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

Diagnosis: Crohn's disease
Treatment: Stelara 90 milligrams (mg) every 5 weeks
The insurer denied the Stelara 90 milligrams (mg) every 5 weeks.
The determination is overturned.

The patient has a history of Crohn's disease (CD). She previously tried and failed infliximab and corticosteroids. She was started on Stelara standard dose, however, she continued to have active disease. She had a low Stelara level and required dose escalation.
The requested service is Stelara at 90 milligrams (mg) every 5 weeks. This is under review for medical necessity.

Yes, the requested treatment is medically necessary.
Stelara is approved by the Food and Drug Administration (FDA) for treating Crohn's disease. The safety and efficacy of Stelara are well-established. However, some patients do not respond adequately to the standard dose. Dose escalation is often required in biologics in order to achieve therapeutic levels and clinical remission. There are many peer reviewed literature reports showing that low Stelara levels were associated with poor clinical response. The requested dose of 90 mg every 5 weeks (or higher, every 4 weeks) is proven to be effective in patients who fail the standard dose.
Per Ollech, Jacob E., et al.: "Shortening the ustekinumab 90 mg dose interval to 4 weeks for patients with CD who did not respond to doses every 8 weeks improved clinical and biological indices of disease activity. Patients who lose response to the standard dose of ustekinumab might benefit from dose interval shortening, which was effective and safe."
Per Cohen, Erica et al.: "A majority of patients with moderate to severe CD benefited from ustekinumab (UST) dose escalation suggesting the clinical utility of optimizing dosing in the treatment course. "
This patient has a history of refractory Crohn's disease which failed anti-tumor necrosis factor alpha (infliximab). The patient also failed to respond to Stelara standard dose (90 mg every 8 weeks) and required dose escalation.
Therefore, continuation of Stelara at 90 mg every 5 weeks is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Cholecystitis.

Treatment inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This is the case of a female with history of alcohol abuse, biliary colic and gastric reflux who presented with RUQ (right upper quadrant) epigastric tenderness, nausea, and vomiting.
 
As per the emergency department (ED) triage note, the patient had stable vital signs and was afebrile and presented with abdominal pain intermittently for 1 year with worsening today associated with nausea. She was diagnosed with gallstone two weeks ago and had an appointment tomorrow with the GI (gastrointestinal) doctor for abdominal pain. As per the ED provider note, the patient complained of abdominal pain and had gallstones with questionable chronic cholecystitis and returned with same RUQ/epigastric pain. On exam she had tender to palpation RUQ. The principal diagnosis was biliary colic. She was admitted to surgery. 

In addition, according to MCG (Milliman Care Guidelines) Inpatient and Surgical Care 26th Edition cholecystectomy by laparoscopy the operative status criteria is ambulatory. Thus, this patient should have been managed without an inpatient acute admission for this procedure. MCG also noted "that analysis of a cohort of 95,523 adult patients who underwent laparoscopic cholecystectomy within 10 days of presentation with acute cholecystitis found that 65% (percent) of the laparoscopic cholecystectomies were performed either the day of presentation (day 0) or the following day (day 1)."  Thus, ambulatory status would have been appropriate.

Finally, MCG General recovery care 26th edition Ambulatory surgery exception criteria notes that potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Inpatient care needed for clinically significant preoperative disease or condition; Complex surgical approach or situation anticipated; Procedure is not low risk and patient at high anesthetic risk; Presence of drug-related risk; Inadequate outpatient care situation; Postoperative event, condition, or finding that warrants inpatient stay. Given the above the patient did not warrant inpatient status but ambulatory for this procedure as she did not warrant inpatient care.

The admission was not justified at the inpatient admission level as the patient should have been managed in an ambulatory/observation setting. Denial is UPHELD.

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

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

Diagnosis: hallux valgus.
treatment: home health care.
The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 40 Hours per Week. 
The health plan's determination is overturned. 

The patient is a female with past medical history of hallux valgus, lesion of the plantar nerve, metatarsalgia, and abnormal gait who underwent surgery for correction of these conditions with long arm bunionectomy and excision of neuromas in the second and third interspace of the right foot who requested Consumer Directed Personal Assistance Services (CDPAS) following her surgery. 

