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

Diagnosis: Dental Disorder
Treatment: Braces and monthly visits
The insurer denied Braces and monthly visits
The determination is overturned.

The patient is a female with a Class II Division 2 malocclusion with maxillary and mandibular crowding. She has an 8-millimeter (mm) overjet and 8 mm overbite. Tooth 28 is in crossbite. She is treatment planned for 24-36 months of orthodontics to correct her malocclusion. At issue is the medical necessity of braces and monthly visits.

This patient, like fifteen percent of the population, exhibits an Angle's Class II bite. (1) Patients with a Class II malocclusion exhibit prominent maxillary teeth and a retrusive mandible. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (2) Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Furthermore, there is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) mm overjet, which this patient has. (3) For these reasons, the orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Amyotrophic Lateral Sclerosis (ALS)
Treatment: Relyvrio
The insurer denied Relyvrio.
The health plan's determination is overturned.

The patient is a male who has been diagnosed with Amyotrophic Lateral Sclerosis (ALS). He was status post percutaneous endoscopic gastrostomy (PEG) tube placement, tracheostomy and colostomy. He has previously been treated with riluzole and Radicava. The most recent SVC (slow vital capacity) reported was 21% (percent). He was more recently prescribed Relyvrio and this is under review.

Relyvrio is not medically necessary for this patient.
The primary body of evidence on which the Food and Drug Administration (FDA) granted approval of this drug was from the phase 2 CENTAUR study (Paganoni et al 2020). That study only enrolled participants with a SVC >60% (percent) and who had onset of symptoms within 18 months of trial participation. The study also excluded participants who were status post tracheostomy. Even the results from that study were largely indeterminate. In this case, the information provided for review does not otherwise place the patient in the demographic for which this medication has been shown to potentially be of benefit (given his low SVC, duration of symptoms prior to initiation of therapy and the presence of a tracheostomy). In as much, given the lack of literature to support the use of the requested drug in the patient's clinical presentation, it is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: home health care
The insurer denied Personal Care Aide Services 56 Hours per Week.
The health plan's determination is overturned. 

The patient is a female with past medical history of vascular dementia, hypothyroidism, depression, anxiety, vision loss of the right eye, macular degeneration of the left eye, history of cerebrovascular accident (CVA), atrial fibrillation, chronic anticoagulation, vestibulopathy, and lumbar radiculopathy who had been assigned PCA (personal care aide) services. 

Personal Care Aide Services: 56 Hours per Week, Consumer Direct, 1 Client is medically necessary for this patient.
There is documentation from the patient's ophthalmologist and PCP (primary care provider) of medical necessity of increased PCA (personal care aide) hours. The medical review and practitioner's order stated the patient had moderate assistance needs with most tasks. The patient's telephonic assessment underestimated the patient's care needs. The requested increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. 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, the requested PCA services 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: Upheld

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

This is the case of a male who presented to the emergency department (ED) with nausea, vomiting, and abdominal pain. He has pertinent past medical history of cannabinoid hyperemesis syndrome, Gilbert syndrome, childhood epilepsy, attention deficit hyperactivity disorder (ADHD), and anxiety. He was recently discharged from the hospital for treatment of vomiting due to cannabinoid hyperemesis syndrome. Additional symptoms include inability to tolerate oral intake, chest pain when vomiting, and recent 10-20 lb (pounds) weight loss. He reports no recent cannabis use for 2 weeks.

The inpatient hospitalization is not medically necessary. A lower level of care was appropriate for this patient.
This otherwise healthy patient presented with persistent vomiting and weight loss secondary to cannabis use. He demonstrated intestinal dysmotility which required antiemetic and nutritional support; however, he had stable vital signs, no electrolyte abnormalities, and normal physical examination. Therefore, his condition was not medically necessary for an inpatient level of care. His stay could have been accomplished at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Non-segmental Vitiligo

Treatment: Opzelura 1.5% cream (G)

The insurer denied coverage for Opzelura 1.5% cream (G)

The denial is overturned

The patient has a diagnosis of non-segmental vitiligo affecting 10% total body surface area (TBSA), including the trunk and extremities.  The patient has failed therapy with topical steroids and tacrolimus. The request is for Opzelura cream. 

