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

Diagnosis: Sleep apnea, decreased endurance, and shortness of breath on exertion

Treatment: Increase in consumer directed personal assistance services (CDPAS), 5 hours per day, 5 days per week, for a total of 25 hours per week

The insurer denied coverage for an increase in CDPAS, 5 hours per day, 5 days per week, for a total of 25 hours per week.

The denial is upheld.

This is a patient with chronic medical problems including sleep apnea, decreased endurance, and shortness of breath on exertion. A requested increase from 20 hours per week (4 hours per day x 5 days per week) to 5 hours per day, 5 days per week, for a total of 25 hours per week is currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "modified independence." He requires maximal assistance for bathing and lower body dressing. Extensive assistance is required for personal hygiene, upper body dressing, ambulation, toilet transfer/use and bed mobility. He is independently able to eat and drink. The patient is occasionally incontinent of bladder and continent of bowel. There has not been a significant functional decline compared to the prior assessment. This physician agrees with the insurer; the patient's health and safety can be appropriately provided and maintained by the currently approved consumer directed personal assistance services (CDPAS) 20 hours/week (4 hours/day x 5 days/week).

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested increase in CDPAS, 5 hours per day, 5 days per week, for a total of 25 hours per week is not medically necessary.  

The insurer's denial of coverage for CDPAS, 5 hours per day, 5 days per week, for a total of 25 hours per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Seizure. 
Treatment: Inpatient Stay. 
The insurer denied inpatient stay. 
The denial is overturned.

The patient is a male who presented to the emergency department after a seizure. He was well until two days prior to presentation when he began to vomit. He had been vomiting every 30 minutes, and he felt warm to the touch and was given acetaminophen. He also had decreased oral intake and decreased wet diapers. The morning of presentation he vomited after eating breakfast. He then stood up, leaned against a door, slid to the ground, and had a 30 second tonic clonic seizure. He was described as having twitching of the extremities, pallor, and drooling. He was subsequently brought to the emergency department for care.
Upon arrival in the emergency department, he was described as lethargic and arousable with touch. He received Zofran and a normal saline bolus. Laboratory values were significant for a bicarbonate of 14.9. An electrocardiogram (EKG) was obtained as well as a chest x-ray which showed peribronchial thickening. He was admitted to the hospital for a febrile seizure with dehydration due to gastroenteritis. He was treated with intravenous fluids with monitoring of his intake and output. The fluids were weaned over time as he was able to tolerate oral intake without vomiting. He had no further seizures, and by the following day he was felt to be back to baseline and stable for discharge to home with follow-up as an outpatient.
The medical necessity for the inpatient stay is the subject under review.

The health plan's determination is overturned.

The requested health service/treatment of inpatient stay was medically necessary for this patient.
This is a patient who presented after a seizure. He had been repeatedly vomiting and had decreased wet diapers and was dehydrated at the time of arrival. His bicarbonate level was very low at 14.9. He required hospital admission for ongoing administration of intravenous fluids to treat his dehydration as well as monitoring of input and output and for further seizure activity.
The decision making at the time of admission for this patient was consistent with his age, the history of repeated episode of emesis and a witnessed seizure, and the need for treatment of significant dehydration along with evaluation and monitoring for seizures.
According to the Milliman Care Guidelines (MCG) Health Inpatient and Surgical Care Guidelines, 25 Edition; Seizure, Pediatric; hospital admission is indicated for patients with a febrile seizure from an etiology that requires intervention available only at inpatient level of care. This patient had significant dehydration from recurrent emesis and had a very low initial bicarbonate level of 14.9. He therefore required hospitalization for ongoing management of dehydration with intravenous fluids along with close monitoring of his clinical status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exotropia, myopia, hypertension, diabetes, osteoarthritis, and varicose veins
Treatment: Consumer Directed Personal Assistance Services a total of 105 hours per week
The insurer denied: Consumer Directed Personal Assistance Services a total of 105 hours per week.
The denial is upheld.

The patient is an elderly female. She has multiple medical conditions, including exotropia, myopia, hypertension, diabetes, osteoarthritis, and varicose veins. Denial of increase consumer directed personal assistance services for a total of 105 hours per week is being appealed. The plan has approved 70 hours per week. The patient's daughter requested increased hours because the patient is becoming more unsteady and more confused.

