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

Diagnosis: Cerebrovascular accident (CVA). 
Treatment: Home health care 70 hours per week. 

The insurer denied home health care 70 hours per week. 
The health plan's determination is upheld. 

The patient is a male with past medical history of cerebrovascular accident (CVA) with right hemiplegia, seizures, urinary incontinence, diabetes mellitus (DM) Type 2, atrial fibrillation, hyperlipidemia, hypertension, depression, and benign prostatic hyperplasia (BPH) who was hospitalized with seizure and transient ischemic attack (TIA) with subsequent rehabilitation stay. There was a request to increase PCA (personal care assistance) services at home as a contingency of discharge and the patient underwent a telephonic assessment that assessed the patient at total assistance with tasks of meal preparation, ordinary housework, and stairs while maximum assistance with tasks of managing medication, shopping, transportation, bathing, dressing lower body, walking, locomotion, and transfer toilet. With tasks of managing finances, dressing upper body, toilet use, and bed mobility the patient was assessed at extensive assistance while limited assistance with tasks of phone use and personal hygiene. The patient was assessed at independent with task of eating and notes from assessment stated the patient ambulated via wheelchair or scooter and had no informal help at home. 

PCA: 7 days per week, 10 hours per day (70 hours per week) is not medically necessary for this patient. 

There is documentation from rehabilitation social worker, rehabilitation physical therapist, and the patient's lawyer that the patient requires assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs) 24 hours/day, 7 days/week to be safely discharged from rehabilitation facility. The patient is currently living in a skilled nursing facility where he is able to obtain assistance with all of his ADLs/IADLs. There is a specific request for PCA services 10 hours/day, 7 days/week, to total 70 hours/week and the patient has care needs outside of the 10 hours/day and therefore should remain in a skilled nursing facility. The patient has no informal help. The patient does not have a reliable support in the community and needs a consistent backup caregiver who could provide him with assistance as he was not safe to be left alone the other 14 hours a day outside of the requested 10 hours a day of PCA services. Taking into account 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 10 hours/day, 7 days/week, to total 70 hours/week are not medically necessary for this patient, as he requires 24-hour per day, 7 days/week assistance and does not have a reliable support in the community or a backup caregiver.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroduodenitis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for an inpatient hospital admission. 

The denial is upheld. 

This is a patient with a past medical history of prematurity, necrotizing enterocolitis, right sensorineural hearing loss, recurrent abdominal abscesses, and ileostomy placement. The patient presented to the hospital with complaint of abdominal pain and vomiting. A urinalysis and a rapid viral panel were negative in emergency department. A computed tomography revealed possible gastroduodenitis and bladder distention. The patient was admitted for further care. A bladder scan revealed 450ml (milliliters) of post void residual. No urologic intervention was required. The patient was given intravenous fluids and her diet was advanced. The patient was discharged home. 

The insurer has denied coverage for the inpatient admission. They noted there was no hemodynamic, pulmonary, neurologic, or metabolic reason to treat the patient at an acute level of care (LOC), and that the patient could have been placed in observation under monitoring. The appeal on behalf of the hospital is noted and read in detail. Per MCG (Milliman Care Guidelines) health (25th): 

1) Urologic Disease - the patient fails to meet clinical indications of admission to inpatient care under "Urine retention requiring inpatient care." 2) Abdominal Pain, undiagnosed - patient fails to meet guidelines for admission to inpatient care. 

The health care plan acted reasonably, with sound medical judgement, and in the best interests of the patient. 

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent. 

The insurer denied coverage for Dupixent. 

The denial is overturned. 

The patient has a history of severe atopic dermatitis. The patient has failed therapy with topical steroids. The requested medication is Dupixent. 

Dupixent is medically necessary for the treatment of the patient's diagnosis, atopic dermatitis. The patient is a child with decreased systemic treatment options available which could safely be administered given his age and severity of atopic dermatitis. The patient has failed topical therapy with steroids. The severity of his disease requires systemic therapy. Igelman, et al, in a multicenter study of 111 children, found that "Associated morbidities, treatment response, and adverse events were comparable to those in previous adolescent and adult trials." [1] 

Dupixent is approved for use in the treatment of the patient's atopic dermatitis under close medical supervision and at an appropriate dosing schedule at the discretion of the treating physician. 

