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

Diagnosis:  Arthritis.
Treatment:  Consumer Directed Personal Assistance Services (CDPAS) Total Hours for the week: 20 hours per week.

The insurer denied Consumer Directed Personal Assistance Services (CDPAS) Total Hours for the week: 20 hours per week.  The determination is upheld.

This is a female patient with a medical history notable for arthritis, hypertension, and hyperlipidemia. The patient was previously approved for 20 hours per week of consumer directed personal assistance services. The plan discontinued services because they did not receive a valid doctor's order for ongoing consumer directed personal care assistance services. This denial of continued services is the subject under review.

A physician's order for personal care services was provided and reviewed. The order was completed by the physician. The patient's diagnoses are arthritis, hypertension, hyperlipidemia, and osteopenia. Her condition is stable and her current treatment plan is physical therapy and pain management. The documentation states that she uses a cane to ambulate and cannot lift heavy objects. She is able to direct her own care and call for help in an emergency. She is able to ambulate only when using a cane as an assistive device. She is continent of bowel and bladder. She can self-administer medications. The notes state that she requires assistance with monitoring her blood pressure and sugar, although there is no diagnosis of diabetes listed in the case file. The physician recommended the provision of service to assist with skilled tasks, personal care, and/or lighthouse keeping tasks. There was no description of which tasks were recommended for assistance. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS) Total Hours for the week: 20 hours per week.

The requested health service of Consumer Directed Personal Assistance Services (CDPAS) Total Hours for the week: 20 hours per week has not been demonstrated to be medically necessary for this patient.

There is insufficient documentation regarding whether the patient requires ongoing personal assistance services, and if so, for which tasks she would require assistance. She has some documented mobility issues secondary to arthritis but is able to ambulate independently with a cane. The documentation provided does not describe which tasks she would need assistance with. The physician checked the box for "yes" with regards to requesting skilled or personal care services, but did not describe which services were necessary for the patient. Therefore, there is insufficient documentation that the requested service of 20 hours per week of consumer directed personal assistance services is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip Pain, Hip Surgery
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a female patient with a history of acetabular dysplasia in her left hip. She underwent elective left hip surgery for peri-acetabular osteotomy, in addition to arthroscopic debridement and labral repair. These surgeries were successful with no documented complications. The patient had an uneventful hospital course and was deemed stable for discharge. The patient's health plan denied coverage for the inpatient hospital admission. At issue is the medical necessity of the inpatient hospital admission.
The requested health service/treatment of a full hospital admission was not medically necessary for this patient. The records document that this patient with persistent left hip pain and known acetabular dysplasia failed conservative management for her condition. She opted to undergo elective hip peri-acetabular osteotomy in addition to arthroscopic hip chondral debridement and labral repair. This surgery was consistent with the current standard of care as documented by Murata and colleagues in the Orthopedic Journal of Sports Medicine in 2021. The records, however, do not document any complications of the operation and the patient had normal lab values and vital signs following this elective hip operation. The patient had her Foley catheter removed and had normal voiding of urine. Thus, based upon the peer-reviewed literature and the documentation in the provided medical records, the inpatient hospital admission from was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: obesity/diabetes
Treatment: Ozempic
The insurer denied Ozempic.
The health plan's determination is upheld. 

This is a case review for a male being prescribed Ozempic pen injectors for the diagnosis of obesity and type 2 diabetes.

Ozempic is not medically necessary for this patient.
Ozempic is FDA (Food and Drug Administration) approved to treat type 2 diabetes. However, there is no clear consensus or best practice guideline which states that it should be used preferentially as the first-line treatment for a new diagnosis of diabetes. Metformin has been well studied and has proven efficacy in lowering blood glucose and providing cardioprotective benefits for individuals with type 2 diabetes. Its use is generally recommended as a first-line medication as is recommended by the pharmacy benefits step therapy policy. Although Ozempic is an acceptable treatment option for type 2 diabetes, the documentation provided does not demonstrate that it is medically necessary to use this medication as other first line treatments are available.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar Spinal Stenosis

Treatment: Outpatient Surgery

The insurer denied coverage for outpatient surgery

The denial is overturned

This patient has low back pain and lumbar spinal stenosis most pronounced at L (lumbar) 4-L5 with ligamentum flavum hypertrophy.  The patient has failed medication therapy, Physical Therapy and home exercises, as well as Epidural Steroid injections.  The request is for the Minimally Invasive Lumbar Decompression (MILD) procedure at L4-L5.