Based on the clinical documentation, the use of Opzelura is medically necessary and is not cosmetic.  The patient has been diagnosed with an autoimmune skin condition affecting 10% TBSA.  The use of topical steroids and calcineurin inhibitors, such as tacrolimus is first line standard of care in the clinical management of non-segmental vitiligo.  Opzelura is the only Food and Drug Administration (FDA) approved treatment available for treatment of non-segmental vitiligo.  The patient has failed reasonable (non-FDA approved) topical therapies and would benefit from treatment with Opzelura.  It is not medically reasonable, and not in line with sound medical judgement, to classify an autoimmune skin condition as cosmetic simply because it affects the skin.  The use of FDA approved Opzelura is medically necessary for the treatment of the patient's non-segmental vitiligo.  The decision is reversed.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Opzelura 1.5% cream (G) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda
The insurer denied coverage for Saxenda.
The denial is Overturned.   

This is an adult patient diagnosed with obesity. This request is for Saxenda. As reported; the patient has body mass index (BMI) of 42.71. The patient is consistently following nutrition monthly plan. The patient is unable to reach goals with diet and exercise. As per visit note the patient has lost 5 pounds in 2 months. The patient had gastric sleeve approximately 9 years ago. The patient's BMI was 42.73; weight was 124 kilograms (kg). The BMI was 43.38; weight was 126 kg.

Saxenda is a GLP1 (glucagon-like peptide) agonist that is used in the treatment of obesity [1-7]. The standard of care is to use the medication most compatible with the patient's condition and other medications. 

The standard of care requires that the patient is participating in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension, hyperlipidemia. The patient has a BMI of 42.73 and the patient has and is participating in lifestyle modifications including diet and exercise.

The request is consistent with generally accepted standards of medical practice. The request is medically necessary. 

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Saxenda is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute cholecystitis
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult male with acute cholecystitis. The patient went to an initial hospital where he left against medical advice (AMA) and then went to another hospital for definitive treatment. He was hemodynamically stable at admission. He had impending necrosis of the gallbladder at the time of surgery. He was admitted post-operatively and discharged against medical advice (AMA). This is a review for the inpatient admission.

The requested health service was not medically necessary.

Per the documentation, this is not medically necessary as the patient was hemodynamically stable and had a stable white blood cell (WBC) count. The patient did not need post-operative infectious disease workup or delay in diet advancement. There were not any post-operative complications that needed inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Community acquired pneumonia
Treatment: Inpatient admission 
The insurer denied coverage for: Inpatient admission
The denial is: Upheld 
This is a child with a history of Down's Syndrome and three previous admissions to the hospital for reactive airways disease. The patient was sick with a cough and congestion for 4 days. The patient had one episode of post tussive vomiting. The patient was noted to have a fever at school and was sent home. The mother treated the child with 2 doses of Albuterol but then she noted a decrease in urine output, and she decided to bring the child to the emergency room (ER) for treatment.

In the ER, the child was noted to have coughing and some crackles were audible in the right lung field. The patient was noted to have nasal congestion, but the patient was not in respiratory distress and there was no wheezing noted. The pulse oximeter on room air was 100%. A white blood count (WBC) was elevated at 24,000 and a procalcitonin level was elevated at 4.18. A chest radiographic image (x-ray) demonstrated an infiltrate of the right lower lobe, and the patient received treatment with an intravenous (IV) dose of antibiotics.

Based on the febrile illness with crepitation's audible in the right lung field, pneumonia on chest x-ray and blood testing demonstrating an elevated white blood count, the child was diagnosed with pneumonia and the decision was made to admit for continued IV antibiotics and Albuterol every 3 hours.

The insurer has denied coverage for acute in-patient admission to the hospital.