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

The insurer's denial of coverage for Dupixent is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart Disease. 
Treatment: Inpatient stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male with a history of coronary disease, bypass surgery, percutaneous interventions, myocardial infarction with V. fib (ventricular fibrillation) arrest, hypertension, hyperlipidemia, diabetes, and kidney disease. He was admitted electively for cardiac catheterization. He was generally feeling well and had no cardiac symptoms. Myocardial perfusion imaging exercise testing was abnormal. The left ventricular ejection fraction (LVEF) was 29%. He was in no distress. Vital signs and the oxygen saturation were normal. The electrocardiogram (ECG) was not acute. He underwent successful and uncomplicated percutaneous intervention of the left circumflex artery. He remained stable. There were no complications. He was discharged in stable condition. 

The inpatient hospital admission was not medically necessary. This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, or renal failure requiring acute treatment. There was no need for urgent revascularization, prolonged intravenous medications or oxygen support, need for ongoing invasive hemodynamic monitoring, or introduction of high risk medications requiring prolonged in-hospital monitoring. In this setting an inpatient level hospitalization, compared to a lower level of care, has not been established as standard of care towards improved percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case. A lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiolitis. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is overturned. 

This is a male with a history of congenital hypothyroidism who had been sick for one week with a runny nose and a cough. His two siblings were also sick. He was seen in the emergency room (ER) 4 days prior to the admission and was diagnosed with an upper respiratory infection. On the night prior to the admission, he was crying and very irritable, and he could not sleep. The mother also reported that he had a decreased appetite and was vomiting. His mother brought him to the pediatrician who noted intercostal retraction and shortness of breath. The pediatrician noted crackles on examination of the chest and recommended that the mother bring the child to the emergency room (ER) for further evaluation and treatment. 

In the ER, he was noted to be lethargic, pale and very irritable. He was also noted to be tired, and he looked dehydrated. His pulse oximeter reading was 92% (percent). On physical exam he was noted to have intercostal retraction, wheezing on the right lung and crackles and rhonchi on the left side. He was treated with an IV (intravenous) bolus of normal saline, oxygen supplementation, albuterol and ceftriaxone. He had blood testing including a blood gas and a chest x-ray which were unremarkable. He tested positive for RSV (respiratory syncytial virus). When upon repeat examination after treatment in the ER he was noted to have prolonged expiratory phase of respiration and persistent crackles on the left lung, the decision was made to admit the child to the hospital with a diagnosis of bronchiolitis and possible left sided pneumonia for continued treatment with IV fluids, antibiotics, albuterol treatments and oxygen. 

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

The inpatient hospital admission is considered medically necessary for this patient. 

The patient was treated appropriately in the ER for clinical evidence of lethargy and dehydration. He was treated with an IV bolus of normal saline, antibiotics and nebulized albuterol but continued to have intercostal retraction and crackles upon examination of the left lung.  When he did not respond to treatment in the ER it was appropriate and consistent with the standard of care to admit the infant to the hospital with a diagnosis of bronchiolitis for ongoing oxygen supplementation. He was not stable enough to be safely treated as an outpatient. 

The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Crohn's Disease. 
Treatment: Pharmacy/Prescription Drugs. 

The health plan denied the requested medication, Stelara. 
The health plan's determination is upheld. 

The patient has a history of Crohn's disease. The patient previously tried and failed Pentasa and Prednisone. The patient was then started on Stelara at the standard dose (90 mg every 8 weeks). However, the patient continued to have active disease. The measured Stelara drug level from 2021 was adequate. 
At issue is the medical necessity for Stelara at 90 mg. 

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

No, the requested treatment is not medically necessary. 

Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease. 
Chavannes M et al, reported a multi-centered cohort study supporting the safety and efficacy of Stelara in pediatric patients with Crohn's disease. 
The clinical practice guidelines support the use of Stelara in pediatric Crohn's patients who failed TNF-alpha (tumor necrosis factor) inhibitors. (van Rheenen, Patrick F., et al). Therefore, Stelara use in children with refractory Crohn's disease is appropriate and well supported by peer reviewed evidence. 
This patient does not have refractory Crohn's disease, because the patient has not yet tried and failed the FDA approved therapies for this condition, Infliximab or Adalimumab.
Furthermore, the approved dosing regimen for Stelara is 90 mg (milligrams) every 8 weeks. Dose escalation is sometimes required in biologics in order to achieve therapeutic levels. 
However, the patient had a therapeutic drug level of Stelara on the standard dose. The current literature support maintaining a drug level above 1-4 mcg/mL (micrograms/milliliter). The patient's recorded level was 11.6 mcg/mL. Further dose escalation and achieving higher drug levels is not expected to be beneficial in this case.
The patient has more appropriate and less costly therapeutic options than dose escalation. The patient can be treated with Infliximab or Adalimumab (Humira) safely and effectively. 
The medical necessity of Stelara dose escalation is not established.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Low back pain. 
Treatment: Oxycontin (oxycodone ER). 
The insurer denied coverage for Oxycontin (oxycodone ER (extended release).
The denial is upheld. 

