied coverage for Cosentyx 150mg/ml (milligram per milliliter)
Syringe.

The denial is upheld.

 
The patient is an adult female with psoriasis affecting 9% total body surface area (TBSA), including the scalp.  The patient has tried and failed only topical steroids and prednisone.  The request is for Cosentyx.  

The patient has failed topical therapy and has no true contraindications to numerous appropriate available treatment modalities which would make the use of Cosentyx necessary.  There are no definitive, comparative, controlled, double blinded, head-to-head studies showing that Cosentyx has a superior efficacy or safety profile for a patient of this type compared to reasonable alternatives such as Humira, Stelara, Tremfya or other formulary biologics.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.  

The patient has failed only one topical steroid and prednisone. There is no documentation to suggest that Cosentyx would be more effective than available formulary alternatives or that the patient has a contraindication to a preferred medication which would specifically necessitate Cosentyx.  

The formulary drugs are not expected to cause adverse effects.
 
The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug(s) 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 Cosentyx 150mg/ml (milligram per milliliter) Syringe to treat psoriasis is upheld.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Home health care

Diagnosis: Mobility issues
Treatment: Home health care
The insurer denied Consumer Directed Personal Assistance Servies (CDPAS): 7 Days per Week, 12 Hours per Day; 84 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. The patient's child provided a letter of support for this appeal. The letter states that the patient requires the increased hours to ensure his safety, well-being, and overall quality of life. He requires assistance with bathing, dressing, hygiene, meal preparation, and medication prompting. Additionally, his wife passed away which has resulted in feelings of loss and isolation. The child requests the additional time in part to ensure his safety.

The patient's physician provided a letter of support for this appeal. The letter states that the patient has diagnoses of hypertension, depression, anxiety, dizziness, arthritis, and back pain. His current medication list was provided for review. The physician states that the patient requires assistance with activities of daily living including toileting, transfers, bathing, and dressing.

The requested Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 12 Hours per Day; 84 Hours per Week service is medically necessary for this patient.

The patient requires assistance with all activities of daily living. He is unable to toilet, transfer, or ambulate without assistance as documented in the Uniform Assessment System (UAS) and by the patient's physician. His care needs can therefore be expected to be continuous and unscheduled throughout the day. He cannot be without a caregiver if he is not able to toilet or ambulate without assistance. His son is willing to provide intermittent assistance overnight, but his son works full-time and cannot provide care continuously throughout the day. The increase in hours would not be merely for emotional support and supervision, as the hours are necessary to provide for the patient's personal care needs. Therefore, the requested hours are medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right Knee Pyogenic Arthritis

Treatment: Continued Long Term Custodial Care

The insurer denied coverage for Continued Long Term Custodial Care

The denial is upheld. 

This is a patient who was diagnosed with right knee pyogenic arthritis.  The patient underwent right knee incision and drainage.  The patient has long since completed the antibiotics.  The patient is currently a resident in a nursing facility.  Under review is the medical necessity for coverage of continued Long Term Custodial Care.

The patient's clinical condition and functional ability are not at a level as to require long term care for the time period under review.  There are no acute medical, complicated nursing issues of skilled functional needs.  The clinical records do not document a level of care or functional incapacity that requires long term (facility) care.  Based on the clinical records submitted for review, the patient can be discharged home with visiting nursing services as necessary.  

The health plan act reasonably, with sound medical judgment and in the best interest of the patient.  (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations.  All decisions are evidence-based).  

From a physical medicine and rehabilitation perspective, Continued Long Term Custodial Care is not medically necessary.  

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

The medical necessity for Continued Long Term Custodial Care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fluid Volume Overload

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld.

The patient was admitted for worsening shortness of breath. The patient was evaluated by nephrology service and underwent hemodialysis for clearance and volume removal with ultrafiltration. The patient left against medical advice.

The patient was admitted for shortness of breath and volume overload.  The patient was treated with hemodialysis and intravenous blood pressure medication on admission.

The patient's condition responded to daily dialysis, and the patient did not have persistent severe hyperkalemia, no signs of severe volume overload or hypoxia, and there was no documentation of severe uremia such as encephalopathy or uremic bleeding.  The patient already had established dialysis access and did not require emergent vascular intervention.

The patient's condition could have been treated safely under lower level of care.

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: Left Buttock Abscess

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

 
The patient has a past medical history significant for hydronephrosis, asthma, and recurrent skin abscesses who presented to the emergency department with complaints of left buttock abscess. 

Vitals on presentation included: Temperature 98.0 Fahrenheit, Blood Pressure 136/80, Pulse 100, Respiratory Rate 20, oxygen (O2) saturation 98% on room air (RA). Laboratory values were notable for the following: white blood cell count (WBC) 12.7, hemoglobin (Hgb) 11.8, hematocrit (Hct) 36.26, creatinine 1.0, glucose 115.

The patient was empirically started in intravenous antibiotics (Unasyn) for left gluteal abscess.
General Surgery was consulted and patient taken to the operating room for incision and drainage procedure for pilonidal cyst. The patient received local wound care. The patient remained afebrile, hemodynamically stable and clinically improved. The patient was discharged to continue outpatient management on oral antibiotics.

According to documentation, patient presented with worsening left buttock abscess secondary to pilonidal cyst. The patient was afebrile, but tachycardic (heart rate 100) and laboratory results were notable for an elevated WBC. Additionally, the patient required surgical intervention in  the operating room. Based on above findings, hospital admission was 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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: VACTERL syndrome.
Treatment: Durable medical equipment L1300 Body Jacket Mold X 0 L1210 Lateral Thoracic Extension x 0.
The insurer denied coverage for Durable medical equipment L1300 Body Jacket Mold X 0 L1210 Lateral Thoracic Extension x 0.
The denial is: Overturned.
 
Durable medical equipment L1300 Body Jacket Mold X 0 L1210 Lateral Thoracic Extension x 0 is considered medically necessary for this patient. The medical records show an unusual diagnosis, vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities (VACTERL) syndrome. This is a complex of congenital deformities and conditions affecting many sites. 

The brace denial is based on standard criteria for adolescent idiopathic scoliosis. This is not the case. The most applicable guideline would be that of congenital or juvenile scoliosis. The VACTERL syndrome has a vertebral abnormality. 

There is progression as the brace was not utilized. The physician reported a growth of 4 inches. The previous brace which was custom would not likely fit. The report by a physician of likely progression without additional bracing has credence. The Sanders scale (i.e. measurement of maturity) shows additional growth is to be expected. 

There would be no other treatment option. The use of the brace in this particular clinical instance is necessary and appropriate. 

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 durable medical equipment L1300 Body Jacket Mold X 0 L1210 Lateral Thoracic Extension x 0 is substantiated.