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

Diagnosis: Chest pain.
Treatment: Inpatient hospital admission.
The insurer denied coverage for an inpatient hospital admission. 
The denial is overturned.

This patient was sent to the hospital by his cardiologist after complaining of episodic chest pain for a period of months and rapid ventricular tachycardia (VT) that was noted on interrogation of his CRT (Cardiac Resynchronization Therapy) implantable cardiac defibrillator (ICD). Plans were for telemetry monitoring while being loaded on mexiletine therapy. Past medical history was significant for Chagas disease, Heart failure with reduced ejection fraction, atrial fibrillation (AF) and VT treated with sotalol antiarrhythmic therapy, ICD status post extraction and reimplantation. Upon arrival to the hospital, vital signs were stable and physical exam was unremarkable. A 12-lead electrocardiogram revealed ventricular pacing. Serum troponin levels were not elevated [high sensitivity 12ng (nanograms)/L (liter)]. The patient was admitted while being treated with mexiletine and sotalol therapy. He was discharged after 48 hours.

This patient presented with chest pain and had a past medical history of heart failure and reduced ejection fraction and VT. Interrogation of his ICD system demonstrated rapid VT terminated by his device. In addition to VT, this patient suffered from AF. An analysis of 68 million Medicare patients admitted to the hospital for AF over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. In addition to AF, this patient had chest pain and ventricular tachycardia making his pretest probability of coronary artery disease elevated. (Reference 3). The standard of care for patients presenting with VT is inpatient hospital admission for antiarrhythmic drug loading and or catheter ablation. In conclusion, inpatient hospital admission in this case was medically necessary. 

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right Facial Numbness and Shoulder Numbness. 
Treatment: Inpatient admission. 

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

The patient is a male with past medical history of intracerebral hemorrhage, with residual right sided weakness as well as bacterial endocarditis with mitral valve replacement, and heart block requiring use of a pacemaker. 

The patient was admitted due to intermittent right facial and shoulder numbness/tingling for one week. Neurological consult was done and impression was that of cervical plexus and less likely stroke. The patient was admitted for stroke workup including magnetic resonance image (MRI) of the brain and magnetic resonance angiogram (MRA) of the head and neck which did not show any signs of stroke. 

Yes, the proposed inpatient emergency admission was medically necessary. 
Inpatient hospitalization was medically necessary as the patient already had high risk factors for recurrent stroke such as endocarditis and prior intracerebral hemorrhage. Until the workup was complete, the patient needed close neurological monitoring as well as telemetry monitoring. which could not have been done in the outpatient setting. Those with history of endocarditis are at high risk for strokes- both ischemic and  hemorrhage. Although the neurological examination was normal, given patient complaints, a stroke could not be ruled out and therefore admission for workup was necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 
The healthcare plan, in deciding to deny admission especially to someone with high risk of strokes, did not act in the patient's best interest.  Potentially sending the patient home without proper workup could have lead to further complication if he did in fact have a stroke.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache. 
Treatment: Inpatient Admission. 

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

This female was admitted with headache associated with photophobia, nausea and vomiting.  On day two, vital signs were as follows: temperature 97.8, pulse 90, respiratory rate 20, blood pressure 105/72 and pulse oxygenation 98%. Headaches had resolved with Toradol and anti-nausea medication. Assessment was likely migraine.  The patient was given liquids and advanced on a diet. She was discharged on day three. 

No, the inpatient hospital admission was not medically necessary.  

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

This patient was admitted to inpatient care after presenting with a headache. The headache had resolved after being managed with Toradol and antiemetics. The patient was hemodynamically stable.  She was tolerating oral intake.  Inpatient hospital admission for dates of service was not medically necessary. The patient's symptoms had resolved and she was clinically stable.  She was not receiving intervention that required an inpatient level of care. Treatment could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity. 
Treatment: Saxenda 3mg/0.5 ML Pen Injector. 

The insurer denied the Saxenda 3mg/0.5 ML Pen Injector. 
The denial is upheld. 

The patient is a woman whose provider has requested Saxenda for weight loss. 

The health plan issued an initial adverse determination indicating that the medication was not medically necessary. The plan issued a final determination letter indicating that the denial had been upheld, due to no documentation of a complete weight management program and also noting that the documented Body Mass Index (BMI) of 25.8 did not meet criteria for approval which requires a BMI (body mass index) of at least 27 with 2 risk factors or 1 serious disease. 

A patient written appeal letter indicates that the patient has had long-standing issues with being overweight due to hypothyroidism. She notes that she has arthritis of both knees. The patient reports she lost approximately 50 pounds after using Wegovy. She notes gaining back 20 pounds after being off Wegovy. 