According to the medical records, the claimant is a female who suffers from low back pain. Oxycontin is prescribed for pain relief which is extended-release Oxycodone. The requested drug is not in formulary, however extended-release Oxycodone is. 

The preferred formulary version of Oxycontin will not cause an adverse reaction. 

It is not documented in the medical records if the formulary drug has been effective based on clinical history. 

The requested drug would not be more effective than the formulary drug. It is the same drug; one is generic, and one is product name.

"Abstract Oxycodone is a semisynthetic - and -opioid receptor with agonist with a broad scope of use including postoperative analgesia as well as control of neuropathic and cancer pain. Advantages over other opioids include prolonged duration of action, greater potency than morphine and lack of histamine release or ceiling effect. Individual responses to oxycodone can vary due to genetic differences. This review article aims to summarize the oxycodone literature and provide context on its pharmacogenomics and pharmacokinetics. The evidence for clinical effect of genetic polymorphisms on oxycodone is conflicting. There is stronger evidence linking polymorphic genetic enzymes CYP2D6 (liver enzyme) and CYP3A (liver enzyme) with therapeutic outcomes. Further, research is needed to discern all of oxycodone's metabolites and their contribution to the overall analgesic effect." (Umukoro, N. N. et al. 2021). 

"In the etiology of non-malignant pain, a significant proportion is constituted by patients with pain originating in the musculoskeletal system. The use of strong opioids in the treatment of non-malignant pain is still controversial. Therefore, the aim of this study was to establish the efficacy and safety of oxycodone with a controlled release (CR) of the active substance in the treatment of patients with chronic, not well-controlled musculoskeletal pain. Here we present our preliminary results. In this prospective, open, single-center study conducted at a rheumatology center we enrolled consecutive patients with musculoskeletal pain due to a variety of musculoskeletal diseases (osteoarthritis, pain in the lower back, spondyloarthritis), who suffered from moderate to severe pain despite previous analgesic therapy (with NSAIDs (non-steroidal anti-inflammatory drugs), weak opioids, or a fixed combination of paracetamol and weak opioids). Patients were switched to therapy with oxycodone CR and followed for 14 days. The starting dose of oxycodone CR was 10 mg (milligram), and later the dose was adapted as necessary." (Grazio, S. et al. 2016). 

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

The insurer's denial of coverage for Formulary Exception for Oxycontin (oxycodone ER) is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Aortic regurgitation 

Treatment: Transcatheter aortic valve replacement or (TAVR) (procedure codes 33361 and 33370) and full hospital admission

The insurer denied coverage for transcatheter aortic valve replacement or (TAVR) (procedure codes 33361 and 33370) and full hospital admission

The denial is overturned

Asked to review the case of a woman with a history of symptomatic severe aortic regurgitation and determine medical necessity for TAVR (Jenna valve) and associated hospital admission. Past medical history is significant for severe mitral regurgitation status post mitral clip repair, non-ischemic heart failure with reduced ejection fraction (28%) due to Adriamycin therapy, breast cancer, Hodgkins lymphoma status post mantle cell radiation therapy. Following mitral clip repair, the patient noted worsening exercise tolerance with dyspnea after climbing 2-3 steps. Intraprocedural TEE (transesophageal echocardiogram) demonstrated severe aortic insufficiency with a pressure half time of 226msec (milliseconds), a vena contracta of 7mm (millimeters), and a significant diastolic flow reversal in the descending aorta. Open heart surgery for AVR (aortic valve replacement) is high risk in this patient with an STS (society of thoracis surgeons) score of 19.5%.

The health care plan did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient suffers from worsening heart failure and severe aortic regurgitation. Untreated, severe AR (aortic regurgitation) results in a 10-20% mortality. (Reference 1). The Jenna valve has been demonstrated to effectively treat severe aortic stenosis and is currently being evaluated in an FDA (food and drug administration) Breakthrough device program. (Reference 2-4). This patient is not a candidate for open surgical valve replacement due to a high degree of morbidity and mortality. She continues to suffer from severe AR and symptoms of worsening heart failure. As such, TAVR and full hospital admission is medically necessary.

