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

Diagnosis: hyperlipidemia
Treatment: Nexletol
The insurer denied Nexletol. The health plan's determination is overturned.

The patient is a woman with a history of hypertension, hyperlipidemia and stroke. She experienced ankle pain while on pravastatin, arm and neck pain on rosuvastatin, myalgias with atorvastatin and simvastatin and finger numbness with ezetimibe. The dosages of these medications tried was not provided. 

Nexletol is medically necessary for this patient.
Bempedoic acid (nexletol) is non-statin lipid lowering agent. It is an oral pro-drug that is activated in the liver to inhibit ATP (Adenosine triphosphate)-citrate lyase, which acts upstream of HMG-CoA (3-hydroxy-3-methylglutaryl coenzyme A) reductase and increases clearance of LDL (low density lipoprotein) cholesterol. In clinical studies involving patients with established atherosclerotic cardiovascular disease and/or familial hypercholesterolemia, bempedoic acid decreased LDL cholesterol levels by an average of 17%. It is Food and Drug Administration (FDA) approved as an adjunct to diet and maximally tolerated statin therapy for adults with heterozygous familial hypercholesterolemia or established atherosclerotic cardiovascular disease who require additional lowering of low-density lipoprotein cholesterol.
This woman has been intolerant to four statins and to ezetimibe. Since the doses of statins she has tried were not provided, it is not clear that she has complete statin intolerance, which is defined as a complete inability to tolerate any dose of a statin, including a minimum of two statins, at least one of which was tried at the lowest approved daily dosage. At a minimum, she has partial statin intolerance. Given her history of stroke, her pre-treatment LDL cholesterol level of 132 which is nearly twice her recommended goal level of less than 70, and her elevated serum triglyceride level, this woman would be classified as being at high risk for recurrent cardiovascular events.
Per the 2022 National Lipid Association scientific statement on statin intolerance, "In high and very high risk patients who are statin intolerant, clinicians should consider initiating non-statin therapy while additional attempts are made to identify a tolerable statin in order to limit the time of exposure to elevated levels of atherogenic lipoproteins."
Thus, initiation of a non-statin therapy, such as bempedoic acid, in this instance is supported by current guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological: Pelvic Inflammatory Disease
Treatment: Inpatient Admission
The health plan denied the Inpatient Admission as not medically necessary. 
The health plan's determination is upheld.

This is a case of a female admitted for a diagnosis of pelvic inflammatory disease (PID). The patient presented with symptoms of nausea/vomiting and the inability to tolerate any liquids or solids. There was right lower quadrant and epigastric pain which had worsened throughout the day. The patient had chills at home but no fever at home or in the emergency department. She had history of pelvic inflammatory disease with right pyosalpinx and bilateral pyosalpinx. The patient's vital signs demonstrated a temperature of 98.7 Fahrenheit (F), a blood pressure of 128/102 millimeters of mercury (mmHg), a pulse of 56 beats per minute (bpm), a respiratory rate of 18 per minute, and an oxygen (O2) saturation level of 99%. The patient's physical examination showed mild distress from pain. 

The medical necessity of the inpatient hospital admission has not been established. 

The patient in this case required treatment for pelvic inflammatory disease and did not have a surgical emergency, actual or suspected. The beta hCG (human chorionic gonadotropin) was negative and there was no pregnancy. The patient was given 24 hours of antibiotic therapy and had good response to treatment. There was no persistent inability to tolerate or comply with outpatient and oral treatments. There was no severe illness, fever, or persistent nausea and vomiting. After further review of the imaging, there was not thought to be any abscess requiring drainage. There was no hemodynamic instability, leukocytosis, or hypoxia.

Although the patient required services in the hospital setting, the monitoring, diagnostic testing, and therapeutic interventions prescribed could have been rendered at a lower level of care. Therefore, the medical necessity of the inpatient admission has not been established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Hours per Week - Total of 63 Hours per Week.
The insurer denied Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Hours per Week - Total of 63 Hours per Week.
The health plan's determination is overturned. 

The patient is a female with past medical history of multiple sclerosis and urinary incontinence who had been assigned PCA (personal care aide) services based on an assessment performed via telephone assessing the patient at maximum assistance with tasks of preparation, ordinary housework, managing medication, managing finances, and shopping while extensive assistance with tasks of transportation, bathing, and dressing lower body. With tasks of stairs, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, and toilet use the patient was assessed at limited assistance while set up only with task of phone use. The patient was assessed at independent with tasks of bed mobility eating. There was a request to increase PCA services.  

