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

Diagnosis: Dementia, spina bifida, and weakness
Treatment: Increase in Personal Care Service (PCS) level 2 to 24 hours per day, 7 days per week (live-in)
The insurer denied the increase in PCS level 2 to 24 hours per day, 7 days per week (live-in).
The denial is overturned.

The patient is a female. Her conditions include dementia, spina bifida, and weakness. She lives alone. Denial of increase in personal care service (PCS) to 24 hours per day, 7 days per week (live-in) is being appealed. The health plan approved 12 hours per day, 84 hours per week.

Uniform Assessment System (UAS) evaluation completed shows moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, phone use, transportation, bathing, and lower body dressing' extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toileting; and limited assistance with bed mobility and eating. Night time logs show the patient needing assistance to the bathroom approximately once per night.

Letters from the patient's provider note the patient is homebound. She requires assistance with ADLs (activities of daily living) as already accounted for in the UAS evaluation. She is a high risk for falls. She needs constant oversight due to cognitive decline. She needs assistance with scheduled and unscheduled transfers and toileting overnight.

Yes, the requested increase in PCS level 2 to 24 hours per day, 7 days per week (live-in) is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

PCS is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs, including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase PCS to 24 hours per day, 7 days per week (live-in) is being appealed. The health plan approved 12 hours per day, 84 hours per week.

This patient has multiple chronic conditions, including dementia, spina bifida, and weakness. UAS evaluation completed shows the patient requires assistance with all ADLs. The appeal statement from her provider notes that she has cognitive decline and is a high fall risk. Nighttime logs are provided, showing the patient consistently requiring assistance with transfers and toileting. This information provided supports the patient having both daytime and nighttime needs. The approved PCS 84 hours per week is insufficient to meet the patient's needs for assistance with ADLs and personal care that occur during the daytime and nighttime. The proposed PCS 24 hours per day, 7 days per week (live-in) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic lower back pain

Treatment: Pain injections between the spine and hips

The insurer denied coverage for pain injections between the spine and hips.

The denial is overturned.

This is a patient with complaints of chronic lower back pain. Sacrum/coccyx MRI (magnetic resonance image) scan did not demonstrate evidence of pathology. Treatment included physical therapy, activity modification and analgesic medications. Her treating physician recommended bilateral sacroiliac joint injections, which are under review.  

Typical provocative tests to evaluate SI (sacroiliac) joint pain include the FABER (flexion, abduction, and external rotation), thigh thrust, pelvic distraction, pelvic compression and pelvic torsion (Gaenslen) tests. Although no single test is specific for SI joint-mediated pain, if 3 of the 5 tests are positive, there is an 85% (percent) pretest probability of a positive diagnostic injection. The insurer denied the request for bilateral SI joint injections citing, "the criteria was not met because the records did not show that there was a positive response to at least 3 different ways of putting pressure on this joint (provocation tests)." However, according to the doctor treatment notes, FABER, Gaenslen's and compression test were positive, which are sufficient to support the medical necessity of the pain injections between the spine and hips. 

The health care 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/pain management perspective, as well as within a reasonable degree of medical certainty, pain injections between the spine and hips were medically necessary.

The insurer's denial of coverage for pain injections between the spine and hips is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Central nervous system
Pain Management

Diagnosis: Migraine
Treatment: Botox
The insurer denied Botox. The health plan's determination is overturned. 

The patient is a woman with chronic migraines. The patient has tried and failed propranolol, topiramate, and nortriptyline for prevention of migraine. The patient has also tried and failed multiple Triptan and Gepant abortive medications. The patient has 20-25 headaches per month. Some notes indicate that she has daily migraine headaches that are unrelenting. These have been present for years. She experienced relief with prior Botox injections.

Botox is medically necessary for this patient. The patient has a diagnosis of chronic migraines. Prior denials have focused on specific documentation of migraine and headache frequency. However, the documentation clearly indicates that the patient has near daily disabling migraine headaches and has adequately tried multiple preventative therapies including beta-blockers, antidepressants, and anticonvulsants.

