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

Diagnosis: Alzheimer's disease
Treatment: Personal care worker (PCW) 12-hours times (x) 2 per day split shifts, 7 days a week
The insurer denied the  personal care worker (PCW) 12-hours times (x) 2 per day split shifts, 7 days a week.
The determination is overturned.

The patient has a past medical history of Alzheimer's disease and hypertension (HTN). Review is regarding the medical necessity of a personal care worker (PCW) 12-hours times (x) 2 per day split shifts, 7 days a week. Current approved hours are 12 hours daily, 7 days a week.

She had undergone an assessment for PCA (personal care assistant) services assessing the patient with moderately impaired cognition with memory problems. The patient was noted to be alert and confused. She has minimal hearing and no vision difficulties. She requires total dependence with the tasks of ordinary housework and meal preparation. The patient was assessed at maximal assistance with the tasks of bathing, personal hygiene, dressing upper body and dressing lower body, limited assistance with walking and locomotion, transfer toilet, maximal assistance with toilet use, supervision with bed mobility and extensive assistance for eating. She ambulates independently. She was noted with a decline in activities of daily living (ADL) status in the last 90 days, with deterioration in self-sufficiency. She is bladder incontinent and bowel continent. It is noted that she requires maximum (max) to total assistance (assist) in all activities due to confusion. At issue is the medical necessity of a personal care worker (PCW) 12 hour x2 per day split shifts, 7 days a week. 

The requested health service/treatment of personal care worker (PCW) 12 hour x2 per day split shifts, 7 days a week is medically necessary for this patient. The requested increase in assistance was not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL)s and Instrumental activities of daily living (IADL)s. Per the documentation, the patient has no assistant during nocturnal hours. Based on the uniform assessment, the patient required maximal assistance with toilet use. Her assessment indicates that she needs maximal (max) to total assistance in all activities in the 24 hour period due to confusion, severe tremor in both hands, shoulder pain, and limited range of motion (ROM). She is noted with an unsteady gait based on the sleep study progress notes. The patient requires significant personal care assistant (PCA) hours for the safe completion of all her activities of daily living (ADLs).  Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7 days/week, times (x) 2 per day split shifts, are medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a boy with asthma who presented to the emergency department with right sided pleuritic pain.
He was well until 3 days prior to presentation when he developed pain over his right lateral chest. The pain radiated down to his right flank and was exacerbated with movement and deep breaths. He was given ibuprofen at home with no resolution. He also had a mild cough. The evening prior to presentation he awoke with pain and was seen in the emergency department. He was diagnosed with right middle lobe pneumonia at that time and was given Ceftriaxone and sent home with a prescription for Augmentin. However, the following day he awoke with difficulty breathing due to 10 out of 10 pain and tachypnea, and so he returned to the emergency department for care.

Inpatient Hospital Admission was medically necessary for this patient.
This is a teenage boy who presented with severe pain and difficulty breathing in the setting of a right middle lobe pneumonia. He continued to have pain despite appropriate treatment at a prior emergency visit and home pain management, and at the time of presentation was tachypneic and taking shallow breaths with significant pain. He required prompt initiation of treatment including parenteral pain medications as well as further evaluation including imaging, an EKG (electrocardiogram), and laboratory studies. He was appropriately admitted for ongoing management with intravenous antibiotics and pain medicines, intravenous fluids, respiratory treatments and monitoring.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pycnodysostosis.

Treatment: Prenatal carrier screening.

The insurer denied coverage for prenatal carrier screening.

The denial is upheld.

The patient is a female with a history of a child with multiple comorbidities. There is no report of the genetic testing done on that child and if there was any genetic anomaly found. She had an expanded carrier screening panel performed. Testing was positive for being a carrier of Pycnodysostosis.

The insurer has denied coverage for prenatal carrier screening, as not medically necessary. In a Final Adverse Determination letter, they stated that the requested test is not considered part of routine care.

The patient is appealing. In an appeal letter, the Reproductive Endocrinologist, stated that the request is for Sema4 Expanded Carrier Screen of 283 recessive and X-linked disorders. The patient tested positive for at least one pathogenic variant. The information provided from the test will allow for a prompt referral to the appropriate medical professionals.  

The patient underwent extensive genetic carrier studies. Expanded panels may include the diseases that are present with increased frequency in specific populations, but typically include testing for a wide range of diseases for which the patient is not at risk of being a carrier.