Personal Care Aide (PCA) Level 2 Services: 9 Hours per Day, 7 Hours per Week - Total of 63 Hours per Week are medically necessary for this patient.
There is documentation from the patient's medical provider of medical necessity of increased PCA services. The patient requires assistance with all activities of daily living (ADL) except for toilet use, bed mobility, and eating. The patient therefore has unpredictable and unscheduled care needs that span a continual time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The plan suggested splitting hours to better meet morning and evening needs but they have been unable to find an aide to work the short shifts. The patient requires prompting to complete some Instrumental activities of daily living (IADL) and ADLs due to worsening cognitive function. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA level 2 services 9 hours/day, 7 days/week, to total 63 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned

Dental/orthodontic

Diagnosis: Class II malocclusion
Treatment: Braces
The insurer denied braces. The health plan's determination is overturned.

The patient in question is a male. He has a Class II malocclusion with protrusive maxillary incisors. He has 7 millimeter (mm) overjet and a 5mm deep bite. Tooth 19 is in crossbite. He has severe maxillary and mandibular crowding. He is treatment planned for 24-30 months of orthodontics (braces) to correct this malocclusion. 

Braces are medically necessary for this patient. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, this patient's overjet is greater than 6mm. Overjets of this magnitude are shown to negatively affect the oral health quality of life. For these reasons, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Ozempic
The insurer denied the Ozempic.
The determination is overturned.

The patient is diagnosed with type 2 diabetes mellitus (T2DM). As reported; he has been taking Ozempic and it has controlled his blood glucose (BG). Due to a formulary change he was switched to Trulicity which caused pain at the injection site and severe nausea. Formulary medications are Trulicity, Victoza. The patient is nonverbal and has autism. The change to Trulicity a has been extremely stressful for him and his caregivers. He is also on Tresiba. He uses a Dexcom. The Dexcom data reveals an average A1c equivalent of 6.5% (per His maximum A1c was 10.2% and the most recent A1c was 6.3%. This request is for Ozempic. 

Yes. The Ozempic is medically necessary. Ozempic is a glucagon-like peptide-1 receptor (GLP1R) agonist[1] that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes [2-4]. The patient has type II diabetes. The patient has tried and failed the formulary of Trulicity. The failure is related to the patient and pain at the injection site. The patient has autism and is nonverbal. The patient had gastrointestinal (GI) side effects to Trulicity and has not had side effects with Ozempic. Given the patient's past history with GI side effects with a glucagon-like peptide-1 (GLP-1) receptor agonist, having to try another is not in the best interest of the patient. Given the failure of Trulicity, and the fact that Ozempic previously worked for the patient, makes the requested medication medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral artery disease 
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay. 
The determination is overturned.

The patient is a male with a pertinent history of diabetes, type 2, hypertension, peripheral arterial disease, and coronary artery disease, status/post (s/p) coronary artery bypass. The patient lives alone in a camper and has no family support. He presented to the hospital for an amputation of his left 4th and 5th toes, possible transmetatarsal amputation, and he recently underwent left lower extremity revascularization including percutaneous transluminal balloon angioplasty (PTBA) of the left tibioperoneal trunk and peroneal arteries for chronic pedal ischemia associated with non-healing ulcerations of the 4th and 5th digits. Of significance, the patient had no active primary care provider, had poorly controlled diabetes which continued post-operatively, was not treating his diabetes, and lives alone in a camper. After his operation, the patient was admitted to the hospital for medical/surgical management. Endocrinology was consulted for diabetes management, and he was not deemed ready for discharge. Physical therapy and social services were consulted since it was felt that the patient would need placement in a skilled nursing facility. The latter required coronavirus disease (COVID) testing, etc. and when he was accepted to a facility, the patient was discharged with recommendations from endocrinology, physical therapy, and vascular surgery.

The requested health service of inpatient stay was medically necessary for this patient. The patient required hospital admission and was not medically stable and ready for discharge until he secured a sub-acute rehabilitation (SAR) bed, had his diabetes under control, and understood and was able to comply with the physical therapy recommendations. In addition, given the patient's living conditions, his lack of primary care, his lack of diabetes management, and his inability to climb stairs without assistance, he required placement in a skilled nursing facility which also requires time and screening test results.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Abdominal Pain
Treatment: Inpatient Hospital
The health plan denied the requested inpatient stay. The health plan's determination is upheld.