There are two prospective randomized controlled trials (1,2) that support this procedure.

Staats et al (1) conducted the MiDAS ENCORE study which was approved by the Centers for Medicare & Medicaid Services (CMS) as a Coverage with Evidence Development study for the purpose of providing level I evidence to support the safety and effectiveness of the MILD procedure. This randomized controlled trial assessed outcomes of the MILD procedure compared with epidural steroid injections (ESIs) in subjects with lumbar spinal stenosis (LSS) and neurogenic claudication symptoms, with verified Ligamentum Flavum Hypertrophy as a contributing factor. Study follow-up intervals occurred at 6 months and 1 year for the randomized phase of the study, and subjects in the MILD treatment group were followed at 2 years. Study design and 6-month and 1-year follow-up comparative results between MILD and ESI were previously reported. This is a report of 2-year clinical outcomes of patients treated with the MILD procedure in the MiDAS ENCORE study which were statistically significant for improvement in pain and disability scores.

Deer et al (2) also conducted a randomized controlled trial and reported the One-year results of this Level-1 study which demonstrated the superiority of MILD+Conservative Medical Management (CMM) over CMM alone for patients with lumbar spinal stenosis who were suffering from neurogenic claudication secondary to hypertrophic ligamentum flavum. Use of the validated Walking Tolerance Test to objectively measure increased ability to walk without severe symptoms provided evidence of statistically significantly better outcomes for MILD+CMM than for CMM alone. With no reported device or procedure-related adverse events, the long-standing safety profile of the MILD procedure was reaffirmed. MILD is a safe, durable, minimally invasive procedure that has been shown to be effective as an early interventional therapy for patients suffering from symptomatic lumbar spinal stenosis.

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 Surgery is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bowel obstruction

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is overturned.
 

Bowel obstruction is an important cause of morbidity and mortality and is responsible for approximately 15% (percent) of hospital admissions for acute abdominal pain in the United States. [1] Afferent loop obstruction is a complication that may occur after a Roux-en-Y gastric bypass or reconstruction. The causes include entrapment by postoperative adhesions, internal herniation, volvulus, intussusception, stenosis, recurrence of cancer, or foreign bodies. Acute afferent loop obstruction is a complete obstruction and is considered a surgical emergency. [2]

Per clinical documentation, the patient presented to the emergency department with nausea and vomiting. The patient has a history of a gastric bypass. Vital signs were within normal limits. White blood cell count was normal at 7.8. A computed tomography (CT) of the abdomen and pelvis demonstrated a distended gastric pouch and a distended jejunal alimentary limb. The patient underwent emergent diagnostic laparoscopy, lysis of adhesions, and closure/revision of Peterson's defect. The patient was advanced to a Step 1 bariatric diet and discharged. According to Milliman Care Guidelines (MCG) criteria, goal length of stay for an intestinal obstruction is 2 days. An extended stay beyond the goal length of stay may be needed for patients who undergo surgical intervention. [3] Per the MCG, admission is indicated for patients with signs and symptoms of bowel obstruction and with imaging studies consistent with bowel obstruction. Per clinical documentation, the patient presented with nausea and vomiting and had imaging consistent with a diagnosis of a bowel obstruction.

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 an inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Metastatic Lung Cancer, Pregnancy
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a female patient who was pregnant and found to have metastatic lung cancer including brain metastasis. The patient developed intractable nausea and vomiting after gamma knife therapy. She was admitted for intravenous (IV) fluids and medications for vomiting  At issue is the medical necessity of a full hospital admission.
The hospital admission was medically necessary. The patient has a very complex situation with metastatic brain tumors and intractable nausea and vomiting. Additionally, she was weeks pregnant and has a high risk pregnancy situation. Because of the intractable nausea and vomiting, the patient required IV fluids as well as careful administration of medications due to the pregnancy situation. This could not have been managed on an outpatient basis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angina Pectoris

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

The patient has a history of hypertension, diabetes, CAD (coronary artery disease) with previous stenting, status-post renal transplant and paroxysmal AF (atrial fibrillation) with previous ablation on Eliquis, and septal hypertrophy with previous septal ablation who presented to the hospital for elective cardiac catheterization for Canadian Cardiovascular Society (CCS) Class II angina pectoris. The patient presented to the hospital with mid-sternal chest pressure and shortness of breath. The patient underwent a cardiac catheterization which showed hyperdynamic left ventricle and 60-70% diagonal stenosis in a jailed segment of the left anterior descending (LAD) artery. The patient was observed uneventfully and discharged on Eliquis and Plavix.

