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

Diagnosis: Coronary artery disease, hypertension, and Alzheimer's disease

Treatment: Personal care worker (PCW) services 7 days per week, 12 hours per day; 84 hours per week

The insurer denied coverage for PCW services 7 days per week, 12 hours per day; 84 hours per week.

The denial is overturned.

This is an elderly patient with chronic medical problems including coronary artery disease, hypertension, and Alzheimer's disease. The patient lives alone in a 1-bedroom apartment in a senior housing complex. The caregiver is the daughter. The insurer approved PCW 8 hours/day, 7 days/week for a total of 56 hours/week. The daughter is requesting PCW services 7 days/week; 12 hours/day; 84 hours/week.  

The most recent Uniform Assessment System (UAS) assessment report notes the patient cognitive skills are described as moderately impaired. She requires extensive assistance for bathing, dressing, and toilet use. Limited assistance is needed for ambulation with a walker and toilet transfer. She is frequently incontinent of bladder and infrequently incontinent of bowel. The combination of the patient's cognitive deficits and functional impairments; both of which have declined since prior UAS assessment, support the medical necessity of increasing PCW to 12 hours/day, 7 days/week for a total of 84 hours/week. Her condition and functional needs are at a level or unpredictable as to require the requested increase PCW services; particularly as she lives alone and has personal care service needs greater than the currently approved 7 days/week; 8 hours/day; 56 hours/week.   

From a physical medicine and rehabilitation perspective, the requested PCW services 7 days per week; 12 hours per day; totaling 84 hours per week is medically necessary.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care worker (PCW) services 7 days per week, 12 hours per day; 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient hospital.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a male with a medical history of prediabetes. He presented to the emergency department with three days of lower abdominal pain, nausea, and a feeling of constipation. Vital signs were notable for elevated blood pressure of 177/57. Physical examination was notable for bilateral lower abdominal tenderness with guarding. Labs showed elevated white blood cell count of 24.5 and low sodium of 134; stool test for occult blood was negative. A Computed tomography scan of the abdomen and pelvis showed acute sigmoid colon diverticulitis with inflammation extending to the margin of the bladder. He was treated with intravenous ceftriaxone, metronidazole, Zosyn, and fluids. 

The inpatient hospital admission is not medically necessary. The care provided could have been provided at a lower level of care for the duration of the stay. In patients with uncomplicated diverticulitis (without complications such as abscess or perforation), outpatient management or observation is the standard of care. However, a lower level of care is appropriate when there are significant symptoms and leukocytosis, as in this case. The patient had rapid improvement in symptoms; there was no protracted fever or hypotension to suggest that intravenous antibiotics in the hospital were ineffective, and his leukocytosis also gradually improved. He was appropriately discharged on antibiotics. All of the interventions performed, including observation, labs, imaging, and antibiotic therapy, could have been performed at a lower level of care. For these reasons, the inpatient level of care is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Skyrizi Pen 150MG/ML (milligrams per milliliter) SC (subcutaneous) SOAJ (solution auto injector).
The insurer denied: Skyrizi Pen 150MG/ML (milligrams per milliliter) SC (subcutaneous) SOAJ (solution auto injector). 
The denial is overturned. 

The patient is an adult female with psoriasis, treated with topicals, Humira, Cosentyx, and Stelara. The patient has 10% BSA (body surface area) affected. The patient's provider is requesting Skyrizi. The health plan requires use of preferred agents Enbrel and Siliq. 

The requested Skyrizi is medically necessary. Skyrizi is an approved, appropriate and effective medication for psoriasis. A number of biologic agents are available for the treatment of moderate-to-severe plaque psoriasis. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. Skyrizi is among the most effective therapies for psoriasis according to current peer-reviewed literature. 

According to the meta-analysis by Sbidian et al, compared to placebo, the biologics infliximab, ixekizumab (Taltz), risankizumab (Skyrizi), bimekizumab, secukinumab (Cosentyx), guselkumab (Tremfya) and brodalumab were the most effective treatments for achieving PASI 90 (90% reduction in Psoriasis Area and Severity Index score) in people with moderate-to-severe psoriasis on the basis of moderate to high-certainty evidence. 