As per the American College of Obstetricians and Gynecologists (ACOG), "All patients who are considering pregnancy or are already pregnant, regardless of screening strategy and ethnicity, should be offered carrier screening for cystic fibrosis (81220) and spinal muscular atrophy (SMA) (81401). All other genetic carrier screening in the absence of a positive family history or personal history and in the absence of an ethnic background at high risk for these conditions is considered not medically necessary". ACOG based their recommendation on the fact that there is insufficient scientific evidence that the requested gene panel will have a significant impact on treatment planning or outcome. So based on ACOG's recommendation and standard of care, the expanded carrier screening was Experimental/Investigational because the scientific evidence does not show any benefit from panel testing. 

While the patient had a child with multiple anomalies, there is no documentation submitted as to the genetic cause of these anomalies. If any genetic cause was found, then the patient should have been tested for that condition only rather than undergoing an expanded screen.

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

The insurer's denial of coverage for prenatal carrier screening is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe esophagitis

Treatment: Procedure code 43239, diagnostic esophagogastroduodenoscopy (EGD)

The insurer denied coverage for procedure code 43239, diagnostic esophagogastroduodenoscopy (EGD)

The denial is overturned

The patient was previously found to have severe esophagitis with ulcers. He was treated with Omeprazole 40 mg (milligrams) twice a day. A repeat endoscopy showed that the patient still had esophagitis. The biopsies this time only showed mild reflux esophagitis. 

MCG (Milliman Care Guidelines) guideline ACG: A-0203 lists indications for Upper GI (gastrointestinal) endoscopy. Indications are listed for gastrointestinal reflux disease. One of the indications in this category is severe erosive esophagitis that is known with a need for follow up after 8 weeks of proton pump inhibitor therapy. 

This patient had severe reflux esophagitis with ulcers. He was treated with high dose PPI (proton pump inhibitor) therapy. Having severe esophagitis with ulcers meets the MCG guideline for a repeat endoscopy after treatment. The health care plan did not act reasonably or with sound medical judgment. Doing the endoscopy was 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 procedure code 43239, diagnostic esophagogastroduodenoscopy (EGD) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Altered Behavior. 
Treatment: Inpatient Stay. 

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

This is the case of a male with autism who was brought to the emergency department (ED) due to excessive crying and behavioral change. The patient was previously examined by his PCP (primary care provider) and advised ED evaluation when symptoms persisted. There was no fever, vomiting, or known trauma.
The ED vitals were T (temperature) 99.6F (Fahrenheit), heart rate (HR) 84-132, respiratory rate (RR) 16-20, and O2 (oxygen) saturation 98-100% on room air. Exam was non-focal, and the patient was walking around the room hitting the stretcher and vocalizing. No evidence of abnormalities was noted on exam. Labs were white blood cell count (WBC)=11.14, Hct (hematocrit)=35.8, platelets (Plt)=817. Electrolytes and urinalysis (UA) were grossly normal. Respiratory swab was positive for respiratory syncytial virus (RSV). Abdominal computed tomography (CT) scan showed incidental finding of right adrenal mass measuring 3.4 x 1.9 centimeter (cm). Findings were discussed with the pediatric team and the decision was made to admit overnight for magnetic resonance imaging (MRI) the following day. 

The Inpatient Hospital Admission is not medically necessary for this patient. This patient had stable vital signs, no need for respiratory support due to diagnosis of RSV, and was awaiting preparation for MRI imaging procedure for incidental abdominal mass. Thus, this patient's care could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nasal breathing problems
Treatment: Surgery
The insurer denied the surgery
The denial is upheld.

The patient is a male with a history of nasal breathing problems with reported chronic rhinitis. He had a deviated septum, inferior turbinate hypertrophy, nasal valve pathology.

The patient underwent surgery including a septoplasty, inferior turbinate surgery, nasal cryotherapy and placement of Latera implants. The request was previously denied coverage as not medically necessary. This denial is being appealed.

No, the surgery was not medically necessary.
All records were reviewed. There is a reported history of chronic nasal obstruction.  The photos provided do not demonstrate nasal valve pathology.  There is not a detailed documentation of the failure of medical therapy with agents such as nasal steroids for the patient's condition despite inferior turbinate hypertrophy being noted. Therefore, based on the information provided, the medical necessity of the  septoplasty, inferior turbinate surgery, nasal cryotherapy and placement of Latera implants cannot be confirmed.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain and Vomiting
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She presented to the ED (emergency department) complaining of four days of abdominal pain associated with nausea and vomiting. It is noted that the patient was drinking and smoking a new kind of marijuana.

