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

Diagnosis: Urinary tract infection (UTI).

Treatment: Hospital admission.

The insurer denied coverage for the hospital admission.

The denial is upheld. 

This is a female patient with past medical history of thalassemia minor and asymptomatic cholelithiasis who presented to the emergency department (ED) with urinary tract infection (UTI) symptoms such as back pain - pressure that persisted despite out-patient treatment with Vantin and Pyridium. Computed tomography (CT) scan had revealed a splenic artery aneurysm. The patient was admitted by the vascular service for further workup and possible coil procedure. The patient had low grade fevers, but the white blood cell (WBC) count was normal. Vascular Surgery ultimately decided to postpone the procedure and have the patient return in 2 weeks when UTI was further treated and entirely resolved. 

Per Milliman Care Guidelines (MCG) Health (24th) UTI, the patient fails to meet clinical indications for admission to inpatient care. The patient's urine culture 2 days prior to admission revealed a pan-sensitive Enterococcal UTI. The urine culture performed in the hospital was negative for infection.  

Rocephin/Ertapenem are not considered ideal antibiotics for a pan-sensitive Enterococcal UTI, and this patient did not have a multi-drug resistant UTI or Extended Spectrum Beta-Lactamase (ESBL) bacteria causing the UTI. She was not noted to have elevated WBC count and some of her back pressure could have been due to the splenic artery aneurysm diagnosed by the CT scan. She had no hemodynamic instability, no altered mental status which was severe/persistent, no persistence or worsening of clinical findings despite observation period (patient was able to take oral meds, and the Enterococcal UTI was pan-sensitive to multiple oral antibiotic agents). The patient does meet guidelines for Observation Care: fever. 

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

The hospital admission is not considered medically necessary for this patient. 

The medical necessity for the hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep vein thrombosis (DVT). 
Treatment: Inpatient Hospital Admission. 

The insurer denied coverage for the Inpatient Hospital Admission. 

The denial is upheld. 

This is a female patient with a history of hypothyroidism and deep vein thrombosis (DVT) on Eliquis.  The patient presented to the Emergency Room (ER) with complaints of lower leg pain since two days prior with swelling and redness.  The patient was referred from the urgent care.  In the ER, the patient's Doppler revealed a non-occlusive popliteal vein DVT.  The patient was given 60 milligrams (mg) of Lovenox and 2 grams (g) of cefazolin. The patient's D-dimer level was within normal limits.  The patient was admitted to the Medicine unit for further care.  The patient received Lovenox.  The patient was seen by rheumatology and received a workup for antiphospholipid syndrome and underlying connective tissue disease.  Hematology noted that the patient's DVT was not likely to be new given the patient's normal D-dimer levels trended twice. The patient's thyroid stimulating hormone (TSH) was elevated for which the patient's levothyroxine dosage was increased.  The patient was discharged after a period of medical stability, with Eliquis being continued.  

Based on the review of the medical record and literature, inpatient admission was not medically necessary for this patient. The patient had localized symptoms to the left lower extremity (LLE) with good vital signs (VS) and no other signs of an acute process.  The patient was ambulatory (slowly).  The patient's care could have been provided under Observation status given this patient's history of DVT on Eliquis and for concern of new DVT while on Eliquis.  As per Hematology evaluation of the patient, given the patient's normal D-dimer levels, new DVT was ruled out.  This evaluation could have been done at the Observation status. The issue of a possible rheumatic disease was raised and workup ordered, but there were no other acute signs of such a process for which an acute inpatient level of care was needed. As such, inpatient admission was not medically necessary. 

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

The carrier's denial of coverage for the Inpatient Hospital Admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Taltz, Pre-service
The insurer denied the Taltz, Pre-service.
The denial is overturned. 

The patient is a female with severe psoriasis affecting the head and extremities. She has tried and failed to topical steroids and methotrexate. She has been on Taltz injections and has responded very well.

Yes, the proposed treatment with Taltz is medically necessary.

The current treatment guidelines that are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis recommend typical first line treatments such as topical corticosteroids and calcipotriene followed by typical second line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, acitretin, cyclosporine) or  biologics. This patient has tried and failed topical treatments and methotrexate. 