Uniform Assessment System (UAS) evaluation completed this year shows modified independent cognition and functional status: total dependence with housework; maximal assistance with meal preparation, shopping, and lower body dressing; extensive assistance with managing finances, stairs, transportation, bathing, personal hygiene, upper body dressing, walking, and locomotion; limited assistance with managing finances and toileting; independent with bed mobility; and supervision with eating. The patient has frequent bladder incontinence.

An appeal statement notes the patient has multiple chronic conditions and falls frequently. She is wheelchair bound and needs assistance with all ADLs (activities of daily living).

A statement from the patient's provider notes the patient's conditions impairs her ability to function independently. She is wheelchair bound and has limited mobility. Her health is declining.

The requested Consumer Directed Personal Assistance Services for a total of 105 hours per week is not medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with ADLs; health maintenance activities; and routine support services. This patient has multiple chronic medical conditions. Denial of increase consumer directed personal assistance services for a total of 105 hours per week is being appealed. The plan has approved 70 hours per week. The plan denied the increase in hours because the personal care tasks could be performed in the current hours provided.

Uniform Assessment System (UAS) evaluation completed this year shows the patient requires assistance with all ADLs, except bed mobility and eating. Documents provided indicated the patient's health is declining with increased confusion and limited mobility. She is reported to be wheelchair bound. The information provided does not support that the patient has functional needs requiring increase CDPAS (Consumer Directed Personal Assistance Services) from 70 to 105 hours per week. Personal assistance services are not indicated for supervision or when no tasks are being performed. The approved CDPAS (Consumer Directed Personal Assistance Service) 70 hours per week is appropriate to meet this patient's needs for assistance with ADLs. The requested CDPAS (Consumer Directed Personal Assistance Service) 105 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism.
Treatment: Occupational therapy.
The insurer denied the occupational therapy. 
The health plan's determination is overturned.

The patient is a male with autism. He was denied coverage for occupational therapy sessions.

Occupational Therapy is medically necessary for this patient.

The patient is a male with autism with balance challenges, motor planning issues, sensory processing challenges, and difficulties with regulation. His occupational therapy notes demonstrate that he has made improvements in those areas while receiving therapies. These impact his quality of life and function in the community. His treating therapist and family note that while getting therapies he demonstrates improvements in these areas. The occupational therapist noted that when therapies were decreased, he demonstrated less self-regulation and a decline in overall function in all environments - home, school, and community.

It is standard of care to provide intensive occupational therapy services to children with autism and deficits in sensory processing and self-regulation, especially in a setting that has demonstrated improvement with that intervention. With a constant sensory diet, as well as consistent intervention, children can progress in their ability to self-regulate and tolerate multi-stimulating environments which improve function in the home, school, and community. The goals as noted by his occupational therapist are to set him up for the best functional and cognitive outcomes, and occupational therapy can provide him with that critical foundation for success.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture of the right distal tibia.
Treatment: Inpatient hospital admission.
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This is an adolescent with no significant past medical history. The patient presented to the emergency room (ER) with complaints of right leg pain. The patient fell while roller skating. The patient was medicated for pain and tolerated it well. Imaging revealed a Salter-Harris type II fracture of the right distal tibia. The patient underwent a closed reduction and pinning of ankle fracture. The patient was monitored after surgery, and she was discharged. Milliman Care Guidelines 25th Edition using the guideline of Musculoskeletal Disease was applied to this review. 

The records show the injury was of low energy. It was an isolated fracture to the distal tibia. There were no open wounds nor other conditions to require treatment. A splint was applied after an attempt at closed reduction ER. The operation completed was not complex nor extensive. The physician performed a closed reduction (under general anesthesia) and placed two pins through the skin. He then applied a cast. There was no blood loss. There was no incision for direct reduction. The post-surgical course was noncomplicated. The vital signs were stable. There was no evidence of bleeding or infection. There were no problems with tolerating pain medication. There were no delays in mobilization. No other medical conditions required management.

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

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

Diagnosis: urinary tract infection (UTI).
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns about fever, chills, and dysuria. Initial vital signs revealed a temperature of 103, heart rate (HR) of 103 F, blood pressure (BP) of 93/54, respiratory rate (RR) of 18, and peripheral capillary oxygen saturation (SpO2) of 99% on room air. 