Consumer Directed Personal Assistance Services (CDPAS): 40 Hours per Week is medically necessary for this patient.
There is documentation from the patient and her medical provider that she has had a decline in functional status following her surgery of her right foot. The medical provider documents the patient cannot stand longer than 15 minutes and cannot walk more than 100 feet at one time. The podiatrist also recommended the patient elevate her foot as much as possible to promote wound healing and reduce swelling. The patient requires at least limited assistance with walking, locomotion, transfer toilet, and toilet use. The only tasks that she is independent with our bed mobility and eating. The patient has no informal help. The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAS 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.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient Stay. 

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

The patient is a male with medical history of congestive heart failure, diabetes mellitus, hypertension, hyperlipidemia, transient ischemic attack, obstructive sleep apnea, gastric bypass surgery, and intussusception at the jejunal anastomosis requiring laparotomy and repair. He presented to the emergency department with nausea, vomiting, anorexia, abdominal pain, and melena. He had been evaluated in the emergency department a few days prior. Vital signs were unremarkable. 

The inpatient hospital admission is not medically necessary. In this case, the patient presented with nausea, vomiting, abdominal pain, and melena. However, there was no sustained tachycardia or hypotension, and there was no ongoing visible gastrointestinal bleeding. The patient had close monitoring, which was warranted as bleeding can be severe and sudden in onset. Proton pump inhibitor therapy was appropriately initiated. Gastroenterology performed an endoscopy, which was appropriate, and a gastrojejunal ulcers were seen, but no active bleeding was found. All of the measures that were undertaken, including monitoring, proton pump inhibitor therapy, Gastroenterology consultation, and endoscopy, could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes. 
Treatment: Continued skilled nursing (SNF). 

The insurer denied the continued skilled nursing (SNF). 
The denial is upheld. 

This male with a history of diabetes and chronic kidney disease was admitted to a SNF (skilled nursing facility) for rehab due to debility after right foot incision and debridement of infection. The foot infection was healing well.  He was able to ambulate short distances with supervision and use a scooter for mobility.  He was independent with bed mobility and able to perform ADLs (activities of daily living) with set-up or supervision. 

No. The proposed treatment is not medically necessary. 

Yes. The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. 
A skilled nursing facility level of care is indicated when:  the patient requires skilled nursing services or skilled rehabilitation services; the patient requires these skilled services on a daily basis; it is practical for daily skilled services to provided only on an inpatient basis in a SNF (Skilled Nursing Facility); and the services are reasonable and necessary for the treatment of the patient's illness or injury.  Custodial care is care primarily for the purpose of assisting a patient in ADLs (activates of daily living) or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury. It is care that cannot be expected to substantially improve a medical condition and has minimal therapeutic value.  As of the date in question, this patient no longer required skilled care.  The patient had an infection, which was healing with no complications.  The patient's functional status no longer required therapy on an inpatient basis.  The patient was receiving custodial care because the care provided is no longer expected to substantially improve a medical condition and has minimal therapeutic value. Therefore, continued Skilled Nursing (SNF), was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Injuries from gunshot wounds. 
Treatment: Inpatient admission. 

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

The patient is a male. He presented with injuries after gunshot wounds x (times) 4, resulting in humeral shaft fracture, which required ORIF (open reduction internal fixation). 

Coverage of the patient's inpatient admission was denied by the health plan on the basis of medical necessity. This denial is being appealed. 

No, the Inpatient admission was not medically necessary. 

This patient's major injury was his humerus fracture, for which this patient had ORIF (open reduction internal fixation). 

As per the MCG (Milliman Care Guidelines) National Guidelines: The expected Length of Stay for his injury is Ambulatory. In keeping with this expected length of stay, this patient could have been treated at a lower level of care. As per a review of the submitted Hospital Records and Letters of Appeal dated from : It is evidenced that all the medical care that this patient did receive, including Surgery, IV (intravenous) fluids, Pain control, Follow-up X-rays, DVT (deep venous thrombosis) prophylaxis, PT/OT (physical therapy/occupational therapy), Psychiatry consultation, and incentive spirometry all could have been provided safely, effectively, and efficiently at a lower level of care, not requiring a full Acute Inpatient Admission. 

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient. 