The next appropriate treatment would be phototherapy, oral systemic medications or biologics. This patient has lesions on the scalp, which are not suited for treatment with phototherapy.  Since the patient is of childbearing age, use of methotrexate and acitretin are not medically appropriate. Additionally, they carry a much higher risk of adverse events, while not offering an advantage in efficacy. Cyclosporine is not an appropriate long term solution due to the side effect profile and is used as a bridge or rescue treatment while another treatment's effect is waited upon to "kick in". 

The patient has started Taltz injections and is responding well.

Therefore, Taltz is medically appropriate and necessary.

The patient has severe psoriasis for which systemic therapy is indicated. In the era of biologic therapies for psoriasis, use of methotrexate, cyclosporine or acitretin (acitretin is contraindicated in women of childbearing potential and methotrexate carries a risk of life threatening side effects) is not the most appropriate first line treatment because their long term safety and efficacy are inferior to biologic therapies.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male. He has a past medical history significant for asthma, HTN (hypertension), knee arthritis, polysubstance abuse. He presented to the ER (emergency room) for chest pain.

The patient was hemodynamically stable. His prior cardiac evaluation included an echocardiogram, which revealed normal LV (left ventricle) function with no wall motion abnormalities. He was previously offered a cardiac catheterization, but signed out against medical advice. His troponins were negative. His BNP (brain natriuretic peptide) was not elevated. The patient was admitted to telemetry to evaluate his chest pain. The patient was seen in consultation by cardiology, and a nuclear stress test was ordered. The patient refused to complete the stress test, and the study was not completed. He was discharged home with a recommendation for outpatient follow-up.

No, the Inpatient admission was not medically necessary.

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability. Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma Exacerbation. 
Treatment: Inpatient admission. 

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

The patient is a male with history of asthma who presented to the emergency room with shortness of breath (SOB) and wheezing. The patient was found to have a mild asthma exacerbation. The patient was admitted to acute in hospital level of care. 

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

The patient's mild asthma exacerbation partially improved with emergency room care. The patient was tolerating oral medications. The patient was ambulating. The patient required frequent nebulizations. The patient's symptoms improved within 24 hours of hospital admission. The patient could have been safely and effectively treated at a lower level of care. The acute in hospital level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer/Pancreatic Cancer
Treatment: Home Health Care/Increase in Personal Care Assistance (PCA) hours.
The health plan denied the requested increase in PCA hours due to the lack of medical necessity. 
The health plan's determination is overturned.

The patient is a female with a past medical history of pancreatic cancer, ascites, gastroesophageal reflux disease (GERD), diarrhea, right foot drop, herpetic neuralgia, urine incontinence, and bowel incontinence who had been hospitalized due to a central port infection and a urinary tract infection (UTI). There was a request for personal care assistance (PCA) services and the patient underwent an assessment tool assessing the patient at total assistance with tasks of meal preparation, ordinary housework, shopping, and bathing while maximum assistance with tasks of managing medication, stairs, transportation, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility. The patient was assessed at extensive assistance with tasks of personal hygiene and eating while limited assistance with tasks of managing finances, phone use, and equipment management. 

The patient's oncologist provided a letter stating the patient has the diagnosis of pancreatic cancer, she is undergoing chemotherapy, her health has deteriorated, she has developed complications due to her cancer and chemotherapy treatments, and she has weakness, fatigue, nausea, ascites, and pain. In addition, the oncologist's letter noted the patient is wheelchair bound and unable to perform activities of daily living (ADLs) without full assistance.

At issue is the medical necessity of the requested increase in personal care assistance hours.

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

Yes, the plan did approve PCA services 24 hours/day, live-in, 7 days/week, but 24 hours/day, split-shift/continuous care, 7 days/week were requested. The patient has unscheduled and unpredictable care needs over a continuum of time. Overnight logs were provided showing the patient requires assistance with ADLs at least every 2-4 hours which would not allow a PCA to obtain >5 hours of uninterrupted sleep. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs (instrumental activities of daily living). Considering the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, continuous/split-shift, 7days/week, to total 168 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 in Part

Diagnosis: Glaucoma, gait abnormality, hypertension, urine
incontinence
Treatment:   Increase Consumer Directed Personal Assistance Services to 56 Hours per Week
The insurer denied the   Increase Consumer Directed Personal Assistance Services to 56 Hours per Week.
The denial is overturned, in part. 