The patient's VS (vital signs) were as follows: Temperature 98.4, pulse 67, respiration rate 18, blood pressure 139/87, and oxygen saturation 100%.  The patient's exam on H&P (history and physical) was unremarkable.  The patient's labs were as follows: WBC (white blood count) 15.8, H/H (hemoglobin/hematocrit) 15.2/47.6, and Plt (platelets) 481. CMP (comprehensive metabolic panel) was unremarkable.  EKG (electrocardiogram) revealed prolonged QTC (corrected QT interval).  Pelvic US (ultrasound) was normal.

The patient was admitted.  Plan of care included IVF (intravenous fluids), IV (intravenous) antibiotics, Zofran prn (as needed) and clear liquid diet.

Day three, The patient's vital signs were stable. Her pain came back after drinking some OJ (orange juice). She had diffusely tender abdomen.  Alcohol gastritis vs marijuana vomiting syndrome was noted.  Antibiotics were discontinued.  The plan was to advance diet as tolerated.

No, the Inpatient admission was not medically necessary.
This patient was admitted after presenting with vomiting that began after polysubstance use.  She was hemodynamically stable and afebrile.  She had mild leukocytosis.  She was not dehydrated.  She did not have severe electrolyte abnormalities or renal failure.  Imaging was unremarkable. She did not have persistent nausea and vomiting.  The patient did not require prolonged NPO (nothing by mouth).  She had not failed a lower level of care.  The requested inpatient admission was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hyperlipidemia
Treatment: Formulary exception for Livalo (pitavastatin)
The insurer denied the Formulary exception for Livalo (pitavastatin)
The denial is upheld.

The patient is a male with history of hyperlipidemia. Several years ago, the patient was on atorvastatin and Livalo.  Based on the documentation, the statin was discontinued for elevated creatinine klinase (CK) of 779; Livalo was continued. There is documentation of coronary atherosclerosis and hyperlipidemia for greater than five years. 

The request is for a formulary exemption due to side effects of statins (creatinine kinase rise and myalgias).

No,  the proposed treatment is not medically necessary as alternative low intensity statins are on the formulary.
The patient has indications for lipid lowering strategy with history of coronary artery disease (CAD) and hyperlipidemia.  The patient was treated with atorvastatin and had documentation of myalgias and creatinine kinase (CK) rise above 700. The literature does recommend to not continue the use of statins other than pravastatin, fluvastatin, and pitavastatin. These particular statins are described as the best tolerated in a patient with statin myopathy.

Several of these drugs are on the formulary and their use would not pose a significant risk for myositis or rhabdomyolysis. 

Based on UP-TO-DATE recommendation: "Pravastatin, fluvastatin, and pitavastatin appear to have much less intrinsic muscle toxicity than other statins (see 'Statin characteristics' above). Thus, in patients who have developed statin myopathy (other than rhabdomyolysis) on a statin other than pravastatin, pitavastatin, or fluvastatin, an option is to switch to one of those medications once symptoms have resolved off statin therapy".
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pulmonary Secretions. 
Treatment: Durable Medical Equipment (E0483RRx 3). 

The insurer denied the Durable Medical Equipment (E0483RRx 3). 
The denial is overturned. 

The patient is a female with end-stage COPD (chronic obstructive pulmonary disease) and history of small cell lung cancer status post treatment. She is unable to clear pulmonary secretions. The patient has bronchiectesis. Patient has been on ICS (inhaled corticosteroid)/LABA (long-acting b2-agonist), and LAMA (long-acting muscarinic antagonist) and albuterol nebulizers. The patient has had productive cough for approximately over 6 months and has failed flutter valve therapy.

The patient is now prescribed vest therapy. Coverage for this was denied by the health plan due to lack of medical necessity. This denial is being appealed.

Yes, the requested health service is medically necessary. 

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. 

This patient with end-stage COPD (chronic obstructive pulmonary disease), and bronchiectesis is unable to clear pulmonary secretions. The patient has had productive cough for approximately over 6 months and has failed flutter valve therapy. The patient has had multiple COPD (chronic obstructive pulmonary disease) exacerbations in the past 12 months due to inadequate pulmonary secretion clearance. Since the patient has end stage COPD (chronic obstructive pulmonary disease) and has failed flutter valve therapy, the manual chest physiotherapy is not sufficient to improve clearance. Thus, the requested smart vest is medically necessary. 

Non-cystic fibrosis bronchiectesis patients have showed improved self-reported outcomes associated with the initiation of High frequency chest wall oscillation therapy as measured by number of hospitalizations, antibiotic use, and the subjective experience of airway clearance. The improvement has been observed early on after initiation of therapy and sustained for at least 1 year.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient emergency admission. 
The denial is upheld.