Botox is a Food and Drug Administration (FDA) approved treatment for prevention of chronic migraine. The patient does not have any contraindications. The patient reported some relief with the first injection series decreasing from 20-25 headaches per month to 13 headaches per month. On-going Botox injections are medically necessary for prevention of chronic migraines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders. 
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Skyrizi Pen. 
The denial is upheld.

The patient is a male with psoriasis. Body surface area affected is 40%. He also has psoriatic arthritis. He has tried and failed methotrexate, Siliq, Humira, and Taltz. He has also failed betamethasone, triamcinolone and calcipotriene. He is currently on Enbrel for his psoriatic arthritis. The medication under review is the medical necessity for Skyrizi pen for psoriasis vulgaris.

The health plan's determination is upheld. 

The requested health service/treatment of Skyrizi Pen is not medically necessary for this patient. There are no comparative, controlled studies showing that Skyrizi has a superior efficacy and safety profile to all the conventional alternatives.
According to the "National Physician Specialty Society Recommendations" for psoriasis- the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, phototherapy is an effective treatment for the management of psoriasis (1, 2).
Within the peer-reviewed literature, Racz et al. writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (3). Mehta et al writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with greater than (>)10 % affected body surface area who have not responded to topical treatments...narrow band (NB)-UVB... effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile" (4).
Per the medical and scientific literature and/or evidence based clinical practice guidelines, and the information provided by the patient, the request for Skyrizi is not necessary. It is noted that the patient has failed methotrexate, Humira and Taltz.
Therefore, the administration of Skyrizi is not strongly supported for this patient, and Skyrizi is not medically necessary for this patient based on the current evidence-based medical literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plaque Psoriasis
Treatment: Otezla 30MG
The insurer denied the Otezla 30MG
The denial is overturned.

The patient is a female who has been diagnosed with moderate to severe psoriasis of the scalp and psoriatic arthritis.  The patient has been on Otezla and Cosentyx with a positive response. The patient is being managed by a rheumatologist for Cosentyx but the dermatologist is requesting continuation of Otezla for the psoriasis.

Yes, the proposed treatment with Otezla is medically necessary.
The patient has two medical conditions that are not adequately managed by Cosentyx alone.  She has been on both Otezla and Cosentyx for several months with adequate control.  To deny Otezla after several months of therapy could destabilize the patient.  

Abignano, G. et al concludes "the favorable safety profile of apremilast either in monotherapy or combination therapy makes it highly desirable in some clinical scenarios. Monotherapy could serve to control chronically active disease not responsive to previous conventional or biologic DMARDS (disease-modifying antirheumatic drugs) or to treat patients with less severe joint and skin manifestations earlier who might not yet require a biologic DMARD (disease-modifying antirheumatic drugs). The combination therapy could be used to reduce disease activity that is not adequately controlled with other treatments without increasing the risk for AEs (adverse event)."  

Aragon-Miguel, R.  et al. concludes "Apremilast could be safely and effectively combined with biologic agents in patients with psoriasis and psoriatic arthritis non responders to biologic drugs. Apremilast could provide additional control of the activity of each domain without affecting safety. No adverse events and major side-effects such as cancer or infection were reported."  

Metyas S. et al. writes " Apremilast can be safely and effectively combined with biologic agents in patients with plaque psoriasis or psoriatic arthritis not responding adequately to these agents alone. No major side effects of cancer or severe infection were reported other than nausea and/or vomiting that were manageable in some patients".  

Takamura, S et al writes regarding Otezla in combination with biologics, "These results suggest that the combination therapy of apremilast and biologics could be a safe, effective option for the management of patients with psoriasis showing biologic fatigue."

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The patient has two conditions that require two different medications.  Current medical literature supports the use of both medications when one medication does not stabilize the patient.  Denying continuity of care jeopardizes the patient's stability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Syncope.
Treatment: Inpatient admission.

The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male who was admitted to the hospital after fainting after seeing blood that was sustained during a cut. He hit the back of the head. He was unable to recall the events of the day prior to the fall and was noted to be repeating himself. 