Given the above, the requested Skyrizi is likely to be more effective for this patient's condition than the health plan's preferred agents, Enbrel and Siliq. Therefore, the requested Skyrizi is consistent with the standard of care in the dermatological community, and is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal
Treatment is 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 hospitalized due to alcohol withdrawal symptoms. He was admitted to another facility for subacute rehabilitation. He gradually improved and transitioned to long term custodial care.

According to the physical and occupational therapy discharge Summary notes, the patient was modified independent with activities of daily living including dressing, hygiene, grooming and toileting; well before his transition to long term care. He was also modified independent for bed mobility, transfers and ambulating with a walker. In addition, there were no acute medical or complicated nursing issues that warranted continued long term custodial care. Ongoing care could have been safely provided via home care or as an outpatient.  

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient.  

 From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued long term custodial care was not medically necessary.

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for the continued long term custodial care is upheld. Medical Necessity is not substantiated for continued long term custodial care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nausea and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a male who had symptoms of vomiting after ingestion of eye drops containing Naphazoline.  The patient was taken to the emergency department; poison control was called as well.  The patient had electrolyte abnormalities with elevated heart rate and concerns for further abnormal delayed vitals due to ingestion.  The patient required intravenous fluids, and monitoring of vitals due to ingestion.

Yes, the proposed inpatient hospital admission was medically necessary.
The patient was a child with an ingestion presenting with abnormal vitals, electrolyte findings and emesis.  Due to the concern for further decompensation of vitals and electrolytes, the patient required close monitoring as provided by the physicians of record.  The patient also is developmentally unable to provide an exact history of the amount of and the name of the exact details of the said ingestion, due to their age, and this fact alone requires further management.  In this age group, assessing symptoms and exam findings needs to be monitored closely in an inpatient setting when ingestions are unclear and abnormal exam and lab findings are present.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The admission was medically appropriate considering the history and the exam findings present.  The denial is overturned and the admission and care given was medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Allergic reaction

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

This is a patient who has a history of eczema, and he was brought by EMS (emergency medical services) to the hospital for an apparent food reaction, consisting of hives and lip swelling. In the field Epinephrine 0.1 mg (milligrams) and Benadryl were administered. The initial medical doctor (MD) note states that the child had lip swelling. He was given dexamethasone and then he was given Epinephrine 0.1 mg and Benadryl. The notes states that the patient had new lip swelling and hives. The father was noted to be combative towards the staff. Because of the concerns for protracted anaphylaxis the child was admitted to the floor. The resident note states that the child later had no lip swelling or hives. Vital signs were consistently normal.  

The management of the patient appeared to be appropriate in terms of monitoring and treatment. It should be noted that the recommended epinephrine dose for 10-25 kg (kilograms) is 0.15 mg not 0.1 mg. The patient could have been managed in an observational setting as the patient had a complete normal physical examination 5 hours after arrival to the ED (emergency department). Hospitalization was not necessary.  

The insurer's denial of coverage for the inpatient hospital stay is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal myomectomy
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a female who presented for an abdominal myomectomy.  She underwent an uncomplicated procedure and had four fibroids removed ranging from 1.2 centimeters (cm) to nine centimeters.  She was transferred to recovery with a intravenous (IV) access, sequential compression devices, and a Foley catheter.  She was admitted for monitoring. 

The inpatient hospital stay was denied.  This is being appealed.

Yes, the proposed inpatient hospital admission was medically necessary.
According to the American Medical Association, "Under the two-midnight rule, established by the Centers for Medicare & Medicaid Services (CMS), hospital inpatient admissions are considered reasonable and necessary for patients whose stays cross two midnights, and these stays are payable under Part A. Stays expected to span less than two midnights under the rule are generally considered outpatient and therefore paid for by Part B.  In its rulemaking, CMS (Centers for Medicare & Medicaid Services) maintains the two- midnight benchmark but clarifies that certain stays that are less than two midnights can be payable under Part A on a case-by-case basis based on the judgement of the admitting physician. To qualify, documentation in the medical record must support that an inpatient stay is necessary, subject to medical review."