The patient is a male with coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD), liposarcoma status/post (s/p) resection, who presented with 3 months of dyspnea, cough, and wheeze. In the emergency department (ED), the patient's temperature was 97.5, blood pressure (BP) was 183/93, heart rate (HR) was 70, respiratory rate (RR) was 17, and pulse oxygen saturation (spo2) was 96% on room air (RA). He was in no distress, heart was regular, breathing comfortably, with clear lungs, alert and oriented. His white blood cell count (WBC) was 11.8, sodium (Na) was 140, bicarbonate was 23, blood urea nitrogen (BUN) /creatine (Cr) was 3/1.05, troponin (Tn) less than (<) 0.01; venous blood gas (VBG) was 7.38/46; coronavirus (COVID) and flu were negative. The chest x-ray (CXR) was clear.
In the ED, he was diagnosed with a COPD flare and started on intravenous (IV) steroids and nebulizers (nebs); a few hours later he was still wheezy but felt better. The admitting team also diagnosed a COPD exacerbation, consulted pulmonary, and started prednisone 40 milligrams (mg) daily along with nebs. Pulmonary agreed with the diagnosis and plan.
He was feeling better, cough was nearly resolved, saturating well on RA, still wheezy on exam; transthoracic echocardiogram (TTE) found ejection fraction (EF) of 60%, likely normal right ventricle (RV), normal right atrial pressure (RAP); steroids were continued.
Pulmonary agreed with prednisone taper and were ok with discharge.
He was discharged on prednisone and inhalers.
At issue is the medical necessity of the inpatient emergency admission.

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

The requested health service/treatment of inpatient emergency admission was not medically necessary for this patient.
The patient presented with months of cough and dyspnea and was diagnosed with a COPD exacerbation. He was not severely ill at presentation with no encephalopathy, hemodynamic instability, respiratory distress, or gas exchange abnormality (was briefly on oxygen (O2) at 2 liters (L) but weaned off within 12 hours), or acute kidney injury or marked electrolyte abnormality. Routine scoring systems such as BAP-65, dyspnea, eosinopenia, consolidation, acidemia, atrial fibrillation (DECAF), and Ottawa COPD scale, would suggest his risk of worsening was low. While wheezing was slow to resolve, his symptoms of dyspnea and cough improved over an observation care time frame. With a low severity of illness at presentation, low risk of worsening, and no additional or alternative diagnoses, inpatient only testing, monitoring, or treatment were not needed. As he was not severely ill and was unlikely to become so, an inpatient admission was not medically necessary.
Therefore, the requested health service/treatment of inpatient emergency admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Surgical Services. 
The insurer denied breast reduction surgery. 
The denial is overturned.

The patient is a female who complains of back, neck and shoulder pain and rashes due to her large breasts. She treats her symptoms with analgesics. Her bra size is 38G. Her surgeon recommends bilateral breast reduction. The procedure has been denied by the insurer because of the patient's age. The subject under review is the medical necessity for the requested breast reduction surgery.

Breast reduction surgery is medically necessary for this patient. She has the classic symptoms for macromastia, and her surgeon plans a reduction of 500 grams of tissue from each breast. She has no co-morbid conditions that could explain her symptoms. Symptomatic macromastia is a mechanical problem and conservative treatments have been shown to be ineffective for this condition. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief. The best paper on this topic is by Collins and Kerrigan (1). This report is based on data from the BRAVO (Breast Reduction Assessment of Value and Outcomes) study that prospectively followed 243 patients with symptomatic macromastia. The following is quoted directly from this article: "Breast hypertrophy has a significant impact on women's health status and quality of life as measured by validated and widely used self-report instruments including the Short Form (SF)-36, McGill Pain Questionnaire (MPQ), Multidimensional Body-Self Relations Questionnaire (MBSRQ), and EuroQuality of Life (Qol). In women presenting for surgery, nonsurgical measures including weight loss, physical therapy, special brassieres, and medications were not effective in providing permanent relief of breast-related symptoms. In contrast, both pain and overall health status were markedly improved by breast reduction, essentially restoring functional status to that of age-matched norms. 

The patient's age should not be a contraindication for surgery as she is quite incapacitated by her current condition. Breast reduction is the only treatment that is proven in the medical literature to be curative for symptomatic macromastia, and hundreds of peer-reviewed studies confirm the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy. Non-operative treatments are unlikely to improve her pain, and surgery provides the only real chance for symptomatic relief.