Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Genitourinary/Kidney Disorder/Other/Postmenopausal Atrophic Vaginitis
Treatment: Pharmacy/Prescription Drugs/Estring vaginal ring 2 milligrams (mg) 
The health plan denied the requested medication, Estring vaginal ring 2 milligrams (mg) as not medically necessary. The health plan's determination is upheld.

This patient is a female who is under consideration for Estring vaginal ring 2 milligrams (mg) for the indication of postmenopausal atrophic vaginitis. She is noted to have been on this medication after undergoing a hysterectomy. She reports itching and burning with Estrace and Premarin cream. She has a remote history of endometriosis that led to a hysterectomy. In this case, there has been no documented trials and failures of any of the preferred formulary alternative agents.

I uphold, in whole, the health plan's determination of medical necessity.

Based upon a review of the indication for the use of Estring 2 mg vaginal ring, as postmenopausal atrophic vaginitis, there would be no lack of effectiveness for the use of the formulary drugs of Estradiol patch, Estradiol tablet, Premarin cream, Menast tablet, Premarin tablet or Yuvafem for estrogen replacement in this patient post hysterectomy. 
Each of these formulary agents has the same active ingredient of estrogen for replacement in the case of post hysterectomy estrogen deficiency leading to atrophic vaginitis. In this case, the patient is postmenopausal due to hysterectomy in the setting of endometriosis and has atrophic vaginitis. She is noted to vaginal atrophy resulting in dyspareunia due to her postmenopausal state. Vaginal atrophy is a direct consequence of the hypoestrogenic state associated with menopause resulting in anatomic and physiologic changes in the genitourinary tract. The North American Menopause Society estimates that 10-40% of menopausal women will experience one or more symptoms of vaginal atrophy. Vaginal atrophy causes bothersome vaginal symptoms commonly associated with menopause including, vaginal or vulvar dryness, discharge, itching, and dyspareunia. Estrogen therapy effectively alleviates atrophic vaginal symptoms related to menopause. Local therapy is advised for the treatment of women with only vaginal symptoms. All low-dose systemic estrogen formulations are Food and Drug Administration (FDA) approved for the treatment of atrophic vaginitis. Oral dosages of conjugated Equine Estrogen as low as 0.3 milligrams/deciliter (mg/d) and transdermal Estradiol dosages of 12.5 micrograms/deciliter have demonstrated improvements in vaginal atrophy. Local vaginal estradiol and local conjugated equine estrogen, which can be administered in cream, ring, and tablet formulations, are effective in treating atrophic vaginitis in menopausal women. This application can provide relief from menopausal symptoms of vaginal atrophy and dyspareunia. Each of the formulary drugs is an option for control of these symptoms and would be both effective and not likely to cause side effects/adverse effects. In this case, the formulary drugs have not been proven to have adverse effects in the management of atrophic vaginitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment: Mounjaro.
The insurer denied: Mounjaro.
The denial is overturned.

The patient is a female diagnosed with obesity. This request is for Mounjaro. As reported; she has pre-diabetes; and hypertension (HTN). She has failed weight loss treatment with Saxenda, Ozempic, and maximum Wegovy doses. As per the visit note; she was continued on metformin and was prescribed Victoza (at the previous visit).
Her weight was 226 pounds. Prior weights were 210 pounds, 218 pounds, and 201 pounds (nadir). The subject under review is the medical necessity for Mounjaro.

The health plan's determination is overturned.

The requested Mounjaro is medically necessary for this patient. The requested medication Mounjaro (tirzepatide) is Food and Drug Administration (FDA) approved for the treatment of adults with type 2 diabetes. It is a glucagon like peptide (GLP)-1 and gastric inhibitory polypeptide (GIP) receptor agonist. It has been shown in clinical trials to lead to improvement in glycated hemoglobin (A1c) as well as weight loss [1-3].
Although the medication is only FDA approved for type 2 diabetes, it is safe and effective in the treatment of obesity [4, 5]. Given the fact that the patient has failed all other pharmacologic treatments for obesity, the request is appropriate as an off-label treatment. The use of Mounjaro in this case is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Endocrine/Metabolic/Nutritional/Other/Polycystic Ovary Syndrome.
Treatment:  Pharmacy/Prescription Drugs/Ozempic 0.25 OR .5 Pen Injctr (Injector).

The health plan denied the requested prescription medication, Ozempic 0.25 OR .5 Pen Injctr (Injector).  The health plan's determination is upheld.