This patient required intravenous pain medications.  On post-operative day #1, the Foley was removed.  The patient's vitals were stable.  Her diet was advanced.  She required assistance with ambulation.  Her pain medications were transitioned to oral medications.  On post-operative day #2 she was deemed stable for discharge.  She was tolerating diet, ambulating, had return of bowel function, and pain was controlled.  In review of the medical record, the care provided did require an acute hospital stay given that the appropriate care crossed two midnights as maintained by Medicare as an inpatient stay.  This meets the accepted standard of medical practice.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient
The health plan did not act reasonably and with sound medical judgement or in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic dermatitis
Treatment is Dupixent 300 mg (milligrams)/2 ml (milliliter) Pen weekly
The insurer denied coverage for the Dupixent 300 mg/2 ml Pen weekly.
The denial is overturned.

The patient is an adult male with a diagnosis of severe atopic dermatitis affecting 60% total body surface area (TBSA). The patient has continued to flare despite every 2-week Dupixent therapy. The request is for weekly Dupixent dosing to improve efficacy.  

Based on the current peer-reviewed literature, Dupixent weekly is medically necessary. The patient has tried and failed biweekly Dupixent. In 2019, Thibodeaux et al published "A review of dupilumab in the treatment of atopic diseases," in which they demonstrated that weekly dosing of Dupixent had significant efficacy (1). Beck et al. also have reported on the efficacy of weekly Dupixent in "Dupilumab Provides Favorable Safety and Sustained Efficacy for up to 3 Years in an Open-Label Study of Adults with Moderate-to-Severe Atopic Dermatitis" (2). Therefore, it is appropriate, based on the patient's clinical findings and refractory disease, to approve weekly Dupixent in this patient.

The unique clinical circumstances of this particular patient, including side effects of chronic steroid use, document that he is not currently controlled with biweekly Dupixent. Weekly Dupixent is warranted in this case.  

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for a Dupixent 300 mg/2 ml Pen weekly is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral lower extremity cyanosis.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is overturned.

The patient is a female infant. She presented to the hospital with bilateral lower extremity cyanosis. The baby had been a term baby with good Apgar scores. She had a workup including an echocardiogram, which showed a PFO (patent foramen ovale) with elevated right-sided pressures. The rest of the evaluation included a chest x-ray, EKG (electrocardiogram), and lower extremity Doppler. The baby had delayed capillary refill, estimated at 5-6 seconds.

The inpatient admission was medically necessary.
While lower extremity cyanosis is a common finding in healthy newborns, the delayed capillary refill associated with increased sleepiness qualifies the patient for the treatment she received.

The denial letter notes that the medical records did not provide evidence of unstable vital signs. The delayed capillary refill combined with lethargy constitutes instability in a young infant and makes the management performed to be medically necessary.

Treating this patient at a level lower than inpatient admission would not have been consistent with the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 diabetes
Treatment: Inpatient admission 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

According to the medical records, this patient with type 2 diabetes, hypertension, hypothyroidism, and hyperlipidemia was referred to the emergency room (ER), by his primary care physician, because his finger stick blood sugar was over 600. In the ER his blood fingerstick blood glucose was more than 500. The patient said he stopped using insulin and diabetes pills for more than seven days. He was using Basaglar 30 units and Admelog 12 units with meals along with Metformin and Sitagliptin. He reported stopping all insulin as he was having body pain and thought it was due to insulin use. 

Admission labs showed blood glucose of 505 and serum sodium 130, CO2 (carbon dioxide) 22.8, and Anion gap of 10. Corrected sodium was 136. Treatment included intravenous (IV) fluids and subcutaneous insulin. The patient had elevated blood sugars upon presentation, but labs do not indicate that the patient was either in diabetic ketoacidosis or hyperosmolar hyperglycemic state. There is no indication that the patient failed observation level of care for at least than 24 hours. Thus, coverage of the admission is not medically necessary.      