Clinical documents submitted include an office visit note indicating BMI (body mass index) of 25.8 and other medical issues of knee arthralgia, depression, Hashimoto's Thyroiditis. Plan is to continue Wegovy with diet and exercise. 

No, the requested Saxenda is not medically necessary. 

The literature supports the use of anti-obesity medications, like semaglutide, as adjuncts to diet and physical activity in patients with BMI (body mass index) greater than 30 or BMI (body mass index) of 27 and above with comorbidities (such as type 2 diabetes, hypertension) who are unable to achieve weight loss goals with a comprehensive weight loss program (e.g., 5% of initial weight loss in three to six months) (Chao et al).  Based on the most recent medical documentation from the provider, the patient's BMI (body mass index) is 25.8, and though there is mention of "arthralgia" of the knee, there is no documented diagnosis or imaging showing osteoarthritis, nor is there documentation of other comorbidities such as hypertension, diabetes, dyslipidemia, or sleep apnea. Additionally, there is no provider notation that the patient is engaged in a comprehensive weight loss program.  Thus, based on the clinical information provided and the medical literature, the requested medication is not medically necessary in this case. 

Yes, the plan acted reasonably, with sound medical judgement and in the best interest of the patient. 

The plan based their medical necessity decision on criteria in the coverage policy entitled "Pharmacy Management Drug Policy for Anorexiants."  These criteria mirror evidence-based guidelines on the prescription of semaglutide (Wegovy, Saxenda), which note the need for a comprehensive weight management program and BMI (body mass index) of either greater than 30 or BMI (body mass index) 27 or greater with medical comorbidities (Chao et al).  Thus in applying guidelines supported by the medical literature, the plan acted reasonably and with sound medical judgement.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Inpatient hospital admission
The insurer denied coverage for an inpatient hospital admission.
The denial is overturned.

This is the case of a gentleman that presented to the hospital for elective cardiac catheterization after presenting with chest pain on exertion that was relieved by nitroglycerin. He also noted a recent fall with rib fractures. Cardiac catheterization revealed in-stent restenosis of the left circumflex artery and PCI (percutaneous coronary intervention) to the left circumflex and first obtuse marginal arteries was successfully performed. The patient was monitored on telemetry overnight following an uncomplicated procedure. Past medical history was significant for coronary artery disease, hypertension, diabetes, morbid obesity, obstructive sleep apnea, and peripheral vascular disease. A 12 lead ECG (electrocardiogram) demonstrated normal sinus rhythm with right bundle branch block and left axis deviation. An echocardiogram revealed severe concentric left ventricular hypertrophy and an LVEF (left ventricular ejection fraction) of 55% (percent). A CT (computed tomography) scan of the chest revealed rib fractures likely secondary to trauma from this recent fall. Prior to the planned discharge a cardiac electrophysiology consultation was sought due to bradycardia noted on the telemetry monitor. Recommendations were for continued monitoring and daily ECG in order to assess the safety of beta blocker administration. The patient was monitored for an additional day and ultimately discharged.

This patient presented with unstable angina and was found to have in-stent restenosis of the proximal left circumflex artery. Following PCI to the left circumflex and obtuse marginal arteries, the patient was observed on telemetry where sinus bradycardia was documented. Recommendations from the electrophysiology consultant were for continued monitoring in order to determine whether beta blocker therapy was safe to resume. It was reported that sinus bradycardia was noted during intervention to the proximal left circumflex artery and that in certain cases, temporary pacemaker placement was required. (Reference 1) In an expert consensus document focused on length of stay following coronary intervention, Seto and colleagues recommend hospital admission and a two-night hospital stay in cases where patient symptoms persist following intervention. In their report, hospital admission was more likely in patients with a history of previous coronary intervention and morbid obesity (both noted with this patient). (Reference 2) In conclusion, an inpatient hospital admission was medically necessary.

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

The insurer's denial of coverage for the inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Plexiform Neurofibroma
Treatment: Koselugo 25MG (milligrams) OR (oral) CAPS (capsules), pre-service
The insurer denied the Koselugo 25MG OR CAPS, pre-service.
The denial is overturned.

The patient is a male with a history of a left orbit plexiform neuroma. The provider is recommending treatment with Koselugo 25 milligram (MG) OR (oral) CAPS (capsules).

Yes, the proposed treatment with Koselugo is medically necessary.

Plexiform neurofibromas occur in up to 30% (percent) of cases of neurofibromatosis type one (NF-1), most frequently in the craniomaxillofacial region. These lesions manifest early in life and tend to transform to malignant peripheral nerve sheath tumors (MPNST). Malignant progression is generally considered the main cause of mortality, occurring in two percent to 16% of cases.   