The inpatient hospital admission was not medically necessary. In this particular situation, the patient had no significant medical history and presented with symptoms suggestive of a urinary tract infection. Initial evaluation revealed a temperature of 103 F, tachycardia, elevated lactic acid, and bacteriuria. Following emergency department care, hemodynamics improved and lactate normalized. Treatment thereafter included continued ceftriaxone and intravenous fluids. Following one night, the patient was deemed medically stable and discharged on oral antibiotics. No other issues or complications were documented.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment: Ubrelvy
The insurer denied Ubrelvy.
The determination is upheld.

This is a patient with acute migraines. Treatment with Ubrelvy is the subject of this review. The drug was denied because the patient has not tried and failed the available formulary alternatives. The provider appealed the determination. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug Ubrelvy, or would have adverse effects.

The formulary alternatives have not been ineffective and would be as effective as the non-formulary drug. There is no documentation in the form of consultation notes or letters of appeal indicating that the patient has tried and failed any of the formulary alternatives: Aimotriptan tablet, dihydroergotamine mesylate injection, eletriptan tablet, ergotamine with caffeine tablet, frovatriptan tablet, naratiptan tablet, rizatriptan oral disintegrating tablet (ODT), sumatriptan injection/nasal spray/tablet, zolmitriptan ODT/tablet, zomitriptan nasal spray. These drugs are all considered to be first-line agents for treatment of acute migraine. These drugs are Food and Drug Administration (FDA) approved for this indication and are safe and effective. Ubrelvy has not been shown to be superior to any of these agents. There is no documentation that the patient has a contraindication to the use of these agents.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Several strokes and dementia.
Treatment: Increase in home care hours from 56 hours per week to 24 hours per day live-in home care services.
The insurer denied: Increase in home care hours from 56 hours per week to 24 hours per day live-in home care services.
The denial is overturned.

This elderly male has multiple chronic conditions including several strokes and dementia.  He is appealing denial of increase in home care hours from 56 hours per week to 24 hours per day live-in home care services.  Uniform Assessment System (UAS) evaluation shows minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, and shopping; extensive assistance with managing finances and medications, phone use, stairs, bathing, lower body dressing, and toileting; limited assistance with personal hygiene, upper body dressing, walking, locomotion, and bed mobility; and supervision with eating.  He has bladder incontinence.  Compared to the prior Uniform Assessment System (UAS) evaluation, there has been a decline with cognition and toileting.  A statement from the patient's provider indicates the patient has multiple chronic medical conditions.  He has had a decline in functional and cognitive abilities.  He is no longer ambulatory.   He was hospitalized for failure to thrive with dysphagia.  The patient needs assistance with activities of daily living (ADLs) and needs to be repositioned every four hours.

The proposed increase in home care hours to 24 hours per day live-in is medically necessary.
Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies.  Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with activities of daily living (ADLs), including toileting, walking, transfers, turning/positioning, or feeding.  

This patient has multiple chronic conditions, including dementia.  He was recently hospitalized with failure to thrive.  He is appealing denial of increase home care hours from 56 hours per week to 24 hours per day live-in home care services.  Uniform Assessment System (UAS) evaluation shows the patient requires assistance with all activities of daily living, except eating.  The patient is incontinent of bladder.  The appeal statement from the patient's provider notes that the patient's functional and cognitive abilities have declined.  He needs assistance with all activities of daily living and is wheelchair bound.  He needs repositioning every four hours.  This patient has significant needs for assistance with activities of daily living and needs frequent repositioning.  The approved home care at 56 hours per week is insufficient to meet the patient's needs for assistance with activities of daily living and personal care.  The proposed increase to 24 hours per day live-in home care services is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spondylarthritis

Treatment: Humira (adalimumab)

The insurer denied coverage for Humira (adalimumab)

The denial is overturned

The treating provider has diagnosed the patient with a history of spondylarthritis, arthralgia of multiple sites and positive ANA (antinuclear antibody).  The patient failed multiple non-steroidal anti-inflammatory drugs (NSAIDs), including ibuprofen and diclofenac. The treating provider has requested therapy with Humira. A progress note with Rheumatologist noted seronegative spondyloarthropathy and HLA (human leukocyte antigen) B37 positivity. There was concern for underlying SpA (peripheral spondyloarthritis). Humira was requested. The patient failed multiple NSAIDs. A tumor necrosis factor (TNF) inhibitor is indicated. Humira should be approved.