The patient was treated appropriately in the Emergency Room (ER) for a diagnosis of pneumonia following an illness with fever. The patient had an elevated white blood count and a chest x-ray which confirmed the diagnosis of pneumonia. The patient was noted to have normal oxygen saturation and no evidence of respiratory distress, and not noted to have wheezing. The decision to admit was not consistent with the standard of care for treatment of community acquired pneumonia with oral antibiotics following an IV dose of antibiotics administered in the ER. There was no need for treatment with nebulized albuterol every 3 hours since there was no wheezing. This child could have been safely discharged on oral antibiotics with a follow-up visit with her pediatrician in 24-48 hours. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for a full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Uncomplicated diverticulitis
Treatment: Inpatient admission
The insurer denied coverage for: Inpatient admission
The denial is: Upheld
The patient presented with left lower quadrant (LLQ) abdominal pain. The patient was afebrile and the vital signs were stable. There were no peritoneal signs. The white blood cell count (WBC) was 15.2k. A computed tomography (CT) scan was read as uncomplicated diverticulitis with micro perforation, no abscess was present. Intravenous (IV) antibiotics were given. No surgical interventions were advised at this time. The patient was given a clear liquid diet, and then advanced. 

Medical necessity was determined based on Milliman Care Guidelines (MCG) guideline M-150 for Acute Diverticulitis. Clinical indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant abnormality on an imaging study. This abnormality can be a fistula, obstruction, or frank or free perforation such as free air under the diaphragm. The patient did not have these conditions. The patient also did not require a drainage procedure, have bacteremia, severe vomiting, severe dehydration, or an inability to maintain oral hydration after observation care. 

This patient had diverticulitis that was not complicated by an obstruction or free air under the diaphragm. The patient could have been started on antibiotics with observation care and then discharged on a course of oral antibiotics. The patient did not meet MCG criteria for admission for Acute Diverticulitis. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Quadriplegia
Treatment: Consumer directed personal assistance services (CDPAS) 24 hour (hr) continuous care
The insurer denied Consumer directed personal assistance services (CDPAS) 24 hour (hr) continuous care.
The determination is overturned.

This is a male patient with a medical history notable for quadriplegia. The patient is approved for 12 hours per day, 7 days per week for a total of 84 hours per week of personal care assistance. The patient and his care team requested an increase to 24-hour continuous care, for a total of 168 hours per week. This request was denied by the health plan.
The patient's mother provided a letter of support for this appeal. The letter states that the patient has severe disability and cannot perform any tasks independently, including talking, walking, eating, bathing, and toileting. He is quadriplegic and only able to move his head. The letter describes a typical day for the patient, which requires active hands-on personal care throughout the day. Of note, he requires diaper changes at least every 2 hours if not more often due to incontinence. There are many nights when he wakes up multiple times throughout the night and requires changing due to urinary or fecal incontinence.
An office visit note was available for review. At that time, the patient was being evaluated for a stage 2 pressure injury on the bilateral buttocks. These wounds were the result of a hospitalization in April and May. He subsequently developed an abscess.
A Uniform Assessment System was completed. The assessment was conducted via video teleconference. The patient is nonverbal with severely impaired cognition. For his instrumental activities of daily living, he requires total dependence for all. For his activities of daily living, he requires total dependence for all. He is incontinent of urine and stool and requires 10 to 12 pull-ups per day. He is being turned and repositioned every two to three hours throughout the day and night to treat his pressure ulcer. At issue is the medical necessity of Consumer directed personal assistance services (CDPAS) 24 hour (hr) continuous care.
The requested health service Consumer directed personal assistance services (CDPAS) 24 hr continuous care is medically necessary for this patient.
The patient is nonverbal and he is only able to move his head. He is completely reliant on others for direction of care and for completion of all personal care tasks. He has urinary and fecal incontinence which require diaper changes frequently throughout the day night. He also has a pressure ulcer which requires turning and repositioning every 2 to 3 hours throughout the day and night. The notes also reference suctioning which must take place as often as every 2 hours. The patient's personal care needs are expected to be continuous and unscheduled throughout the day and night. Therefore, it is medically necessary that he receives 24-hour continuous care to address his personal care needs. A live-in personal care aide would not be expected to be able to receive sufficient rest. Continuous care is medically required.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis
Treatment: Inpatient admission 
The insurer denied coverage for: Inpatient admission
The denial is: Upheld  
Patient is an adult with past medical history significant for hypertension, asthma, morbid obesity, anxiety, and gastroesophageal reflux disease (GERD) who presented to the emergency department (ED) with complaints of left lower leg pain and swelling.