This is a female diagnosed with polycystic ovary syndrome (PCOS). This request is for Ozempic. As reported, her PCOS is associated with obesity and insulin resistance syndrome with a strong family history of hyperlipidemia. She had an excellent response to Ozempic, and her weight went down from the 89.4 percentile to 60 percentile. She notes only gaining weight after stopping Ozempic.

Her weight was 58.3 kilograms (kg), body mass index (BMI) was 24.58.

At a later date, her weight was 64.8 kg, BMI was 27.33, and at a later date her weight was 63.5 kg; BMI was 27.33.

At issue is the medical necessity for the requested prescription medication, Ozempic 0.25 OR .5 Pen Injctr.

The health plan's determination of medical necessity is upheld, in whole.

No. Semaglutide is a glucagon like peptide 1 receptor (GLP1R) agonist [1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes and obesity. [2,3,4] Recent studies published in major peer reviewed medical journals have shown safety and efficacy of Semaglutide for the treatment of obesity. [5, 6,7] This medication is now available for the treatment of obesity in the form of Wegovy. There are no studies showing safety or efficacy of the requested medication for patients who do not have diabetes, such as this patient. There are no extenuating circumstances in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cholelithiasis/cholecystitis.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a woman who presented with recurring episodes of abdominal pain. Vital signs identified a normal pulse and elevated blood pressure. She is morbidly obese with a body mass index of 61. She was tender in the epigastrium. The white blood cell (WBC) count was elevated at 11.9. Serum transaminase, alkaline phosphatase, and bilirubin were elevated. Ultrasound showed findings of gallstones, hepatomegaly, and a dilated extrahepatic ductal system. Surgical consultation was requested. The patient was further evaluated with magnetic resonance cholangiopancreatography (MRCP) which was negative for common duct stones. She was admitted to the hospital with the diagnosis of cholelithiasis/cholecystitis. 

The inpatient care was appropriate and medically necessary for this patient.
A lower level of care would not have been consistent with the standard of care for this patient with acute biliary obstructive jaundice and cholecystitis. It was reasonably expected that this patient's clinical needs for intravenous (IV) fluid, pain medications, antiemetics, and appropriate imaging/lab diagnostics would span a period of greater than 48 hours. This diagnosis (based on clinical exam, labs, and imaging results) and the potential for rapid clinical deterioration warranted an inpatient level of care for this patient. The diagnosis of acute cholecystitis, obstructive jaundice, and cholangitis does carry the potential for rapid clinical deterioration. Treatment with NPO (nil per os/nothing by mouth) status and provision of IV fluids during this period of nothing by mouth is a standard treatment in addition to pain management, serial examination, and supportive care. This treatment is necessarily provided in the hospital inpatient environment. The records include daily progress notes, lab data, and imaging results in addition to nursing and medication records. This clinical data supports that inpatient admission was medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:  Personal Care Services, 24 Hours A Day, 7 Days A Week (split shift).

The insurer denied: Personal Care Services, 24 Hours A Day, 7 Days A Week (split shift).  The denial is overturned.

The patient is an elderly female with history of dementia.  Per the most recent assessment, the patient has history of dementia. The patient is alert and oriented to self, and she is aware that she is at home. She ambulates indoors with the use of a walker. She has a slow and unsteady gait. The patient needs assistance in standing from a seated position and needs help in ambulating. The patient wears diapers for urinary/fecal incontinence. The patient is unable to change incontinence supplies on her own, and she is unable to understand her physical limits. The risks of leaving the patient alone and that she should not be by herself were discussed with the patient's daughter. The patient's condition has declined. The patient needs assistance with activities of daily living with maximal to extensive assistance. The patient is frequently incontinent of bladder, and infrequently incontinent of bowel.

The request is for Personal Care Services, 24 Hours A Day, 7 Days A Week (split shift). The health plan approved Personal Care Services 12 hours a day, 7 days a week, 84 hours total.

The Personal Care Services, 24 Hours A Day, 7 Days A Week (split shift) is medically necessary.

As per the most recent assessment, the patient should not be left by herself. The patient has dementia. She is not able to call 911 for emergencies, and she is not safe to be alone at night.

The patient will require at least supervision for her ADLs (activities of daily living) throughout the day and night. The split-shift hours are needed because the aide would be unlikely to obtain five hours daily of uninterrupted sleep on a regular basis, because the patient's condition has declined. The patient needs assistance with activities of daily living with maximal to extensive assistance. The patient is frequently incontinent of bladder, and infrequently incontinent of bowel.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Diabetes.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is overturned.