Koselugo (selumetinib) is a selective and potent orally available non-ATP (adenosine triphosphate) competitive small molecule inhibitor of mitogen-activated protein kinase 1 and 2 (MEK1/MEK2). In a recent phase II study, 34 of 50 patients (68%) had a confirmed partial response, and 28 of these patients had a durable response (lasting one year).

Based on this data, Koselugo would be considered medically necessary for this patient.

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

The use of Koselugo for this indication is considered to be medically necessary and the standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma, arthritis, chronic back pain.
Treatment: Increase Consumer Directed Personal Care (CDPAP) Services to 70 Hours.
The insurer denied the Increase Consumer Directed Personal Care (CDPAP) Services to 70 Hours.
The denial is upheld.

This female patient has conditions including asthma, arthritis, chronic back pain and obesity.  She has a torn rotator cuff and is awaiting surgery.  She lives alone.  She is appealing denial of increase consumer directed personal care (CDPAP) services to 70 hours. The health plan approved 42 hours per week.  

The patient's Uniform Assessment System (UAS) evaluation completed shows independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation and shopping; extensive assistance with bathing and lower body dressing; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; supervision with managing medications; and independent with phone use, bed mobility, and eating.  She has occasional bladder incontinence.  She has refused a bedside commode.  Compared to Uniform Assessment Systems (UAS) evaluation completed previously, there has been a decline with managing medications.

The appeal letters recommend increased personal care services due chronic medical conditions and need for assistance with activities of daily living (ADLs).  Chronic pain has resulted in physical limitations.

No, the proposed increase in consumer directed personal care (CDPAP) services to 70 hours is not medically necessary.
Personal assistance services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  The patient is appealing denial of increase consumer directed personal care (CDPAP) services to 70 hours. The health plan approved 42 hours per week.  

The patient's Uniform Assessment System (UAS) evaluation completed shows she is independent with phone use, bed mobility, and eating; she requires limited assistance with personal hygiene, upper body dressing, walking, locomotion, and toileting; and extensive to maximal assistance with meal preparation, shopping, bathing, and lower body dressing.  There has been no significant change in functioning compared to Uniform Assessment System (UAS) evaluation completed previously.  The appeal letters note the patient requires assistance with activities of daily living (ADLs) as already accounted for in the Uniform Assessment System (UAS) evaluation.  The information provided does not support that the patient has functional needs requiring consumer directed personal care (CDPAP) ten hours per day.  The approved consumer directed personal care (CDPAP) 42 hours per week is appropriate to meet this patient's needs for assistance with activities of daily living (ADLs).  The proposed consumer direct personal care (CDPAP) 70 hours per week is not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
The proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Duchenne Muscular Dystrophy. 
Treatment: Home Health Care. 
The insurer denied of Private Duty Nursing Services by LPN, 24 hours per day, 7 days per week. 
The denial is upheld.

This is the case of a male with advanced Duchenne Muscular Dystrophy.
The patient has a tracheostomy and is ventilator dependent with supplemental oxygen overnight. He additionally has heart failure with current ejection fraction (EF)=30%. He is fed orally and via gastrostomy (G)-tube. He is unable to move on his own, but is verbal and able to clearly communicate needs.
Nursing notes indicate administering midodrine medication for low blood pressures (BPs). The patient uses a urinal in bed, at other times uses a diaper. Patient uses electronic wheelchair and able to scroll on cell phone. Occasional suctioning for cough/secretions. Requires full assist with ADLs, uses lift for transfers.
At issue is whether Private Duty Nursing (PDN) Services by Licensed Practical Nurse (LPN), 24 hours per day, 7 days per week is considered medically necessary for this patient. The patient has been approved for 16 hours per day of private duty nursing (PDN) services.

The health plan's determination is upheld.

This patient with Duchenne Muscular Dystrophy is completely dependent for all activities of daily living, is trach and vent dependent, uses a G-tube, and requires complete assistance for movement-related tasks. He has blood pressure monitoring and is given medication in response to low blood pressures. He uses oxygen overnight and requires intermittent suctioning during the day. There is no indication of recent hospitalization, change in health status, or medical instability.
Based on the medical records provided, the requested health service (Private Duty Nursing Services by LPN, 24 hours per day, 7 days per week) is not medically necessary for this patient. This patient requires 24 hour/day custodial care, but the additional hours could be provided by a trained caregiver. Based on PDN Acuity rating scales, the patient's condition and associated medical needs could be managed by the currently approved hours (16 hours/day) of PDN care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment: Stelara SQ (subcutaneous) 90mg (milligrams)
The insurer denied the Stelara SQ 90mg (milligrams)
The denial is overturned

The patient is a female. She has been diagnosed with severe ulcerative colitis. She failed high dose of Remicade. She was on Stelara 90 mg (milligrams) every 8 weeks, and then on both Stelara and Entyvio. Her disease is stable. Her doctor requested to continue Stelara 90 mg (milligrams) every 8 weeks and Entyvio.

