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

Diagnosis: Diabetes Mellitus. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the inpatient hospital stay. 
The determination is overturned in part. 

The patient was brought to the emergency department (ED) with a week of polyuria and polydipsia, three days of non-bloody vomiting, and worsening fatigue. His mother has type 1 diabetes. His vital signs were normal. His glucose was 458, potential hydrogen (pH) 7.25; urine showed a large amount of sugar and ketones. He received two one-liter normal saline boluses and 10 units of insulin intravenous (IV), and was admitted to the Pediatric Intensive Care Unit (PICU) for management of new onset type 1 diabetes. The next day, he was doing well on insulin, was feeling much better, and was transferred to the floor. A subcutaneous insulin regimen was developed including a sliding scale regimen and diabetes education was underway. He continued to feel well; the nursing staff documented that he was successfully checking his sugar, calculating his sliding scale, and administering his insulin. He was discharged. 

At issue is the medical necessity of an inpatient stay. 

The inpatient stay was medically necessary, in part. 

Management of new onset diabetes is first to stabilize the clinical situation with fluids and insulin to reverse the ketoacidosis and correct any other metabolic abnormalities. Once the patient is stable, management includes continued insulin and the initiation of diabetes education. This education is medically essential, as both diabetic ketoacidosis (DKA) from insufficient insulin and hypoglycemia as a result of overdose of insulin are life threatening. Where this education occurs, however, depends on the resources of the center. Before the development of elaborate and well-resourced outpatient diabetes education programs in some areas, continued hospitalization after stabilization for diabetes teaching was standard of care. In many centers, it remains standard of care. In the center where this patient was admitted, the practice continues to be inpatient diabetes education for new onset diabetics. The length of the hospitalization depends on how long it takes to stabilize and then how long it takes to provide sufficient education that a discharge home is safe. This patient's clinical situation turned around fairly promptly, by the morning after the PICU admission. According to the clinical notes, the education went smoothly as well, and the notes indicate he had learned sufficiently to be discharged. The stay was medically necessary in part as the last day of the stay was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardia/Circulatory Problems/Coronary Artery Disease/CAD. 
Treatment: Home Health Care. 

The health plan denied the requested increase in personal care assistant hours as not medically necessary. 

The health plan's determination is overturned. 

The patient is a female with a past medical history of coronary artery disease, hypertension, peripheral vascular disease, diabetes type 2, constipation, hypothyroidism, atrial fibrillation, vulvar cancer, and depression. This review is for the medical necessity of a request for an increase in Personal Care Assistant (PCA) Services Level 2: 12 hours per day, 7 days a week, for a total of 84 hours per week. Increased hours are requested due to a reported increased fatigue, pain related to cancer and progressive weakness. She had been assigned PCA services based on an assessment tool performed, assessing the patient with minimally impaired cognition and memory problems. She has moderate hearing and vision difficulties. She requires a total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation and shopping. The patient was also assessed at maximal assistance with the task of bathing, personal hygiene, dressing upper and lower body, locomotion, transfer toilet, toilet use, and extensive assistance with bed mobility and eating. She was noted to have a decline in activities of daily living (ADL) status in the last 90 days, with deterioration in self-sufficiency. She has infrequent bladder incontinence and is continent of bowel. There have been no falls in the last 90 days. 
The patient was evaluated by her primary care physician (PCP). The PCP noted that the patient is home bound and requires assistance with activity of daily living (ADLs) and is unable to perform any instrumental activities of daily living (IADLs) independently. 
At issue is the medical necessity of the requested increase in PCA services to 84 hours per week. 

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

Yes, the requested service/treatment of an increase in personal care assistance services Level 2: 12 hours per day, 7 days a week for a total of 84 hours per week is medically necessary for this patient. Based on the assessment, the patient requires assistance with bathing, personal hygiene, dressing upper and lower body, locomotion, transfer toilet, toilet use, bed mobility and eating. She was noted with a decline in ADL status in the last 90 days, with deterioration in self-sufficiency. She is home bound and noted to requires assistance by her primary care physician. She requires care 7 days a week. Given her overall status, including reports of increased fatigue, deconditioning, pain increased debility, and homebound status, the patient needs an increase in hours to 84 hours, as requested.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced dementia, pneumonia and oxygen dependence

Treatment 24 hours per day (split-shift), 7 days per week, total 168 hours per week, Personal Care Services, Level 2

The insurer denied coverage for 24 hours per day (split-shift), 7 days per week, total 168 hours per week, Personal Care Services, Level 2

The denial is overturned

This patient of advanced dementia is oxygen dependent (via nasal cannula) with recent history of pneumonia. She lives alone in a 1-bedroom apartment.  The plan approved 9 hours/day, 2 days/week: 8 hours/day, 3 days/week (total 42 hours per week) for five months. Under review is the medical necessity of requested 24 hours per day (split-shift), 7 days per week, total 168 hours per week, Personal Care Services, Level 2.