The patient had an elective diagnostic heart catheterization. This procedure is typically an outpatient procedure for most patients unless there are unusual circumstances. There were no such circumstances apparent from the medical record for this patient. This patient could have been managed on an outpatient basis. As such, a full admission was not medically necessary. As such the health care plan acted reasonably in the best interest of the patient.

As noted above this patient could have been managed as an outpatient. A full admission was 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 an inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea on exertion

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult male with a history of ischemic heart disease, hypertension, and diabetes who presented to the hospital for elective cardiac catheterization following a positive stress test.  Prior to stress testing, the patient reported symptoms of worsening dyspnea on exertion.  Cardiac catheterization, via radial artery approach, revealed a 70-80 percent (%) a calcified lesion in the proximal left anterior descending (LAD) artery. Left ventricular (LV) ejection fraction was 60%.  A drug eluting stent was successfully placed.  No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization.  He underwent an uncomplicated procedure, and a stent was placed in the proximal left anterior descending (LAD) artery. He was discharged the following day.  Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. Current expert consensus from the society of cardiovascular angiography and interventions support treatment at a 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 the inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: hypertension, diabetes and kidney disease. 

Treatment: personal care services - 12-24 hours a day, 7 days a week (split shift) totaling 168 hours. 

The insurer denied coverage for personal care services - 12-24 hours a day, 7 days a week (split shift) totaling 168 hours. 

The denial is overturned. 

This is an elderly adult with medical problems including hypertension, diabetes and kidney disease. She lives with her daughter in a 2-bedroom apartment. The insurer approved personal care services (PCS) 8 hours/week 7 days/week (total 56 hours/week).  The request is for personal care services (PCS) - 12-24 hours a day, 7 days a week (split shift) totaling 168 hours. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired. She is receiving treatment for depression. She reportedly requires maximal assistance to total dependence for performing much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also reportedly totally dependent for locomotion. Maximal assistance is reportedly required for bathing, personal hygiene, dressing and toilet transfer/use. Extensive assistance is reportedly needed for eating and bed mobility.  She is reportedly wheelchair dependent and non-ambulatory. The patient is reportedly frequently incontinent of bladder and bowel. Her ability to perform activities of daily living and self-sufficiency have reportedly declined and deteriorated, respectively over the prior 90 days. There has been one reported fall over the prior 30 days. 

The patient's medical condition, cognitive deficits and physical limitations are at the level or unpredictable as to require the requested personal care services - 12-24 hours a day, 7 days a week (split shift) totaling 168 hours. The letter from the patient's treating physician describing her medical condition; reportedly requiring "constant supervision with her ADLs" was reviewed. There is also a letter indicting the patient's daughter "cannot leave her mother alone to return to the office for work as she only gets 8 hours a day of aide assistance." 

This physician would agree that given the patient's reported general weakness, debility and falls risk, she may benefit from additional monitoring. The patient's functional ability has reportedly declined and remains substantial. Based on the records reviewed, attention to the patient's functional needs is more appropriately provided and maintained by increasing personal care services (PCS) to 12-24 hours a day, 7 days a week (split shift) totaling 168 hours. 

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 personal care services - 12-24 hours a day, 7 days a week (split shift) totaling 168 hours services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission 

The denial is upheld 

The patient is an adult that presented to the hospital with lightheadedness and syncope.  The past medical history was significant for migraine headaches. The patient reported feeling lightheaded for 10 minutes prior to losing consciousness. On arrival to the hospital, vital signs were stable (blood pressure [BP] 128/66 and pulse 67). The physical examination revealed no significant abnormality. Serum blood tests revealed a blood urea nitrogen (BUN) of 18 and creatinine of 0.8.  Cardiac enzymes were not elevated. An electrocardiogram (EKG) revealed normal sinus rhythm with normal intervals, atrial premature contractions and no evidence of ST or T wave abnormality.  The patient was admitted to the hospital for further testing. A computed tomography (CT) scan of the head revealed no abnormality.  An echocardiogram revealed a normal left ventricular ejection fraction (LVEF) (50% (percent)) and no significant valvular abnormalities. Cardiology evaluation was unrevealing and the patient was discharged the following day.