In the emergency room (ER), the patient was noted to be disoriented. Computed tomography (CT) scan showed faint focal bilateral basal ganglia hyperdensities with punctate calcification. Vital signs were within normal limit. Chest x-ray (CXR) and electrocardiogram (EKG) did not show any acute findings. Neurosurgery evaluated the patient and noted the patient was disoriented to year/time and season. He was unable to recall date or the president. He was noted to have leukocytosis. He was admitted with a diagnosis of post concussive syndrome. Computed tomography angiogram (CTA) did not show any acute findings. Neurology consultation noted post-traumatic amnesia.

Yes, the proposed inpatient admission was medically necessary.
The proposed treatment was medically necessary as it was clearly documented that patient had persistent cognitive change following a traumatic hit to the head following a syncopal event. The Milliman Care Guidelines (MCG) for traumatic injury notes that inpatient admission is warranted for "severe or persistent altered mental status."

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
The plan did not act reasonably with sound medical judgment and in the best interest of the patient because the inpatient stay was denied despite the patient meeting Milliman Care Guidelines (MCG) for inpatient admission as the patient had persistent altered mental status.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems 
Treatment: Home Health Care 
The insurer denied personal care assistance services Monday through Sunday, total of 41 hours per week. 
The denial is overturned.

The patient is a female with past medical history of congestive heart failure, edema, hyperlipidemia, hypertension, asthma, and cellulitis. The subject under review is regarding medical necessity of Personal Care Assistance (PCA) services (Monday through Sunday) for a total of 41 hours. The patient is currently approved for 26 hours per week. Increased hours have been requested as the family reported that the patient is unable to walk or get out of bed, thus weekend hours were requested.

She had been assigned PCA services based on an assessment tool performed, assessing the patient with modified independence cognition and no memory problems. She has no hearing and minimal vision difficulties. She requires total dependence with tasks of ordinary housework and maximal assistance with meal preparation. The patient was assessed at maximal assistance with task of bathing, limited assistance with personal hygiene, extensive assistance with dressing upper and maximal assistance with dressing lower body, limited assistance with locomotion, extensive assistance with transfer toilet, toilet use, and bed mobility and limited assistance with eating. She was noted with a decline in activities of daily living (ADL) status in the last 90 days, with no deterioration in self-sufficiency. She has frequent bladder incontinence, and she is continent with bowel.

The patient's primary care physician wrote a letter of medical necessity. She stated that the patient has multiple medical problems including congestive heart failure, significant pedal edema, fall risk and increasing weakness and disability. She also suffers from incontinence; her physician indicates that she needs 8 hours of assistance daily to meet her needs.

A letter from the patient advocate was reviewed which contains additional information that the patient lives alone with some informal assistance from family members, however they cannot provide the amount of informal assistance the patient requires to meet her needs.

The subject under review is the medical necessity for PCA services Monday through Sunday for a total of 41 hours per week.

The health plan's determination is overturned.

The requested health service/treatment of PCA services (Monday through Sunday) for a total of 41 hours per week is medically necessary. The patient requires assistance with housework, meal preparation, bathing, dressing upper and lower body, and toileting. She was noted to have had a decline in her ADL status and per documentation by her primary care physician, she has increasing weakness and debility and needs assistance with all activities which includes all days of the week. In addition, she lives alone with no consistent informal caregivers. She is also incontinent and on diuretics, thus needs frequent toileting and requires extensive assistance with this, thus increasing services is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Body Aches. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female. She was hospitalized and discharged the following day. The patient presented with generalized body aches. The patient had pneumonia, possibly community acquired. The patient was treated with Levofloxacin and incentive spirometry. 

No, the Inpatient admission was not medically necessary. 

The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. 