According to the Uniform Assessment System (UAS) report, the patient is totally dependent for ordinary housework, meal preparation and shopping.  She requires extensive assistance for bathing, lower body dressing, and toilet use.  She is bladder incontinent.  She requires limited assistance for personal hygiene and upper body dressing.  However, the patient has progressive dementia, gets up multiple times at night and easily agitated/disoriented.  The combination of the patient's limited functional ability and progressive dementia renders her unsafe to live at home alone.  The patient is a woman with dementia, disoriented and often agitated, who requires 24 hours per day (split-shift), 7 days per week, total 168 hours per week, Personal Care Services, Level 2, in order to continue living safely at home.  

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient.  24 hours per day (split-shift), 7 days per week, total 168 hours per week, Personal Care Services is medically necessary. 

The insurer's denial of coverage for 24 hours per day (split-shift), 7 days per week, total 168 hours per week, Personal Care Services, Level 2 is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, hypertension, diabetes, functional urinary incontinence, melanoma of thigh

Treatment: PCW (Personal Care Worker) 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 a patient with chronic medical problems including osteoarthritis, hypertension and diabetes. She recently underwent surgery and subsequent chemotherapy/radiation therapy for malignant spindle cell neoplasm. An increase in personal care worker (PCW) services from 4 hours/day, 7 days/week (total 28 hours per week) to 12 hours/day, 7 days/week (84 hours per week) was requested. The insurer partially denied the request. The patient's hours were increased from 4 hours/day, 7 days/week to 5 hours/day, 7 days/week (from 28 hours per week to 35 hours per week); which is currently under review.

According to the Uniform Assessment System (UAS) report, the patient required maximal assistance for ordinary housework and meal preparation. She required extensive assistance for bathing and lower body dressing. She required limited assistance for personal hygiene, upper body dressing and toilet use. However, the patient's functional ability has likely decreased (within a reasonable degree of medical certainty) as a result of the surgery and subsequent chemotherapy/radiation treatment for malignant spindle cell neoplasm. 

This physician agrees with the requested increase PCW services 7 days per week, 12 hours per day: 84 hours per week. However, this physician also recommends a reassessment over the subsequent 90 days to determine functional ability and necessity for continued increased PCW services.  

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: uterine bleeding
Treatment: Laparoscopic Hysterectomy 
The insurer denied a Laparoscopic Hysterectomy. The health plan's determination is upheld. 

The patient is a female with dysfunctional uterine bleeding and dysmenorrhea. She had a pelvic ultrasound on this date that indicated she had a mildly enlarged uterus 8.2 centimeter (cm) with 2 small fibroids in the posterior myometrium. The pelvic ultrasound was otherwise normal. The patient was evaluated for menorrhagia and pelvic pain. An Endometrial biopsy was negative as was her pap smear. She had a hysteroscopy dilation and curettage with failed ablation secondary to an irregular endometrial cavity. Pathology was negative. She has a history of diabetes, anemia, obesity, allergies, anxiety and depression. Physical exam was normal. Follow up on indicated that the patient had bleeding for several months and this continued despite one month of oral contraceptives. She also now feels fatigue and dehydration. 

The Laparoscopic Hysterectomy is not medically necessary for this patient.
The patient does have negative cytology, and a normal exam including Thyroid and recent imaging. There is also anemia listed in her past medical history; however, no hemoglobin level was provided. The patient has not attempted hormonal therapy or tranexamic acid for three consecutive cycles prior to surgery. The most consistent documentation indicated that she tried oral contraceptives for one cycle without success; however, it is within standard of care to try for at least three cycles prior to surgery. Continued bleeding should then be documented with failure of therapy.
Treatment options also include progestin-only contraception (i.e., levonorgestrel-releasing intrauterine device [IUD; Mirena], medroxyprogesterone acetate [Provera], megestrol [Megace], norethindrone, and depot medroxyprogesterone acetate [Depo-Provera]) and combined hormonal contraception (e.g., transdermal patches, vaginal rings, oral contraceptives). There is no documentation of these therapies as well and therefore the surgery is not medically necessary at this time. The American College of Obstetricians and Gynecologists (ACOG) also indicates that if medical treatment fails, surgery may be an option in the future; however, documentation of this failure has not been provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep apnea/Insomnia.
Treatment: Belsomra.
The insurer denied Belsomra. 
The health plan's determination is upheld. 