This patient is a woman who presented to the emergency department (ED) with the complaint of abdominal pain, nausea and diarrhea. Her past medical history included a seizure disorder. She was alert and oriented at the time of presentation. Vital signs at the time of presentation were normal. Examination revealed abdominal tenderness in the epigastrium and periumbilical area. The white blood cell count (WBC) count was elevated at 17.8. Her hemoglobin was normal at 13.5. The metabolic panel was normal. An abdominal ultrasound showed gallbladder sludge. A computed tomography (CT) scan showed a possible left sided nonobstructive small bowel intussusception without other gastrointestinal pathology noted. The patient was admitted to the hospital.
The patient was kept nothing by mouth (NPO) and was monitored overnight. The records indicate that the patient had normal vital signs and had improvement in her abdominal pain. The WBC count had normalized to 4.9. She was provided a diet and was considered to be stable for discharge home.
At issue is the medical necessity for the inpatient stay.

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

No. In this case, inpatient care was not medically necessary. The care and treatment provided during this time could have been rendered with an alternate level of care and did not require an inpatient designation. This alternate level of care would have provided for surgical assessment, intravenous (IV) fluid as provided, follow up, labs, and overnight monitoring. This patient presented with abdominal pain, nausea and diarrhea. The evaluation with examination, imaging, and lab data identified abdominal tenderness but no obvious indication for acute surgical intervention. The patient was monitored overnight and remained clinically stable during the period of monitoring. The WBC count was elevated, but normalized.
This patient's clinical needs could have been satisfied with an alternate level of care. This alternate level of care would have provided for clinical assessment and monitoring including overnight observation, as was performed. She was clinically stable at the time of presentation and remained so during the period of monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heartburn.
Treatment: Esophagogastroduodenoscopy (EGD) (43239).

The insurer denied the Esophagogastroduodenoscopy (EGD) (43239).  The denial is upheld.

The patient is a female who underwent esophagogastroduodenoscopy (EGD) to evaluate heartburn. There was no evidence of weight loss, dysphagia, persistent vomiting, gastrointestinal (GI) bleeding or failure of two months of acid suppression therapy.

No, the proposed treatment was not medically necessary.

In order for esophagogastroduodenoscopy (EGD) to be medically necessary in a patient with heartburn, the heartburn must be associated with: weight loss, dysphagia, persistent vomiting, gastrointestinal (GI) bleeding or failure of two months of acid suppression therapy. As there was no evidence of weight loss, dysphagia, persistent vomiting, gastrointestinal (GI) bleeding or failure of two months of acid suppression therapy, the requested esophagogastroduodenoscopy (EGD) was not medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient by denying the esophagogastroduodenoscopy (EGD) as it was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular tachycardia
Treatment: Inpatient hospital admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

This male patient was hospitalized for supraventricular tachycardia (SVT). He was seen by Emergency Medical Services (EMS) with complaints of palpitations and was found to be in SVT in the 170s. The patient was transported to the emergency department (ED) via ambulance. The patient's treatment included intravenous adenosine two times with conversion to sinus rhythm. The patient's past medical history (PMH) is unremarkable. Troponin was minimally elevated from demand and the patient was asymptomatic. 

This is an appeal of the denied claim for the requested acute inpatient hospital stay.

No, the proposed inpatient hospital admission was not medically necessary.

Based on the provided guideline (Milliman Care Guideline [MCG] M-510 ISC ORG-AP Supraventricular Arrhythmias), there was not a medical need for the acute inpatient hospital stay because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the guideline, admission is indicated for arrhythmia causing significant symptoms or findings not readily reversible by ED or observation care. However, none of the criteria were met in this particular case. There was no subsequent chest pain reported, myocardial ischemia, dizziness, weakness, lightheadedness, dyspnea, hypoxia, heart failure, hemodynamic instability, thyrotoxicosis, need to initiate antiarrhythmic therapy or cardioversion. Therefore, based on the submitted information and current published medical guidelines, the proposed treatment is not medically necessary.

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

The management of uncomplicated SVT is routinely provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left humeral fracture
Treatment: Subacute Rehabilitation (Rehab) Continued Stay
The health plan denied the subacute rehab continued stay as not medically necessary. 
The health plan's determination is upheld.

The patient is a male with a history of dementia and alcohol abuse who is status/post (s/p) left humeral fracture. He was admitted to a subacute rehabilitation (rehab) for functional restoration.