An observational level of stay would have been more appropriate for this patient. An observational level of stay would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Decompensated heart failure (HF)

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient has a history of hypertension (HTN), chronic obstructive pulmonary disease (COPD), deep vein thrombosis (DVT), status post aortic valve replacement (AVR). She presented to the emergency department (ED) with complaints of shortness of breath (SOB) and lower extremity edema (LE) and pain for 3 days. In the ED, her vital signs Temperature 97.8, heart rate 70, blood pressure (BP) 145/78, respiratory rate (RR) 21. She was in some respiratory distress and noted to be hypoxic with desaturation to 85 % (percent) on 6 liters (L) nasal cannula (NC). She was switched to a non-rebreather mask (NRB) Mask and then BIPAP (bilevel positive airway pressure).  The patient was noted to have some wheezing and rales on exam. Also noted bilateral lower extremity pitting edema.  Brain natriuretic peptide (BNP) was elevated at 2840. Chest x-ray (CXR) Pulmonary Vascular congestion. Her sodium (Na+) was 123.  The patient was evaluated in intensive care unit (ICU) for decompensated heart failure (HF) and possible chronic obstructive pulmonary disease (COPD) who recommended admission to Intermediate Care Unit.  The patient was seen by Cardiology. Serial Cardiac enzymes, intravenous (IV) Lasix and fluid restriction recommended. The patient was on NRB and BIPAP. COPD was treated with Steroids and bronchodilators (BD).

The patient started to improve on current treatment. Myocardial infarction (MI) was ruled out.  She started feeling better. Na+ improved to 131. The patient was still continued on IV Lasix for her congestive heart failure (CHF). The patient was still hypoxic and requiring supplemental oxygen (O2).

The patient remained afebrile and was hemodynamically stable. Lungs were noted to be clear. There was no jugular venous distension (JVD). She was saturating well without supplemental O2. Na+ had improved to 137. The patient was switched to oral Lasix. The patient was cleared for discharge with close follow up in the outpatient setting. Admission was appropriate for this patient who presented with decompensated HF and Hypoxic Resp failure.

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 the inpatient admission is overturned.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe Obstructive Sleep Apnea. 
Treatment: Oral Device (E0486) (custom fabricated). 

The insurer denied the Oral Device (E0486) (custom fabricated). 
The denial is overturned. 

The patient is a male with a history of OSA (obstructive sleep apnea). BMI (body mass index) is 36.3, with an AHI (apnea-hypopnea index) on sleep study of 39.8. The provider is requesting an oral appliance, E0486. 

The request was previously denied coverage by the health plan as not medically necessary, and the provider is appealing the denial. 

Yes, the oral device is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient. 

All records were reviewed. The patient has severe OSA (obstructive sleep apnea) documented on sleep study with an AHI (apnea hypopnea index) of 39.8. It is reported that the patient has not tolerated CPAP (continuous positive airway pressure). The use of an oral appliance for the treatment of OSA (obstructive sleep apnea) is supported by scientific literature as a conservative therapy for patients who cannot tolerate CPAP (continuous positive airway pressure) and are attempting to avoid surgery. Therefore, based on the information provided, the medical necessity of the oral appliance E0486 would be confirmed and therefore it cannot be stated that the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ankle Fracture

Treatment: walking boot (L4361RT x 1)

The insurer denied coverage for walking boot (L4361RT x 1)

The denial is overturned.

According to the documentation submitted, this is a male with no significant past medical history. He presented to the Orthopedist's office with complaints of right ankle pain after falling off his skateboard. Pain was rated at a level of 6 out of 10. Imaging revealed a right ankle nondisplaced fracture of the lateral malleolus of the right fibula. The treating practitioner recommended a CAM (controlled ankle movement) walker boot to treat his injury. 

The medical record was significant where a diagnosis of ankle fracture was reported. There was consistency of history, physical examination and imaging for the condition. The management of this type of injury is immobilization. This can be provided by either a cast or cam walker boot. Limited motion and weight bearing are recommended to allow the fracture to heal. Use of cast or Cam walker boot is at the discretion of practitioner. One type of treatment is not favored over another. 

The use of the Cam walker boot is recognized and accepted as standard of practice. 

It should not be denied. 

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

The walking boot (L4361RT x 1) is considered medically necessary for this patient.

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 walking boot (L4361RT x 1) is overturned. Medical Necessity is substantiated.