"Abstract: Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are the most serious and life-threatening hyperglycemic emergencies in diabetes. DKA is more common in young people with type 1 diabetes and HHS in adult and elderly patients with type 2 diabetes. Features of the 2 disorders with ketoacidosis and hyperosmolality may coexist. Both are characterized by insulinopenia and severe hyperglycemia. Early diagnosis and management are paramount. Treatment is aggressive rehydration, insulin therapy, electrolyte replacement, and treatment of underlying precipitating events. This article reviews the epidemiology, pathogenesis, diagnosis, and management of hyperglycemic emergencies." (Fayfman, M. et al. 2017).

"Conclusions: DKA should only be diagnosed when all three components are present - the 'D', the 'K' and the 'A'. In addition, the definitions used to diagnose DKA should be standardised - in particular for clinical trials." (Dhatariya, K. K. 2019).

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

Diagnosis: Cellulitis. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is overturned. 

The patient is an adult male who developed redness, swelling and pain in the anterior medial left leg with streaking into the thigh. He had been seen at an outpatient facility and prescribed clindamycin for management of cellulitis. The area of cellulitis had been marked. The patient experienced ongoing symptoms after initiation of antibiotic clindamycin. The area of redness increased beyond the confines of the marked margins and he experienced fever at home, measured at 101 Fahrenheit. 

The patient presented to the hospital emergency room with a heart rate of 106 beats per minute, lactic acid level of 2.3 and presence of a three centimeter lymph node in the ipsilateral groin. He failed outpatient therapy, three doses, and had evidence of systemic inflammatory response, in the form of fever and tachycardia with lactic acidosis. 

The proposed inpatient hospital admission was medically necessary. 

The Infectious Diseases Society of America (DSA) guidelines recommend hospitalization for patients with cellulitis who fail outpatient treatment and have evidence of systemic inflammatory response. 

This patient had failed three doses of clindamycin as an outpatient with progression of infection beyond the margins of marked redness at the onset of antibiotic treatment, had measured fever of 101 degrees Fahrenheit at home prior to emergency room presentation, had lactic acidosis of 2.3 and also had tachycardia on presentation of 106 beats per minute. These medical facts classify the patient's condition as severe and the guideline recommendations cited in the references indicate that hospitalization is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis
Treatment: Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day, 7 Days per Week - Total Amount of 56 Hours per Week.
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day, 7 Days per Week - Total Amount of 56 Hours per Week. 
The health plan's determination is overturned.

The patient is a male with past medical history of gout, osteoarthritis, urinary incontinence, hypothyroidism, chronic kidney disease, hyperlipidemia, hypertension, and coronary artery disease who had been assigned CDPAP (Consumer Directed Personal Assistance Program) services based on an assessment that assessed the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and managing medication. With tasks of shopping, transportation, and dressing upper/lower body, the patient was assessed at limited assistance while supervision with tasks of managing finances, stairs, bathing, personal hygiene, walking, and locomotion. With task of phone use, the patient was assessed at set up assistance while independent with tasks of transfer toilet, toilet use, bed mobility, and eating. 

Consumer Directed Personal Assistance Program (CDPAP) Services: 8 Hours per Day, 7 Days per Week - Total Amount of 56 Hours per Week is medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased CDPAP services. The patient previously had more hours as part of a mutual case with his wife but she had since expired. The patient's son was no longer able to provide informal help due to his own medical conditions. The denial incorrectly stated that the patient required set up help with transfer toilet but the recent assessment stated he required supervision. The recent assessment also noted increased assistance needs with tasks of shopping, bathing, personal hygiene, and transfer toilet. The plan incorrectly assumed the patient had informal help outside of the hours of CDPAP services. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs when the patient has no informal help. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 8 hours/day, 7 days/week, to total 56 hours/week are medically necessary for this patient.