The patient is a male who has been diagnosed with bipolar disorder, morbid obesity, type 2 diabetes and non-alcoholic fatty liver disease. For mental health issues, he has been treated with Lithium, Abilify and Zoloft, and admitted in a mental healthcare facilities 4 times in the past. He was admitted in the residential treatment center of the voluntary foster care agency for hard to place children with special needs.

The Anticipated Inpatient Hospital Admission is medically necessary for this patient.
The most important aspect of the management of type 2 diabetes is lifestyle change with diet and exercise followed by medications. He is non-compliant with diet and continues to gain weight. He also has developed nonalcoholic fatty liver. Unless, he makes lifestyle changes with diet and exercise and loses weight, his diabetes is not going to be controlled with medications alone either inpatient or as an outpatient. He also needs management of his bipolar disorder, again either inpatient or as an outpatient.

The idea of residential centers for children with chronic disease is not new and can improve diabetes control in patients with poorly controlled diabetes by providing patient education, improved diabetes management and the psychosocial intervention. Success in such facilities is probably related to the stable environment in addition to medical and mental health supervision. However, it may or may not be sufficient to ensure compliance after discharge from such facility as results are mixed.

Although noncompliance is not an absolute indication for acute rehabilitation admission for chronic illness inpatient management program, this patient's clinical course is also complicated by mental illness, which may be contributing to noncompliance. Considering his history of noncompliance and current status, the Anticipated Inpatient Hospital Admission is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dysphagia.
Treatment:  Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.  
The denial is upheld.

The patient had a history of cardiac disease and presented with a feeling of food caught in his esophagus. He was having chest pain and an inability to swallow. He was afebrile and the vital signs were stable. The abdominal exam was benign. The electrocardiogram (EKG) did not have acute changes. He felt better after receiving glucagon. The endoscopy was negative for an esophageal foreign body. 

Milliman Care Guidelines (MCG) for Gastroenterology reviews indications for admission for dysphagia. These include having a caustic ingestion, severe dehydration, inability to manage secretions, hemodynamic instability, severe electrolyte abnormalities, and acute renal failure. The patient did not have these conditions. 

MCG guideline lists clinical indications for endoscopy. Dysphagia is an indication for the procedure if it is associated with a mechanical obstruction, such as an ingested foreign body. The patient met the criteria to have an endoscopy. However, the endoscopy indications are listed as ambulatory care. 

This patient had a suspected foreign body in the esophagus that improved after Glucagon. Doing an endoscopy was appropriate. However, the endoscopy could have been done as an ambulatory procedure. No obstruction was present, and no complications were reported. He did not meet MCG criteria for admission for Gastroenterology. 

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

Diagnosis:  Arthritis and Dementia.
Treatment:  Personal Care Aide (PCA) services 7 days per week, 12 hours per day, 2 shifts, for a total of 168 hours per week.

The insurer denied coverage for PCA services 7 days per week, 12 hours per day, 2 shifts, for a total of 168 hours per week.  The denial is overturned.

The patient is a female with chronic medical problems including arthritis and dementia. She is currently approved by the insurer for personal care aide (PCA) 7 days/week, 24 hours/day, live in, for a total of 91 hours/week and is requesting PCA services 7 days/week, 12 hours/day, 2 shifts, for a total of 168 hours/week. 

According to the Uniform Assessment System (UAS) report, the patient's cognition is "moderately impaired; decisions consistently poor or unsafe." She requires maximal assistance for bathing, personal hygiene, and lower body dressing.  Extensive assistance is required for upper body dressing, walking, and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. According to the patient's treating physician's note, she has "sleep/wake cycle reversal; resulting in getting "up multiple times to urinate and appears anxious." In addition, "Aide does report that she feels exhausted and is not sure she can continue doing this job as a live in as she is unable to get 5 consecutive hours of sleep."  As a result, and noted in the UAS report, "This leaves the aides exhausted and they will have a hard time taking care of her during the day." The combination of the patient's cognitive deficits and functional impairments support the medical necessity of increasing PCA services 7 days/week, 12 hours/day, 2 shifts, for a total of 168 hours/week. In addition, her condition and functional needs are at a level or unpredictable as to require the requested PCA 24 hours/day, 7 days a week - split shift.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the 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, the requested PCA services 7 days/week, 12 hours/day, 2 shifts, for a total of 168 hours/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 aide (PCA) services 7 days per week, 12 hours per day, 2 shifts, for a total of 168 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease
Treatment: Personal Care Services (PCS), Level 2: 24 Hours/Day, 7 Days/Week (Split Shift) - Total 168 Hours/Week
The insure denied PCS, level 2: 24 hours/day, 7 days/week (split shift) - total 168 hours/week.
The health plan's determination is upheld.