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

The insurer's denial of coverage for transcatheter aortic valve replacement or TAVR (procedure codes 33361 and 33370) and full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypertension and dementia

Treatment: Increase in personal care services (PCS) from 8 hours a day, 7 days a week (total of 56 hours a week) to 24 hours a day, 7 days a week (live-in) for total of 91 hours

The insurer denied coverage for an increase in personal care services (PCS) from 8 hours a day, 7 days a week (total of 56 hours a week) to 24 hours a day, 7 days a week (live-in) for total of 91 hours

The denial is overturned

This patient with multiple medical problems including diabetes, hypertension and dementia. According to the appeal letter the patient fell together with his wife who tried catching him when she saw him falling. As a result, he fell on top of her and did not get hurt. However, the wife broke her hip. The wife required a surgical hip replacement, and the patient was admitted for a urinary tract infection and currently residing in a nursing facility. He is anticipating a return to his residence where he lives with his spouse in a 1-bedroom apartment. Under review is the requested increase in PCS from 6 hours/day, 7 days/week (total of 56 hours a week) to 24 hours/day, 7 days/week (live-in) for total of 91 hours.

According to the Uniform Assessment System (UAS) report, the patient requires extensive to maximal assistance for activities of daily living including dressing, hygiene and bathing. Toilet transfers/use also requires maximal assistance. He is occasionally to frequently incontinent of bowel and bladder. He uses a walker and requires the assist of another person for short distance ambulation. His functional ability has declined over the past 90 days. The combination of the patient's functional decline, maximal assistance for activities of daily living and his primary care giver's (wife) recent hip fracture with subsequent replacement, support the requested increase PCS from 8 hours/day, 7 days/week (total of 56 hours a week) to 24 hours/day, 7 days/week (live-in) for total of 91 hours, in order to allow him to resume living safely at home.  

The requested increase in PCS from 8 hours/day, 7 days/week (total of 56 hours/week) to 24 hours/day, 7 days/week (live-in) for total of 91 hours is medically necessary.

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

The insurer's denial of coverage for an increase in personal care services PCS) from 8 hours a day, 7 days a week (total of 56 hours a week) to 24 hours a day, 7 days a week (live-in) for total of 91 hours is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld.

The patient is a male with a history of back and bilateral leg pain/weakness. He has had physical therapy, injections, and medications without relief. He is a non-smoker. The neurologic exam shows no motor or sensory deficits. No magnetic resonance imaging (MRI) report is provided, however a large, herniated disc at lumbar (L)3-4 is discussed. The provider completed a L3-4 laminectomy and discectomy which was performed. The subject under review is the medical necessity for the inpatient stay in this case.

The health plan's determination is upheld.

The records do not support that the inpatient stay was medically necessary for this patient. There is no lumbar MRI report provided. There is also conflicting information documented, as the provider describes lower extremity weakness, however, the neurological exams documented are normal. The patient underwent surgery, which was completed, and the patient was transferred to the post-anesthesia care unit (PACU) in satisfactory condition.
Based on the records reviewed, the inpatient stay was not supported as medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity.
Treatment Ozempic.
The insurer denied coverage for Ozempic.
The denial is overturned.

The patient has a history of a heart transplant, sleep apnea, gastric sleeve gastrectomy, tricuspid valve replacement, and chronic kidney disease. The creatinine has been 1.6. Her BMI (body mass index) is 30.95. She has been advised to alter her diet and to exercise. Her physician has recommended that she start Ozempic.

Up to Date has an article titled "Obesity in adults: Drug therapy." The article states that a number of medications are approved by the FDA [Food and Drug Administration] for the treatment of obesity. These medications should be used in conjunction with healthy eating, physical activity, and behavior modification. Candidates for drug therapy include those individuals with a BMI of 30 or a BMI of 27 in patients with weight-related comorbidities. Semaglutide Is a GLP-1 [glucagon-like peptide-1] receptor agonist that is approved for the treatment of obesity. It has demonstrated efficacy in weight reduction as well as improvement in glycemia and lipids.

This patient has obesity with multiple comorbid conditions. The recommendation from UpToDate is that Semaglutide is beneficial for a patient with a BMI of 30. There is no requirement that the patient also has to be a diabetic. 

The health care plan did not act reasonably or in the best interest of the patient. Ozempic is medically necessary.

The insurer's denial of coverage for Ozempic is overturned. Medical Necessity is substantiated.