The patient is a female with a history of Glaucoma, Gait abnormality, Hypertension and Urinary Incontinence. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review was requested for potential approval of 56 hours/week Consumer Directed Personal Assistance Services to offer increased activities of daily living support.

Yes, in part.  The proposed treatment of 56 hours/week Consumer Directed Personal Assistance Services is medically necessary, in part. Specifically, Consumer Directed Personal Assistance Services are medically necessary at 38 hours per week.

An assessment of the patient's functionality and ability to perform activities of daily living was completed and revealed that 38 hours/week Personal Assistance Services is sufficient to  meet the patient's current needs. However, the health plan only approved 34 hours. Based on the results of this assessment, the 38 hours/week Consumer Directed Personal Assistance Services are medically necessary. Specifically, this assessment revealed that the patient is currently receiving skilled nursing services 2x (times)/weekly and that her daughter performs wound care for her sacral pressure ulcer. In addition, she is currently receiving Physical Therapy services. In addition, she has a bedside commode for use during the day and night.

There is no additional documentation which demonstrates that the patient has sustained further functional loss since the date of this last assessment. For these reasons, while the proposed treatment 56 hours/week Consumer Directed Personal Assistance Services is in excess of the patient's current medical needs, the currently approved plan of 34 hours/week is insufficient to meet the patient's needs. 38 hours/week of Consumer Directed Personal Assistance Services are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: High Cholesterol and Cardiovascular Disease.
Treatment: Praluent 150MG/ML SC SOAJ, Pre-service.

The insurer denied the Praluent 150MG/ML SC SOAJ, Pre-service.  The denial is upheld. 

The patient is a male with a past medical history of hyperlipidemia and coronary artery disease. The patient had a history of adverse reaction to atorvastatin. There is no history of use of other statins. The patient has been prescribed fenofibrate, and the use of Praluent was requested.

No, the treatment with Praluent is not medically necessary.

Praluent is indicated as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia (HeFH) or clinical atherosclerotic cardiovascular disease (CVD), who require additional lowering of low density lipoprotein cholesterol (LDL-C). According to the records provided for review, the patient has a known diagnosis of hyperlipidemia and atherosclerotic cardiovascular disease (CVD). The patient did not tolerate one statin agent, namely atorvastatin; however, there is no evidence of therapeutic failure or intolerance of any other statin preparations, such as rosuvastatin, alone or in combination with other preferred agents. Therefore, the medical necessity of the requested medication is not established.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hidradenitis Suppurativa.
Treatment: Siliq 210 milligrams (MG)/1.5 milliliters (ML) subcutaneous (SC) SOSY [Solution Prefilled Syringe] to Treat Hidradenitis Suppurativa.

The insurer denied coverage for Siliq 210 milligrams (MG)/1.5 milliliters (ML) subcutaneous (SC) SOSY [Solution Prefilled Syringe] to Treat Hidradenitis Suppurativa.  The denial is upheld. 

This is a female patient with a history of Hidradenitis Suppurativa (HS). Based on the review of the medical record and literature, Siliq (brodalumab) is not considered medically necessary for this patient's condition of HS.  Notes refer to the possible enrollment of this patient in a study evaluating the efficacy of Siliq in the treatment of HS.  The patient has not failed or shown to have a contraindication to medications approved by the Food and Drug Administration (FDA) for the treatment of HS, specifically adalimumab (Humira).  Although case reports have demonstrated possible efficacy of Siliq for the treatment of HS, further studies are needed to demonstrate the long-term efficacy and safety of Siliq.  There is no data to indicate that Siliq would be more effective in the treatment of this patient's condition than existing FDA-approved medications.  No contraindications, allergies, or special situation exists to warrant the use of Siliq in preference to medications known to improve HS.  The standard of care for treatment of HS would necessitate an attempt to use medications shown to be effective for, and FDA-approved, for this condition prior to initiation of alternative treatments.  The guidelines note regarding adalimumab that "Adalimumab at the approved HS dosing is recommended to improve disease severity and quality of life in patients with moderate-to-severe HS."  Siliq (brodalumab) is not mentioned in the guidelines. (3)

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

The carrier's denial of coverage for Siliq 210 milligrams (MG)/1.5 milliliters (ML) subcutaneous (SC) SOSY [Solution Prefilled Syringe] to Treat Hidradenitis Suppurativa should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease.