The patient is a male with past medical history of Parkinson's disease, Parkinson's dementia, constipation, chronic fatigue, anxiety, depression, insomnia, low back pain, visual hallucinations, and vitamin B12 deficiency who had been assigned PCA (personal care assistant) services.

Personal Care Services (PCS), level 2: 24 hours/day, 7 days/week (split shift) - total 168 hours/week are not medically necessary for this patient.

Although there is documentation of the patient's functional and cognitive decline, there was no documentation of overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. There was no documentation of overnight care logs. There was no documentation of medical necessity of turning and repositioning every 2 hours. 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, PCS, level 2: 24 hours/day, 7 days/week (split shift) - total 168 hours/week are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Halo device to support spine
Treatment: Alternate level of care stay in a skilled nursing facility 
The insurer denied alternate level of care stay in a skilled nursing facility.
The determination is upheld. 

The patient has a past medical history significant for genetic malformation involving the base of the skull; a cervical (C) 2 process has been embedded up into the skull impinging the brainstem. The patient had treatment with an external fixation device/halo. He has a past medical history significant for hypertension and hypothyroidism. This review is for the medical necessity of alternate level of care stay in a skilled nursing facility.

Services were denied by patient's health plan stating the following: we decided we would not change our decision to deny a request. The patient was approved for previous rehabilitation. Further services were determined to be not medically necessary. The patient can walk 150 feet with little or no help. He is able to perform activities of daily living including dressing and toileting. The patient has a halo device to support his spine and back. There is no documentation that he cannot be safely discharged back to home. He is able to ambulate and perform most activities of daily living (ADLs) without assistance. It was noted that his wife and/or his other family members were not able to help him at home. Even though he still requires some help at home, therapy notes that he was able to perform most of his ADLs. The lack of a qualified person such as a spouse or a family member to provide nonskilled custodial care does not necessarily create a medical need for further inpatient skilled nursing facility care. There are no other noted ongoing skilled needs that would necessitate inpatient skilled nursing facility care. Further treatment physical therapy (PT)/occupational therapy (OT) can be performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal/Stomach Pain. 
Treatment: Inpatient Hospital Stay. 
The health plan denied the inpatient hospital stay as not medically necessary. 
The health plan's determination is upheld. 

The patient is a female who presented to the emergency department (ED) with a history of progressively worsening abdominal pain. She had previously been treated for appendicitis with nonoperative antibiotic therapy in the prior year. Evaluation included a physical exam, labs, and imaging. She was without fever at the time of presentation, and her heart rate was 62 beats per minute (bpm). Her evaluation yielded findings consistent with appendicitis. Treatment was initiated with intravenous (IV) fluid and antibiotics. Surgical consultation was requested. The patient was admitted to the hospital. 

The patient was initially treated with IV antibiotics on the first two days. She underwent a laparoscopic appendectomy on the third day. The clinical notes indicate an uncomplicated appendectomy with findings of appendicitis. She was provided IV fluid and perioperative antibiotics. Her vital signs remained normal throughout the post-surgical period. Her diet was advanced, and pain management was converted to oral medications. She was discharged home on the fourth day, following the initial recovery period. 

At issue is the medical necessity of the inpatient admission. 

The health plan's determination of medical necessity is upheld in whole. 

The requested health service/treatment of inpatient admission was not medically necessary for this patient. 

This patient presented with abdominal pain. The evaluation supported the diagnosis of appendicitis. She was admitted to the hospital. The initial treatment included nothing by mouth (NPO) status, IV fluid, and antibiotics. An appendectomy was not performed until the third day. The early post-surgical course was uncomplicated, and the patient was hemodynamically stable and tolerating a diet on the first post-surgical day. She was discharged from the hospital following the initial recovery period. 

A lower level of care would have provided for presurgical assessment, operative treatment, and post-surgical monitoring. A lower level of care would have also allowed for overnight monitoring, if needed. 

The diagnosis of appendicitis and the indication for surgical treatment was established the day of presentation. Had this patient undergone surgery the next day, she would have been suitable for discharge from the hospital after 2 days. The care and treatment provided could have appropriately been rendered with an alternate level of care and did not require inpatient admission. An alternate designation would have provided for presurgical assessment, serial examination, operative treatment, and post-surgical monitoring. Therefore, the inpatient admission was not medically necessary.