The patient is a male who is seeking approval for Belsomra. He was also noted to have untreated sleep apnea and a smoking history. An appeal letter noted that he has failed Doxepin, Ambien, and Lunesta. The denial was due to lack of documentation that the member was trialed on other medications (Ambien, Lunesta, Doxepin, and Elavil).

Belsomra is medically necessary for this patient. The patient has a history of sleep apnea. He has continued problems with sleep; mostly with early morning awakenings. 
According to Kawabe et al, Prieto et al, and Qaseem et al, Belsomra is Food and Drug Administration (FDA) approved for insomnia treatment. This patient has failed multiple other medications such as Ambien, Lunesta, Doxepin, and Elavil. Belsomra is an appropriate treatment at this time.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II Diabetes Mellitus.
Treatment: Januvia.

The insurer denied the Januvia.  The denial is upheld.

This is a female patient with type II diabetes. She has tried and was intolerant to metformin due to diarrhea. She has also tried Janumet and glyburide. She has been stable on Januvia for approximately two years. The request for Januvia is under review.

No, the health plan should not cover the proposed treatment.

This request is for Januvia for the treatment of type II diabetes. The formulary alternative is Tradjenta. The patient has not tried and failed Tradjenta. Tradjenta and Januvia are in the same drug class and are expected to be equally safe and effective in this clinical situation. The American Diabetes Association clinical guidelines do not recommend the use of Januvia over Tradjenta. Therefore, no, the health plan should not cover the proposed treatment.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension
Treatment: Formulary Exception for Edarbi 80mg Tablet, Pre-service
The insurer denied the Formulary Exception for Edarbi 80mg Tablet, Pre-service
The denial is upheld

The patient is a male for which Edarbi is under review. There was history of hypertension. Echocardiography demonstrated normal left ventricular ejection fraction (LVEF) and diastolic dysfunction. Pharmacy records include prior treatment with chlorthalidone.

No, the health plan should not cover the proposed formulary exception for Edarbi as it is not medically necessary.
There are multiple angiotensin receptor blockers (ARB) and ARB combinations for the treatment of hypertension (HTN).  However, no single ARB (angiotensin receptor blockers) or ARB (angiotensin receptor blockers) combination has been definitively proven to be more effective treatment of HTN (hypertension) towards overall improved clinical outcomes. Additionally, there was no contraindication to treatment attempt with the following plan formulary alternatives: candesartan/hydrochlorothiazide (HCTZ), irbesartan/hydrochlorothiazide (HCTZ), losartan/hydrochlorothiazide (HCTZ), telmisartan/hydrochlorothiazide (HCTZ), valsartan/hydrochlorothiazide (HCTZ), and olmesartan/hydrochlorothiazide (HCTZ), or these medications without the hydrochlorothiazide (HCTZ) component.   Therefore, Edarbi is considered not medically necessary in this case.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hight Cholesterol.
Treatment: Formulary exception for Lipitor 40mg TABLET, Pre-service.
The insurer denied the Formulary exception for Lipitor 40mg TABLET, Pre-service.
The denial is upheld.

The patient is a male with history of hypertension and hyperlipidemia. It is noted that he has myalgias to rosuvastatin and atorvastatin, but not to brand name Lipitor. The request is for use of brand name.