At issue is the medical necessity of subacute rehab continued stay.

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

No, the requested health service/treatment of subacute rehab continued stay is not medically necessary for this patient.

There is no medical necessity for continued subacute rehab stay at this time. The patient is no longer getting skilled physical therapy (PT) or occupational therapy (OT). He can ambulate long distances independently and is independent with most activities of daily living and set up with bathing. This patient has no skilled needs to justify continued subacute rehabilitation stay.

Therefore, the requested health service/treatment of subacute rehab continued stay is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System - COVID-19.
Treatment: Air Ambulance.
The insurer denied Air Ambulance.
The denial is upheld.

The patient is a male with hypertension (HTN), hyperlipidemia, coronary artery disease (CAD) with coronary artery bypass graft (CABG), ischemic cardiomyopathy with ejection fraction (EF) at 35-40%, and chronic kidney disease (CKD) III who presented with progressive weakness after having been admitted for coronavirus 2019 (COVID-19) pneumonia. He was treated with dexamethasone; remdesivir was withheld due to chronic kidney disease (CKD). After discharge, he went to his sister-in-law's house but returned with progressive weakness and shortness of breath (SOB) and was re-admitted.
During the second hospitalization, he was hypoxemic requiring high-flow nasal cannula and was treated for possible super-imposed bacterial pneumonia and ultimately finished 7 days of piperacillin-tazobactam, was restarted on dexamethasone for persistent hypoxemia; oxygen (O2) ultimately weaned down to 2 liters (L) and room air (RA) (still required 2L of O2 with exertion). He completed his 21 days of COVID-19 quarantine. His second hospitalization was notable for an elevated troponin suggesting a non-ST elevation myocardial infarction (NSTEMI). Cardiology was consulted and recommended medical management.
As he improved, it was felt after discharge he would need care in a transitional care unit (TCU). The patient had been hospitalized while visiting family in other state not his own state. He and his family requested transport to a TCU in his own state. 

At issue is the medical necessity of Air Ambulance.

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

No, the requested health service/treatment of Air Ambulance was not medically necessary for this patient.

Transferring would have been for convenience. While it would be helpful for him to have his rehabilitation/TCU stay closer to family, there is no medical literature (including the studies submitted) that would show this is medically necessary or needed to recover. In these studies, functional independence is a major factor associated with successful discharge from rehab, but presence and engagement of family has not been a studied feature or one that has been noted to change outcomes.
 
Transferring to his own state for rehab would primarily have been for comfort and convenience as the exact same services could have been provided in his family's state. Having family nearby cannot be considered a medical necessity.

Therefore, the requested health service/treatment of Air Ambulance was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent left leg claudication after superficial femoral artery (SFA) stent.
Treatment: Peripheral Revascularization.
The insurer denied the Peripheral Revascularization.
The denial is upheld.

This adult female patient was seen for follow-up of prior left superficial femoral artery (SFA) stent. The patient was not symptomatic. Duplex demonstrated elevated velocity of 231 centimeters per second (cm/s). A computed tomography angiogram (CTA) was ordered. The study demonstrated moderate narrowing proximal to the old stent. The provider proposed left leg angiogram and possible intervention for re-stenosis of the stent. Coverage was denied on the basis that the patient had no reported symptoms of arterial insufficiency. 

In a follow-up office visit (after insurance denial), the provider reported that the patient has recurrent left leg claudication. However, the note does not address how the symptom affects her daily function, if at all. The note makes no reference to conservative therapy.

None of the submitted records show an ankle-brachial index (ABI).

The proposed treatment is not medically necessary.

Redo intervention after prior lower extremity endovascular intervention is medically necessary when (1) patients have lifestyle limiting symptoms of arterial insufficiency (e.g., severe claudication) and have failed conservative therapy; (2) limb threatening symptoms (e.g., ischemic rest pain, tissue loss); or (3) imaging data to suggest a pre-occlusive lesion affecting a stent in a critical location.

Indication #1 is not present in this case. In the office note, the provider stated that the patient had no leg symptoms. The other office note refers to claudication, but the note fails to describe the impact on the patient's function. There is no mention of conservative therapy.

Indication #2 is not present. None of the records suggest limb threatening symptoms.

Indication #3 is not present. The highest velocity seen on the duplex was 231 centimeters per second. The computed tomography angiogram (CTA) showed only moderate re-stenosis above the old stent. These findings are not suggestive of a severe re-stenosis.