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

Diagnosis: Psoriasis vulgaris
Treatment: Ilumya
The insurer denied coverage for Ilumya.
The denial is upheld.

The patient is an adult who has a diagnosis of psoriasis vulgaris affecting the elbows and knees. The patient has failed therapy with topical tacrolimus. The requested medication is Ilumya.

Based on the provided documentation, Ilumya is not medically necessary. The documentation does not seem to indicate that the patient has tried and failed numerous standard therapies, including topical steroids or any other systemic therapeutic options.  The patient was only recently provided betamethasone topical therapy. The disease involvement appears to be minimal with only elbows and knees affected and no history of psoriatic arthritis.

There are no comparative, controlled head-to-head studies showing that Ilumya has a superior efficacy or safety profile to alternatives such as Humira. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient. (1-4)

Numerous options exist in the treatment of the patient's condition. There are no head-to-head studies which conclusively show that Ilumya would provide a greater safety or efficacy than alternatives. The provided medical notes do not provide any evidence of an absolute contraindication for the use of any alternatives. The denial for Ilumya is upheld in whole based on the submitted documentation.

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 Ilumya is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dementia
Treatment: home care/personal care - level 2 personal care services (PCS), per 15 minutes increase to 24 hours per day (split shift)
The insurer denied coverage for home care/personal care - level 2 personal care services (PCS), per 15 minutes increase to 24 hours per day (split shift)
The denial is modified.

This is an elderly patient who lives alone in a 2-bedroom apartment, 9th floor, the son visits every day and stays until next morning. The son indicates he cannot do so on an ongoing basis.

The Uniform Assessment System (UAS) was reviewed. Cognition is moderately impaired decisions are consistently poor or unsafe, and the patient is oriented to person/place. The patient does not know how to activate Personal Emergency Response Services (PERS) due to cognitive decline. Regarding instrumental activities of daily living (IADL) the patient is totally dependent for meal preparation, housework, managing finances, maximal assistance for medications. 

Regarding Activities of Daily Living (ADLs) the patient is maximal assist for bathing, lower body dressing, locomotion, toilet use and transfer. The patient is extensive assist for personal hygiene and upper body dressing. The patient is independent for bed mobility and eating. The patient is frequently bladder incontinent - daily but some control - and infrequently bowel incontinent. The patient is maximal assist for locomotion and toileting. Wandering is noted as not present. No falls in last 90 days. No Emergency Room visits or inpatient overnight stays.

The patient's cognitive and functional deficits are not at a level or unpredictable as to require the requested level 2 Personal Care Services (PCS) 24 hours per day (split shift). However, the combination of the patient's cognitive deficits and functional decline support the medical necessity of increasing personal care services PCS to a live-in Personal Care Aide (PCA), 24 hours per day, which is more appropriate as they are likely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home by increasing level 2 PCS 24 hours/day, 7 days/week (live-in).

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient given the need for maximal assistance with toileting, transfer, and locomotion.

Home care/personal care - level 2 personal care services (PCS), per 15 minutes increase to 24 hours per day (split shift) is not considered medically necessary, but live-in PCS 24 hours/day for 7 days is medically necessary.

Based on the above, the insurer's denial must be modified to allow live-in PCS 24 hours/day 7 days per week for home care/personal care services (PCS).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a male patient with no past medical history (PMH) who was admitted with complaints of (c/o) a three-day history of chest pain associated with dyspnea on exertion (DOE). The vital signs were unremarkable. The physical exam was notable for 1 plus (+) lower extremity (LE) edema. Lab work was notable for a creatinine of 1.4, a urinalysis (UA) with (w/) proteinuria, decreased albumin, negative troponin, significantly elevated cholesterol. Imaging studies included computed tomography angiography (CTA) of the chest which showed no pulmonary embolism (PE) and no pulmonary edema. An electrocardiogram (EKG) showed normal sinus rhythm (NSR) without ischemic changes. The patient was diagnosed with nephrotic syndrome and treated with a nephrotic syndrome work-up, oral anti-coagulation, diuresis, and expert consultations. The patient was discharged in stable condition for an outpatient renal biopsy. At issue is the medical necessity of an inpatient level of care. 

The admission was not medically necessary at an acute inpatient level of care. 