In keeping with National MCG (Milliman Care Guidelines) Criteria: The medical care provided this patient all could have been provided safely, effectively, and efficiently at a lower level of care, not requiring a full Acute Inpatient Admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Good's Syndrome with lung disease, oxygen-dependent, stiff person syndrome, and lupus. 
Treatment: Increase Consumer Directed Personal Assistance Care (CDPAS) To 80 Hours per Week. 

The insurer denied the Increase Consumer Directed Personal Assistance Care (CDPAS) to 80 Hours per Week. 
The denial is overturned. 

The patient is a female with multiple chronic medical conditions, including Good's Syndrome with lung disease, oxygen-dependent, stiff person syndrome, and lupus. She is status post gallbladder removal. The patient is appealing the denial of the request to increase consumer-directed personal assistance care (CDPAS) to 80 hours per week.  The health plan approved CDPAS (consumer-directed personal assistance care) 56 hours per week. 

Uniform Assessment System (UAS) evaluation completed shows modified independent cognition and functional status: total dependence with completing housework; maximal assistance with meal preparation, shopping, and bathing; extensive assistance with personal hygiene, dressing, walking, locomotion, and toileting; limited assigned with managing medications and eating; set up with phone use; and independent with bed mobility.  Compared to UAS (Uniform Assessment System) evaluation completed previously, there has been a functional decline in housework, bathing, upper body dressing, walking, locomotion, and toilet transfer. 

Yes, the requested increase in consumer directed personal assistance service to 80 hours/week is medically necessary. 

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

Personal Assistance Services provide hands-on assistance to individuals including assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. The patient is appealing denial of increasing CDPAS (consumer-directed personal assistance care) to 80 hours per week. The health plan approved CDPAS (consumer-directed personal assistance care) 56 hours per week. 

This patient has multiple chronic medical conditions. Uniform Assessment System (UAS) evaluation completed shows the patient requires assistance with all ADLs (activities of daily living), except bed mobility. Compared to UAS (Uniform Assessment System) evaluation completed previously there has been a functional decline in housework, bathing, upper body dressing, walking, locomotion, and toilet transfer. She has infrequent bowel incontinence. The information shows the patient has significant physical limitations with ADLs (activities of daily living) and personal care. UAS (Uniform Assessment System) evaluations show that her physical functioning is deteriorating. The approved CDPAS (consumer-directed personal assistance care) is insufficient to meet the patient's needs for assistance. The proposed CDPAS (consumer-directed personal assistance care) 80 hours per week is medically necessary to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rhinosinusitis with Nasal Polyps and Asthma
Treatment: Dupixent 300MG/ML [milligrams per millileter] SC SOSY [subcutaneous Solution Prefilled Syringe]
The insurer denied the Dupixent 300MG/ML [milligrams per millileter] SC SOSY [subcutaneous Solution Prefilled Syringe]
The denial is overturned.

The patient is a male with chronic sinusitis with nasal polyposis. He had sinus
surgery. He has used oral antibiotics, oral steroids and nasal steroids. The patient
is a diabetic. Exam revealed bilateral polyps and septal perforation. Dupixent is
topic of this review.

Yes, the patient has nasal polyposis and has had previous surgery. He has used nasal
steroids, antibiotics, and oral steroids without improvement. Dupixent has been
shown in well designed trials to be effective for the treatment of nasal polyps in
patients who have failed surgery and nasal steroids. (see references)
Dupixent is FDA approved for treatment of chronic sinusitis with nasal polyps.
Therefore, the proposed treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the
best interest of the patient.
There is adequate documentation that the request for Dupixent is medically
necessary and consistent with current standard of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rhinosinusitis with Nasal Polyps and Asthma
Treatment: Dupixent 300MG /ML SC SOSY

The insurer denied the Dupixent 300MG/ML SC SOSY
The denial is overturned

The patient is a male with chronic sinusitis with nasal polyposis. He had sinus surgery. He has used oral antibiotics, oral steroids and nasal steroids. The patient is a diabetic. Exam revealed bilateral polyps and septal perforation. Dupixent is topic of this review.