The health plan's reason for prior denial was that the requested Stelara is not medically necessary because it is used with another biologic. The denial is being appealed.

Yes, the requested Stelara is medically necessary.
Dual therapy with Stelara and Entyvio were reported in children with refractory inflammatory bowel disease including ulcerative colitis (1-4). The most recent meta-analysis concluded that "Dual biologic or small molecule therapy may be a possible option in highly selected, refractory IBD [inflammatory bowel disease] patients at specialized centers" (4). Another systemic review concluded that "In pediatric IBD [inflammatory bowel disease], combining the different mechanisms of action of the two biological drugs seems to be safe and effective" (3).

This patient has been diagnosed with severe refractory ulcerative colitis and failed high dose of infliximab (Remicade). The patient was on Stelara and still had symptoms. She has been on Stelara 90 mg [milligrams] every 8 weeks and Entyvio since. Her disease is stable. The treatment option would be to continue the dual therapy with Stelara and Entyvio. Thus, the proposed treatment is medically necessary, as supported by current literature.

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

Diagnosis: HTN (hypertension), CHF (congestive heart failure), and spinal stenosis. 
Treatment: Increase Home Care/Personal Care Level 2 Per 15 minutes Increase From 49 Hours Weekly To 70 Hours Per Week. 

The insurer denied the Increase Home Care/Personal Care Level 2 Per 15 minutes Increase From 49 Hours Weekly To 70 Hours Per Week. 
The denial is overturned. 

The patient is a female. She has PMH (past medical history) of HTN (hypertension), CHF (congestive heart failure), and spinal stenosis. She reportedly has memory loss and gait disorder. The patient has been having progressive functional and cognitive decline. She has been relocated to assisted living-facility due to multiple co-morbidities. 

Increase in Home Care/Personal Care Level 2 Per 15 minutes Increase From 49 Hours Weekly To 70 Hours Per Week has been requested and is the subject of this review. 

Yes, the requested increase in personal care/home health care service hours to 70 hours/week is medically necessary. 

The patient has history of congestive heart failure, impaired gait and memory loss. She has had multiple falls, with one fall resulting in her left arm fracture. She is requiring assistance with all her ADLs (activities of daily living), including ambulation, transfers, toileting, bathing and dressing. She cannot prepare her meals. She needs reminders to take her regular medications. Patient has been having cognitive and functional decline. The requested Increase Home Care/Personal Care Level 2 Per 15 minutes Increase From 49 Hours Weekly To 70 Hours Per Week is medically necessary and appropriate. The plan-approved 49 hours will not be enough, as patient needs help with all her ADLs (activities of daily living) and is a fall risk. 

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

The patient has multiple co-morbidities and has progressive functional decline. She needs increased home care services.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vocal cord nodules
Treatment: Speech therapy services
The insurer denied the Speech therapy services
The denial is upheld

The patient is a female reported by speech to have had vocal cord nodules.  She has had voice therapy in the past.  In the appeal template, it is reported that the patient had a hemorrhagic polyp which resolved with conservative care and then was diagnosed with vocal cord nodules.

No, the proposed speech therapy is not medically necessary.
Inadequate medical records were provided to establish medical necessity.

Yes, the health plan act reasonably, with sound medical judgment and in the best interest of the patient.
Inadequate medical records were provided to establish medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infertility. 
Treatment: Hysterosalpingography (procedure code 74740 x 1 unit). 

The insurer denied the Hysterosalpingography (procedure code 74740 x 1 unit). 
The denial is upheld. 

The patient is a woman with a history of infertility. She consulted a reproductive endocrinologist. A semen analysis was performed. An HSG (hysterosalpingogram) is planned. 

No, the requested Hysterosalpingography is not medically necessary. 

The medical records and medical literature were thoroughly reviewed. The standard of care requires a normal semen analysis to support indication for an HSG (hysterosalpingogram) procedure. A semen analysis was undertaken. The medical records indicated that the semen analysis included the sperm density and sperm motility. There is no evidence that the sperm morphology was assessed. According to the WHO (World Health Organization) laboratory manual for the examination and processing of human semen, sperm morphology is an essential part of the semen analysis. Therefore, the semen analysis does not meet the standard of care and is incomplete. Therefore, the requested hysterosalpingogram is not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.