This patient presented to the emergency department (ED) with chest pain associated with DOE, with some concern for congestive heart failure (CHF). The patient was not in acute distress and was hemodynamically stable. Additionally, the patient was not severely compromised, did not have elevated blood urea nitrogen, low admission systolic blood pressure, significant hyponatremia, cardiac ischemia, airway instability, cardiac arrhythmias requiring continuous intravenous (IV) intervention, or inadequate systemic perfusion, nor did the patient require vasodilator therapy. The patient did have chest pain, but the electrocardiogram (EKG) had no acute ischemic changes while the patient's troponins remained negative. Overall, this patient was clinically monitored and received a work-up for newly diagnosed nephrotic syndrome, and this could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment: Wegovy.
The insurer denied the request for Wegovy.
The health plan's determination is overturned.

The patient is a female with a medical history of obesity. The patient has been on Wegovy for a year with successful weight loss. Her body mass index was 39.62 prior to treatment. The patient's weight has decreased from 213 pounds (lbs) to 187 lbs with a body mass index of 34.76. 

The health plan, in its determination of medical necessity, did not act reasonably with sound medical judgment and in the best interest of the patient as the requested Wegovy that was denied is medically necessary.

The requested Wegovy is medically necessary for the patient. This request is for Wegovy for the treatment of obesity. This patient has successfully lost 12 percent (%) of her body weight on Wegovy. The formulary alternatives are Trulicity, Ozempic, and Victoza. These alternatives are not indicated for the treatment of obesity. These alternatives are indicated for the treatment of type 2 diabetes, which this patient does not have. Ozempic and Wegovy are both forms of Semaglutide, but at different doses. This patient is currently stable on Wegovy 2.4 milligrams (mg) weekly, which is not a dose that is available with Ozempic. The Endocrine Society guidelines on the management of obesity support the continuation of Wegovy in this clinical situation as the patient has lost more than 5% of her body weight. Without Wegovy, the patient will be at increased risk of the complications of untreated obesity, including type 2 diabetes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Issues.
Treatment: Nerve Treatment on Molar Tooth for Tooth 31, D4341 Deep Gum and Root Cleaning for Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant and Upper Right Quadrant.

The insurer denied the Nerve Treatment on Molar Tooth for Tooth 31, D4341 Deep Gum and Root Cleaning for Lower Left Quadrant, Lower Right Quadrant, Upper Left Quadrant and Upper Right Quadrant. The health plan's determination is overturned.

The patient is a female who presented for evaluation and treatment of tooth number 31 as well as full mouth periodontal therapy. Provided for review are previous letters of appeal and denial, full mouth radiographic images, and one page of claim forms. In question is the medical necessity of the planned treatment of (2791) base metal crown, (3330) root canal therapy, (4341) Scaling and root planning (SCRP) for the upper right (UR) quadrant, upper left (UL) quadrant, lower left (LL) quadrant and the lower right (LR) quadrant.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment nor in the best interest of the patient.

The requested health service/treatment of nerve treatment on molar tooth for tooth number 31, D4341 deep gum and root cleaning for the lower left quadrant, lower right quadrant, upper left quadrant and upper right quadrant is medically necessary for this patient. Previous denials for root canal therapy have been on the basis that only teeth that serve as critical abutments for an existing partial denture or bridge are eligible. This is not based on any medical science nor any scientific basis for lack of necessity.