No, the health plan should not cover the formulary exception for Lipitor.
Extensive literature review failed to show any case reports stating adverse reaction to generic atorvastatin, but not to Lipitor brand. To the contrary, profile of side effects is stated to be the same regardless of generic or branded drug.  Nor could a pathophysiologic explanation of different adverse side effects be found. Studies have shown significant complaints in generic drugs even if placebo. If he is intolerant of atorvastatin, alternatives for LDL (low-density lipoprotein) treatment exist. The generic drug and branded drug have been shown to be equally efficacious in lowering LDL (low-density lipoprotein).
Appeal type: Medical necessity
Decision: Overturned

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

This case involves a  woman with diarrhea-predominant IBS (irritable bowel syndrome), chronic low back pain, and alcohol abuse who presented to the hospital complaining of abdominal pain, nausea, and diarrhea for one week. The patient has been consuming 2-3 shots of vodka every day. Over the past week, the diarrhea has been more frequent than usual, and her typical lower abdominal pain is not subsiding. She describes it as a 7 out of 10 on the pain scale. The Assessment in the emergency department (ED) was most concerning for alcohol-induced pancreatitis and acute kidney injury. The Principal admitting diagnosis is alcoholic pancreatitis as well as acute kidney injury. The medical team placed the patient on a clear liquid diet, continued with IV fluids, provided morphine every 4 hours, and Zofran as needed

The inpatient hospital admission is medically necessary for this patient.
The patient presents to the hospital with acute abdominal pain concerning for alcohol-induced acute pancreatitis. The lipase level is severely elevated by more than 100 times the normal level. Concurrently, the patient has acute renal failure, with a more than threefold increase in creatinine from baseline. There is also evidence of severe lactic acidosis. These findings are concerning for severe pancreatitis, and therefore, inpatient criteria are satisfied. The documentation states although initially, the patient was placed on a clear liquid diet and had to be downgraded to nothing by mouth (NPO) status due to severe pain and inability to tolerate liquids. The patient was aggressively hydrated with IV fluids and treated with pain medications. Four L (liters) of normal saline boluses are documented before admission from the emergency department. Nationally established medical guidelines for evaluation and treatment of acute pancreatitis call for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque psoriasis
Treatment: Humira
The insurer denied the Humira as not medically necessary.
The determination is upheld.

The patient has a diagnosis of plaque psoriasis. The body surface area affected is 15%. He has failed triamcinolone. He failed methotrexate-he developed a rash after taking it. He has failed narrowband ultraviolet B (UVB) phototherapy treatment. The medication under review is Humira.

The requested health treatment of Humira is not medically necessary for this patient.
The requested service is not considered medically necessary based on the current peer-reviewed literature. Soleymani et al writes "By following guideline recommendations, cyclosporine remains an excellent and indispensable tool for the dermatologist treating moderate-to-severe psoriasis" (1). The American Academy of Dermatology Guidelines for Psoriasis include cyclosporine as a treatment for psoriasis, as do the current dermatology textbooks (2,3). The preferred therapies, such as cyclosporine, should be tried for at least 3 months, and failed, prior to Humira. It is noted that the patient has morbid obesity. However, acitretin and cyclosporine are not contraindicated in this case.  Morbid obesity is not a contraindication.  There is also no documentation or clinical evidence or medical records provided that the patient has fatty liver disease.  Therefore, these medications are not contraindicated and are appropriate for use in this patient. 
The evidence-based literature is consistent. The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to initiating Humira. It is noted that the patient has tried and failed topical therapies. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Humira prior to the formulary alternatives such as cyclosporine. Therefore, Humira is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot Pain
Treatment Custom Shoe Inserts x2
The insurer denied Custom Shoe Inserts x2.
The determination is overturned.

The patient had a right congenital clubfoot, treated with serial casting shortly after birth. It is unclear whether he had an Achilles lengthening as part of his treatment. He received physical therapy for strengthening of the right calf muscles. He was born prematurely, and wore braces on his legs for several years. After that, he wore custom inserts in his shoes to support the longitudinal arch of the foot. He sometimes complains of pain in his feet with activity. At issue is the medical necessity of custom shoe inserts.
The custom shoe inserts are medically necessary.
The patient has pain in his feet with activity, and a history of a right clubfoot, treated with serial casting. The physical exam by his orthopaedic surgeon documents decreased ankle dorsiflexion and subtalar motion of the right foot compared to the left. Some decrease of range of motion is common in treated clubfeet. He also has had a history of calf muscle weakness on the right, treated with physical therapy; this is also a common finding in a treated clubfoot. His history of prematurity and of wearing braces for the first four years of life also suggests some degree of problem with motor development, which may have contributed to his ongoing problem with painful planovalgus feet. The deficits in range of motion and possibly in strength and neuromuscular control can increase stress on the foot, which can be a source of pain. The purpose of the custom insert is to more evenly distribute these stresses, and hopefully to reduce the pain. The custom inserts are medically necessary.