Per Ward, M. M., et al., (2019), "Recommendations for AS [axial disease],  and nonradiographic axial SpA are similar. TNFi (Tumor Necrosis Factor Inhibitor) are recommended over secukinumab or ixekizumab as the first biologic to be used."

Per Sen, R., Goyal, A., Hurley, J. A,. (2022), "Treatment goals for SpA are reducing symptoms, reducing functional limitations, and decreasing complications associated with the disease. A mainstay of therapy is an exercise to preserve spine and peripheral joint strength and range of motion. Often, formal physical therapy is beneficial. The main pharmacologic therapy is a NSAID, usually in maximal doses (except in IBD (irritable bowel disease) associated arthritis), and at least two NSAIDs must be tried before advancing to the next class of pharmacologic agents. In the event NSAIDs fail to control symptoms, are intolerable due to side effects, or are contraindicated due to other co-morbid conditions, the next step in treatment depends on whether the disease is axial disease or peripheral disease. In axial disease (AS), biologics (TNF inhibitors) are the next line of therapy. Five TNF inhibitors, infliximab, etanercept, adalimumab, golimumab, and certolizumab, are shown to achieve partial or full remission of symptoms."

Humira (adalimumab) is considered medically necessary for this patient. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

Based on the above, the insurer's denial must be overturned.   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 Humira (adalimumab) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Increase Personal Care Aide (PCA) Level II to Daily 24 Hour Live in. 

The insurer denied: Increase Personal Care Aide (PCA) Level II to Daily 24 Hour Live in. 
The denial is overturned. 

The patient is an elderly female. Her conditions include dementia. She lives in a single-family home with her daughter. Denial of increase personal care aide (PCA) to daily 24 hour live in is being appealed. The health plan approved an increase from 50 to 70 hours per week. Uniform assessment system (UAS) shows severely impaired cognition and total dependence with meal preparation, housework, managing medications and finances, phone use, stairs shopping, bathing, personal hygiene, and dressing; extensive assistance with walking, locomotion, toileting, and bed mobility; and limited assistance with eating. The patient has bowel and bladder incontinence. An appeal letter notes that the patient is nonverbal. She is totally dependent with ADLs (activities of daily living) and is a fall risk. Her daughter is her only caregiver but has a full time job. The patient needs assistance with ADLs (activities of daily living) as accounted for in the UAS (uniform assessment system) evaluation. Clinical records show that the patient needs end-of-life care. She has confusion, reduced mobility, urge incontinence, stable pressure ulcer of left buttock, diabetes and dementia. A letter from the daughter notes needs for assistance with ADLs (activities of daily living). 

The requested Increase Personal Care Aide (PCA) Level II to Daily 24 Hour Live in is medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of increase personal care aide (PCA) to daily 24 hour live in is being appealed. The health plan approved an increase from 50 to 70 hours per week. 

This patient has multiple chronic conditions, including dementia. Uniform assessment system (UAS) shows the patient requires assistance with all ADLs (activities of daily living). She is incontinent of bowel and bladder. The records and appeal statements support that the patient's physical and cognitive status have declined, and she is dependent with all ADLs (activities of daily living). Her daughter is unable to continue with informal support. The information provided shows that this patient has significant limitations in functioning. The approved PCA (personal care aide) 70 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase home care/personal care personal care services PCA (personal care aide) 24 hours per day, live in, is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Bowed legs-post surgery.
Treatment:  Inpatient Admission.

The insurer denied the inpatient stay.  The determination was overturned.

The patient is a male with a history of bilateral infantile Blount disease. His previous treatment had included both guided growth procedures and tibial osteotomy. Despite this he had persistent bowing of both legs that led to difficulty walking. He saw a pediatric orthopaedic surgeon, who recommended a fixator-assisted osteotomy of the left tibia with internal fixation and a guided growth procedure for the right tibia to address the deformity. The patient was admitted to the hospital for three days.

While the guided growth procedure on the right tibia is a relatively small procedure that can often be done on an outpatient basis, the osteotomy with fixation of the left tibia is a major procedure with significant risks, including nerve and vascular injury, as well as limb ischemia. The intensity of services required for this procedure justifies inpatient hospital admission.

Close monitoring is required after this type of surgery, particularly when a cast is used, as it was in this patient. The pain is often sufficient to require intravenous analgesics and sedatives, as it was for this patient. After surgery, the patient required a wheelchair and training in transfers from wheelchair to bed and toilet. The intensity of services required for this procedure justifies inpatient hospital admission.