There is radiographic evidence of decay resulting in exposure of the pulp on the mesial in the same location where the patient has lost a cusp, resulting in the need to remove the infection from the pulp with a root canal and restore the tooth with an indirect restoration, such as a crown, as direct restorations are contraindicated in cuspal loss. Denials of the SCRP have been on the basis that there is not significant bone loss; however, there is evidence of loss of lamina dura along the bone peeks between the majority of the teeth, as well as angular bone defects consistent with the presence of active periodontal disease, serving as proof of the medical necessity of the treatment of scaling and root planing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left foot cellulitis/abscess
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This is a male patient who presented to the emergency department with increasing left foot swelling, severe pain and difficulty walking. He had redness and swelling for 6 days which was getting worse despite taking antibiotics (clindamycin 300 milligrams (mg)) for 3 days. The previous day he received "intravenous (IV) Amoxicillin" with no improvement of symptoms. He reported difficulty ambulating secondary to pain. He developed a large blister and was concerned. His exam was remarkable for a large fluid filled blister/bullae to the lateral dorsal aspect from the lateral 5th digit extending to the base of the left 5th digit with surrounding erythema, warmth, swelling, and tenderness to dorsal aspect of the left foot. An x-ray of the left foot noted a dorsal opacity. He was diagnosed with a left foot cellulitis/abscess. He was started on intravenous (IV) antibiotics (Vancomycin and Zosyn). Wound cultures and blood cultures were taken. Podiatry and infectious disease were consulted. A small bedside incision and drainage was performed. The patient was afebrile but the erythrocyte sedimentation rate (ESR) was 20 and C-reactive protein (CRP) was 5.9. A wound cultures showed rare gram positive (+) cocci in pairs and was staphylococcus aureus-oxacillin resistant. The podiatry evaluation noted left foot dorsal lateral forefoot lyse bullae with residual seropurulence within the bullae. They expressed approximately 1 cubic centimeter (cc). Upon deroofing the bullae, denuded granular wound down to the subcutaneous, it measured 5.0 centimeter (cm) x 6.0 centimeter (cm) x 0.1 centimeter (cm). There were concerns for a clinically infected open bullae with associated cellulitis secondary to friction. An infectious disease evaluation noted the patient failed outpatient treatment and advised continue Vancomycin IV and Zosyn IV. Local wound care was ordered and the patient was advised to offload the left lower extremity. The patient was discharged with a 7-day course of antibiotics. At issue is the medical necessity of the inpatient stay.

After review of the submitted documents and current medical literature and standard of care, inpatient stay was medically necessary for this patient. The patient developed an infection of his left foot and was placed on oral antibiotics for 3 days. After 3 days the infection became worse and proved to fail oral therapy. The patient developed worsening symptoms and severe pain, 10 out of 10. Inpatient care was medically necessary to receive IV antibiotics and when the wound improved and cultures returned, the patient was sent home with proper oral antibiotic coverage. Thus, the health service/treatment of inpatient stay was medically necessary in this care and is the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient was brought to the emergency department with about 24 hours of a fever, chills, abdominal pain, and vomiting. Her father had coronavirus disease (COVID). On arrival, her vital signs were normal. She appeared well, in no acute distress. The exam was normal except for right lower quadrant tenderness. There was no indication that she had physical signs of dehydration. The plan was a "GI [gastrointestinal] cocktail' and computed tomography (CT) scan and ultrasound of the abdomen and pelvis. The emergency department (ED) notes that the radiologist said the CT scan was suggestive of appendicitis, but wished the study repeated with oral contrast. The ED contacted the pediatric service to admit for observation. Overnight, she improved and appendicitis was ruled out. She was discharged home. At issue is the medical necessity of an inpatient stay.

An inpatient stay was not medically necessary for this patient. Some of the findings were suggestive of appendicitis: right lower quadrant pain, fever, elevated white blood cell count (WBC), and fluid in the cul de sac. Overnight, the patient improved and appendicitis was ruled out. The patient did not require acute inpatient hospitalization. Care could have been provided at a lower level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The health plan denied: Inpatient Hospital Admission
The determination is: Upheld

This female patient with end-stage renal disease (ESRD) was transported from her dialysis center to the emergency department (ED) via Emergency Medical Services (EMS). She had just started her hemodialysis session when she developed weakness, lightheadedness, abdominal pain, chest pain, and nausea, and she vomited once. Her medical history was remarkable for diabetes, hypertension, fibromyalgia, and ovarian cancer. Notably, she had undergone cardiac catheterization earlier in the week that revealed normal coronary arteries. In the ED, her blood pressure was 125/76 millimeters of mercury (mmHg) with a heart rate of 73 beats per minute (bpm). Her room air oxygen saturation was 97%. She was afebrile. Her physical exam was remarkable for epigastric tenderness. An electrocardiogram (EKG) showed sinus rhythm without acute changes. Her serum troponin level was in the indeterminate range; there was no significant delta troponin. Her serum creatinine level was 6.2. A urinalysis suggested a urinary tract infection (UTI). Her white blood cell count was 14,830. Her lactate level was 3.1. The patient was treated with antibiotics and admitted to the hospital with a diagnosis of urinary tract infection. She continued to have intermittent chest wall pain and tenderness that was attributed to her fibromyalgia. She underwent hemodialysis since her session the prior day was not completed. The next day, she was discharged.