Vital signs on presentation included: Temperature 99.0 Fahrenheit, blood pressure 143/80, pulse 99, respiratory rate 16, oxygen (O2) saturation 96% on room air. Laboratory results included the following: White blood cell count (WBC) 10.9, hemoglobin (Hgb) - 12.3, hematocrit (Hct) - 38.3,  creatinine - 0.66, glucose - 195, procalcitonin < 0.05.  

The patient was started empirically on intravenous (IV) antibiotics (Linezolid and Ceftriaxone) for left lower extremity cellulitis. Infectious Diseases consulted and adjusted antibiotics. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue oral antibiotics (Keflex) as an outpatient.

According to documentation, the patient presented with left lower leg cellulitis. Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results except for a mildly elevated WBC. The patient had no evidence of a disseminated infection and no surgical intervention was required. Based on above findings, the patient met criteria for observation level of management. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the inpatient emergency admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

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

This patient is a female who presented to the emergency room (ER) with complaints of right upper quadrant (RUQ) abdominal pain for 5 days. Vital signs were normal. Labs revealed a normal white blood cell (WBC) count and mildly elevated transaminases. An ultrasound (US) was consistent with acute cholecystitis. Hepatobiliary iminodiacetic acid (HIDA) scan was obtained and was positive. The patient underwent a laparoscopic cholecystectomy which was uncomplicated. Post-procedure, the patient was advanced to a regular diet which was tolerated.

The inpatient hospital admission was medically necessary and is considered standard for treatment of acute cholecystitis in this patient. The patient presented to the ER, and evaluation to confirm acute cholecystitis with HIDA scan was performed given some equivocal clinical findings with length of pain as well as normal WBC findings. The patient was made nothing by mouth (NPO), started on intravenous (IV) antibiotics and supported with IV pain medications and anti-emetics. Based on confirmation of acute cholecystitis, a decision was made to proceed with surgical treatment with laparoscopic cholecystectomy on hospital day (HD) 2. The patient met medical necessity for the acute inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory Failure
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.

This is a female patient with a medical history significant for insulin dependent diabetes mellitus, chronic kidney disease, heart failure with a preserved ejection fraction, and hypertension who was admitted for hypertensive emergency with symptoms of lower extremity edema, orthopnea, and shortness of breath for three days with an acute worsening on the day of admission. On presentation, the patient's physical exam demonstrated that the systolic blood pressure was greater than (>)180 millimeters of mercury (mmHg) (245 mmHg), and diffuse expiratory wheezing on auscultation of the chest with respiratory distress. She was admitted for hypertensive emergency with acute hypoxic respiratory failure secondary to heart failure with resultant pulmonary edema. At issue is the medical necessity of an inpatient stay.
The requested health service/treatment of inpatient admission was medically necessary for this patient.
This patient with a medical history significant for insulin dependent diabetes mellitus, chronic kidney disease, heart failure with a preserved ejection fraction, and hypertension was admitted for hypertensive emergency with symptoms of lower extremity edema, orthopnea, and shortness of breath for three days with an acute worsening on the day of admission. 
The patient was admitted for hypertensive emergency with acute hypoxic respiratory failure secondary to heart failure with resultant pulmonary edema. She required non-invasive positive pressure ventilation with supplemental oxygen to keep her oxygen saturation greater than (>) 90 percent (%) due to the acute hypoxic respiratory failure. In addition, she was started on intravenous Lasix and a nitroglycerin continuous infusion for diuresis and blood pressure control. Despite the initial care she still required non-invasive ventilatory support, supplemental oxygen and intravenous titration of her anti-hypertensive medications. Based on the hypertensive emergency with heart failure causing pulmonary edema and acute hypoxic respiratory failure requiring non-invasive positive pressure ventilation with supplemental oxygen requiring continuous monitoring of hemodynamics and titration of anti-hypertensive medications, the inpatient level of care was appropriate, and treatment could not have been rendered at a lower level of care. Therefore, it would be considered in accordance with generally accepted standards of medical practice in the United States, and clinically appropriate, in terms of type, frequency, extent, and duration; and would be considered effective for the patient's illness, disease, and its symptoms to be admitted to an inpatient level of care. In addition, based on the current standard of care treatment based on credible scientific evidence in the peer-reviewed medical literature and consistent with the standards in the medical community, an inpatient level of care was required.