This patient presented with lightheadedness and syncope following a 10 minute prodrome. The physical examination and serum blood testing revealed no major abnormalities. Echocardiography revealed a structurally normal heart with a normal left ventricular ejection fraction (LVEF) and no rhythm abnormality was noted on EKG or telemetry. This patient falls into a low to intermediate risk group for syncope.  According to American Heart Association (AHA)/American College of Cardiology (ACC)/Heart Rhythm Society (HRS) guidelines such patients should be managed utilizing a structured emergency department (ED) observational protocol (1). In a study of individuals presenting to the ED, patients that were low risk or intermediate risk for cardiac events had an excellent prognosis and did not require admission to the hospital for further testing (2).  In this case, the patient had a normal echocardiogram and a normal 12 lead EKG. Acute inpatient admission was not medically necessary for this patient.

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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

This is the case of a young female with parental history of asthma who presented to the emergency department (ED) with wheezing. Symptoms began the day of presentation with cough and shortness of breath. There is a history of prior admission to the Pediatric Intensive Care Unit (PICU) for bronchiolitis. Past medical history (PMHx) includes CCAM (Congenital cystic adenomatoid malformation) on the right status/post (s/p) resection and delayed developmental milestones. Home meds include albuterol and budesonide. The review of symptoms (ROS) was negative for fever, gastrointestinal (GI) symptoms or rash, positive for cough and congestion. 

The inpatient hospital admission was medically necessary for this patient.
According to the medical documentation, this patient received asthma pathway treatment in the emergency department (ED) with ipratropium-albuterol nebulizer, steroids, and magnesium sulfate. She continued to have tachypnea and wheezing more than 1.5 hours after treatment initiation, and admission vital signs showed continued tachypnea. The child's medical history was notable for asthma diagnosis and daily budesonide treatments, as well as CCAM resection surgery as an infant. Thus, she was at high risk for status asthmatics and the inpatient treatment was the appropriate care.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who was admitted to the hospital with one month of dizziness. The patient reported worsening lightheadedness when standing up, without any dyspnea or chest pain. Vital signs on arrival showed a normal temperature, heart rate of 75, and blood pressure of 120/74. The exam showed a well-appearing individual with no trauma to the head. The cardiopulmonary exam was unremarkable. The musculoskeletal exam was normal, and neurologically, the patient appeared intact.

The inpatient hospital admission was not medically necessary. The patient was admitted with relatively chronic symptoms of dizziness while standing and had completely normal imaging in the emergency department. Labs were relatively unremarkable for life-threatening conditions. Work-up included checking for vitamin deficiencies, of which vitamin D deficiency was identified along with iron deficiency anemia. Endoscopic evaluation showed no evidence of active gastrointestinal (GI) bleeding. The vitamin D deficiency was treated with high doses of vitamin D supplementation. There is no evidence of hemodynamic instability or cardiac causes of dizziness, such as arrhythmias, heart attack, or congestive heart failure. There is no hypoxemia. There is no evidence of major intra-abdominal abnormalities. A work-up and treatment of vitamin deficiencies can be completed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Mesalamine ER (extended release)
The insurer denied Mesalamine ER (extended release).
The denial is overturned.

The patient is an adult male with mild ileal Crohn's disease. His provider is requesting treatment with Pentasa (mesalamine). This was denied coverage by the health plan, as the plan does not consider it to be effective for the treatment of Crohn's disease. The denial is being appealed.

The requested health service is medically necessary.

Pentasa is a form of mesalamine that has been shown to be effective for the treatment of small bowel Crohn's disease.
Due to its formulation being pH dependent, it is released proximally in the small bowel, and has been shown to be effective for the treatment of small bowel Crohn's disease. Therefore, the use of Pentasa (mesalamine) is medically necessary, as supported by current medical literature in small bowel Crohn's and is medically appropriate as supported by current medical literature.