At issue is the medical necessity of the inpatient level of care. The health plan's determination of medical necessity is upheld in whole. Based on the documentation provided an inpatient level of care was not medically necessary.

This patient presented with multiple symptoms, including chest pain. She was hemodynamically stable, without acute electrocardiographic changes. Her cardiac biomarkers were not consistent with acute coronary syndrome. She did not require intensive monitoring or infusion of intravenous cardioactive medications. Recent coronary angiography had shown normal coronary arteries. The care this patient received for her chest pain did not require an inpatient admission and could have been provided under an alternate status. This approach has been shown to be both safe and cost-effective and is in accordance with current guidelines including the 2021 Guideline for the Evaluation and Diagnosis of Chest Pain and the 2014 American Heart Association (AHA)/American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes.

The patient's urinalysis suggested possible UTI. She had no high-risk features, such as urinary tract obstruction, renal stones, or an indwelling urinary catheter, and she did not meet diagnostic criteria for systemic inflammatory response syndrome (SIRS) or sepsis. While treatment with antibiotics was reasonable, it did not require an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

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

This patient is seen with Systemic Lupus Erythematosus (SLE) and Venous Thromboembolism (VTE) on warfarin who presented with skin ulcers and mouth ulcers with severe pain. The patient had an elevated international normalized ratio (INR). The patient was admitted to the hospital. She left against medical advice (AMA) the following day.

Based on the records reviewed, this patient had a condition that could reasonably be expected to be stabilized within 24 hours and observational status would be appropriate. The patient presented with skin ulcers and mouth ulcers with severe pain. The patient had an elevated INR. The patient left AMA the following day. 

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

The medical necessity for an inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Guillain-Barre syndrome, dementia, diabetes mellitus, gastrostomy tube, hypertension and depression. 
Treatment: Skilled Nursing Facility Long Term Custodial Care. 

The insurer denied coverage for Skilled Nursing Facility Long Term Custodial Care. 

The denial is overturned. 

This is an adult with multiple medical problems including Guillain-Barre syndrome, dementia, diabetes mellitus, gastrostomy tube, hypertension and depression. He was admitted to a skilled nursing facility for custodial care. Under review is the medical necessity for Long Term Custodial Care. 

This physician agrees with the treating providers. The patient has multiple medical problems including Guillain-Barre Syndrome, Dementia, Schizophrenia and depression. He requires gastrostomy feeding due to malnutrition. He is totally dependent for activities of daily living and fully dependent for custodial care. He is clinically inappropriate and unsafe for discharge.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained via Skilled Nursing Facility Long Term Custodial Care. 

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 Skilled Nursing Facility Long Term Custodial Care is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male with medical history of perforated appendicitis status post laparoscopic appendectomy, and tobacco use. He presented to the emergency department as a transfer from the referring hospital with 5 days of left lower quadrant abdominal pain, nausea, constipation for 5 days, and elevated temperature reaching 99 Fahrenheit. Vital signs were unremarkable. Physical examination was notable for soft, nontender, non-distended abdomen with normal bowel sounds. Labs showed elevated white blood cell count of 11.0, low hemoglobin of 13.2, hematocrit of 41.4%, and an unremarkable comprehensive metabolic panel. Computed tomography scan of the abdomen and pelvis showed sigmoid diverticulitis with small intramural [1.2 centimeter (cm)] and exophytic/mesenteric (2.7 cm) abscess, and lateral sigmoid colon diverticulum that appeared mildly inflamed; there were postsurgical changes consistent with appendectomy, and lack of bowel obstruction. 

The inpatient hospital admission is not medically necessary based on the submitted information, and the care provided could have been provided at a lower level of care for the duration of the stay. In patients with uncomplicated diverticulitis, outpatient management or observation is the standard of care. The safety and efficacy of outpatient management of acute uncomplicated diverticulitis has been demonstrated. A prospective randomized trial demonstrated that patients can be given intravenous antibiotics in the emergency department and then discharged with oral antibiotics. A systematic review of the literature underscored this. A lower level of care can be appropriate when there are significant symptoms and leukocytosis, as in this case. However, there was no documented protracted fever or hypotension to suggest that antibiotics in the hospital were ineffective; imaging did not ultimately confirm diverticulitis. No other cause for the inpatient level of care, such as peritonitis, toxic megacolon, bowel obstruction, sepsis, fistula, or other complication was documented. For these reasons, the inpatient level of care is not supported in this case.