Treatment: Inpatient hospital admission.

The insurer denied coverage for the inpatient hospital admission.

The denial is upheld. 

This is a male patient who was admitted electively to the hospital for a coronary angiogram and possible percutaneous coronary intervention (PCI). The patient's past medical history was significant for coronary artery disease, hypertension, hyperlipidemia, myocardial infarction (MI), deep vein thrombosis (DVT), gastric bypass, inferior vena cava (IVC) filter, coronary artery bypass graft (CABG) x3 and multiple PCI. The patient underwent the coronary angiogram and PCI. Post-procedure, the patient denied any symptoms including chest pain and shortness of breath. There was no bleeding or hematoma noted at the patient's incision site, and the patient's lower extremity pulses were palpable. On physical exam, the patient was described as being in no acute distress and no abnormalities were described on his examination. The patient's vital signs were stable and there was no evidence of bleeding or hematoma. The plan was to discharge the patient home on aspirin, Plavix, simvastatin and Coreg. The patient was medically stable for discharge and was instructed to follow-up with the cardiologist for planned return for staged PCI in five weeks.

As per Shroff et al. (2016), the evolution of PCI has led to improved safety and efficacy, such that overnight observation can be avoided in some patients. Investigators sought to provide a narrative review of the recent literature regarding the outcomes of same-day discharge (SDD) PCI and to describe a framework for the development of an SDD program. A literature review showed that when compared with overnight observation, there was no increase in adverse events (bleeding, repeat coronary procedures, death, or re-hospitalization) among patients in studies who were discharged on the same day of their PCI procedure.  Same-day discharge was associated with significant cost savings and was preferred by patients.

In this case, this patient was electively admitted to the hospital for a coronary angiogram, and possible intervention, after a nuclear stress test was done and showed evidence of ischemia. The diagnostic angiogram was uncomplicated as was this patient's PCI. The patient's vital signs, physical exam and laboratory studies revealed no significant changes. The literature review supports that this type of patient can safely be discharged home after a short period of observation and monitoring. Thus, the inpatient admission was not medically necessary for this patient.

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

The carrier's denial of coverage for the inpatient hospital admission should be upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alcohol withdrawal.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female. She was admitted with alcohol withdrawal.

The patient was treated with CIWA (clinical institute withdrawal assessment) protocol.  The patient's vital signs were as follows: Temperature 98, pulse 68, respiration rate 20, blood pressure 102/63. She was noted to be NAD (no acute distress). The plan was to continue IVF (intravenous fluids), CIWA (clinical institute withdrawal assessment) protocol, Thiamine, Folic acid, Methadone, and Seroquel. She was noted to need psych follow up. She was on regular diet. The plan was for inpatient rehab.

On the last day of admission, the patient's vital signs were stable. No withdrawal symptoms were noted. She was cleared for discharge.

No, the Inpatient admission was not medically necessary.

Medically necessary services are those which are: safe, effective, generally accepted national standard of medical practice, not provided primarily for convenience of the patient or the practitioner,  the least intensive and/or most appropriate alternatives among diagnostic and treatment option.

The requested ongoing inpatient admission was not medically necessary, because it was not in accordance with generally accepted national standard of medical practice.

This patient was admitted with alcohol withdrawal. During the period of admission, the patient was hemodynamically stable and afebrile. The patient did not have active comorbid conditions. The patient did not have signs of withdrawal. The patient's medication regimen had been established. The plan of care was transfer to inpatient rehab. She did not have symptoms and was not receiving intervention that required an acute inpatient level of care during this period.