Yes, the patient has nasal polyposis and has had previous surgery. He has used nasal steroids, antibiotics, and oral steroids without improvement. Dupixent has been shown in well designed trials to be effective for the treatment of nasal polyps in patients who have failed surgery and nasal steroids. (see references) 
Dupixent is FDA approved for treatment of chronic sinusitis with nasal polyps. Therefore, the proposed treatment is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
There is adequate documentation that the request for Dupixent is medically necessary and consistent with current standard of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female. She was hospitalized for acute pulmonary embolism (PE). Her PMH (past medical history) is remarkable for hypertension, GERD (gastroesophageal reflux disease) and resected colon cancer. Acute on chronic versus residual chronic PE (pulmonary embolism) was diagnosed as part of her OP (outpatient) preoperative evaluation for planned surgical management of left adnexal mass. Treatment included SC (subcutaneous) Lovenox while her oral anticoagulation was held and IVC (inferior vena cava) placement was considered, but not done. This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient.

No, the Inpatient admission was not medically necessary.
Based on the peer-reviewed medical literature, there was not a medical need for the acute inpatient hospital stay, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. Per the MCG (Milliman Care Guidelines) guidelines for Pulmonary Embolism #M-89, criteria for inpatient admission is not met. The patient did not demonstrate hemodynamic instability, need for IV (intravenous) narcotics to treat respiratory distress, hypoxia, current use of home O2 (oxygen), active bleeding, systemic or catheter-directed thrombolysis, appropriate monitoring and therapy that could not be provided in home or OP (outpatient) setting, IVC (inferior vena cava) filter placement or any other medical condition, symptom or finding for which observation care had failed or would not be considered appropriate. The care she received for uncomplicated PE (pulmonary embolism) is routinely provided safely and effectively at a lower level of care. Therefore, the Inpatient admission was not medically necessary, based on the submitted information and the current published medical literature.

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: Prolonged vaginal bleeding, weakness, dizziness
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld

The patient is a female. The patient in this case presented to the emergency department with a several month history of vaginal bleeding and lower abdominal pain. She had been transfused multiple times during that period of time. She had last been transfused one to two months prior to presentation.

The patient's vital signs were notable for tachycardia. Labs were notable for hemoglobin of 5.2. She was transfused in the emergency department and felt better after that, with stable vital signs and symptomatic improvement. She was admitted to the hospital and treated with Proveral and tranexamic acid.

The patient had an MRI (magnetic resonance imaging) pelvis done, which revealed a fibroid uterus with severe endometriosis. She was seen by gynecology and hematology with recommended outpatient follow up with both specialties. Tranexamic acid was continued following discharge for a total of a 5 day course.

No, the Inpatient admission was not medically necessary.
This patient had symptomatic anemia and was noted to be improved following transfusion without significant ongoing active bleeding necessitating continued acute care inpatient admission. She was not hypotensive, and also records note that she was being transfused every one to two months. While she clearly required further evaluation for her ongoing vaginal bleeding, given the absence of significant ongoing bleeding or hemodynamic instability following transfusion she did not require acute care inpatient admission.

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: Congestive heart failure. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He was hospitalized for acute on chronic CHF (congestive heart failure) after going off his medications. His PMH (past medical history) is pertinent for HFrEF (heart failure with reduced ejection fraction), cardiomyopathy, HTN (hypertension) and DM2 (diabetes mellitus type 2). Vital signs were stable: BP (blood pressure) 125/99, RR (respiration rate) 24, HR (heart rate) 95. Respirations were non-labored. Lungs were clear. Legs had edema. BNP (brain natriuretic peptide) was 3810. 

The patient's treatment included IV (intravenous) Lasix 40mg (milligrams) and transition to oral diuretic and meds. This is an appeal of the denied claim the requested Acute Inpatient Hospital Stay was medically necessary for this patient. 

No, the Inpatient admission was not medically necessary. 

Based on the peer-reviewed medical literature, the documentation submitted for review do not establish the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), inpatient admission was not medically necessary, because the severity of this patient's illness did not meet the intensity of service for inpatient hospital stay per the guideline. Criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism (PE), aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs for which emergency and observation care have failed or are not considered appropriate and that would require acute inpatient management. The care the patient received for mildly decompensated chronic LV (left ventricle) systolic HF (heart failure) from noncompliance is routinely provided safely and effectively at a lower level of care. There was no clinical decline or inadequate response to treatment which required continuation of the hospital stay past the observation period. Therefore, the Inpatient admission was not medically necessary, based on the submitted information and the current published HF (heart failure) guidelines. 

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.