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

Diagnosis: Alzheimer's dementia
Treatment: Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift) 
The insurer denied Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift) 
The health plan's determination is overturned in part. Personal Care Aide (PCA) Services 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary for this patient.

The patient is a female with medical history notable for Alzheimer's dementia, unsteady gait, and recurrent falls. 

The requested health service of Personal Care Aide (PCA) Services: Total Amount of 168 Hours per Week (Split-Shift) is not medically necessary for this patient.
Personal Care Aide (PCA) Services 12 hours per day, 7 days per week for a total of 84 hours per week is medically necessary for this patient.
The documentation provided in the letters and the Uniform Assessment System (UAS) demonstrate that the patient requires personal care assistance for essentially all activities of daily living, including toileting, transfers, and ambulation. Her provider requests additional hours to help with her needs as well, specifically requesting 12 hours per day. This is a reasonable amount of hours to request, given that she requires extensive assistance for most activities of daily living. 12 hours per day will allow a caregiver to be present during most waking hours of the day to address her needs.
There is insufficient documentation provided regarding which personal care needs that she would need addressed overnight or why she would require split-shift personal care. Split-shift personal care aides are used for care needs which are continuous and unscheduled throughout the night, such as turning and repositioning to treat a pressure ulcer. There is no documentation providing regarding if there are any unmet overnight care needs. Therefore, the requested increase to split shift care has not been demonstrated to be medically necessary. An increase to 12 hours per day of personal care assistance is medically necessary and reasonable for the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
Treatment: Mounjaro
The insurer denied Mounjaro.
The determination is upheld.

This is a female diagnosed with overweight, obesity, pre-diabetes, obstructive sleep apnea, and hyperlipidemia. She has been exercising daily and eating a low-calorie diet for at least 6 months. However, she has not been able to lose enough weight, and her glycated hemoglobin (A1C) is still high. 
As per the recent visit note she just started on Mounjaro 5 milligrams (mg) and she did not lose any weight on 2.5 mg weekly. Two years ago, she was on Saxenda 3 mg daily; she lost 11 pounds (lbs) and could not lose anymore. She tried Lomaira, but it made her nervous. Her A1C was 5.5 percent (%). 
Recently, her weight was 78.5 kilograms (kg); her height was 162.6 centimeters (cm) and her body mass index (BMI) calculated was 29.7. This request is for Mounjaro 5 mg. 
The health plan's determination is upheld in whole. 
The formulary drugs, Victoza and Trulicity, will be ineffective as the patient does not have a Food and Drug Administration (FDA)-approved diagnosis for the formulary alternatives.
The formulary alternatives are FDA-approved for type II diabetes. The patient is diagnosed with prediabetes and obesity. 
The requested medication, Mounjaro (Tirzepatide), is FDA-approved for treating adults with type 2 diabetes [1-3]. It is a glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) receptor agonist. Tirzepatide in the form of Zepbound is FDA-approved for obesity [4]. The name brand Mounjaro is no longer used for the treatment of obesity. The patient has obesity. The patient can try Zepbound. The request does not meet the standard of care and is, therefore, not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 Braces
The insurer denied: D8080 Braces
The denial is overturned.

The patient is a school aged male. The request is for orthodontic benefits. He has a Class I malocclusion, with excessive overjet and an anterior open bite. The health plan's prior denial of coverage was due to the patient "not having a poor bite position." The denial is being appealed.

The requested braces are medically necessary.

The patient has rotated upper central incisors. They are rotated about 45 degrees from where they should be. With the teeth in this position, there can be no "anterior incisal guidance." This means that during protrusive movements of the lower jaw, the lower front teeth are supposed to glide along the backs of the upper front teeth, and the posterior teeth will open up, or "disarticulate," and not touch. With the upper front teeth rotated, this cannot happen. All the lower teeth will hit into the upper teeth in a traumatic way, and over time fractures and/or tooth loosening will occur. The posterior teeth will not disarticulate, and grinding will occur. Also, the patient will notice it is hard to bite into foods with his front teeth, since they are rotated from the ideal position, which will make chewing more difficult. This case has medical necessity, and orthodontic treatment is needed to correct things.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a past medical history (PMH) of Crohn's disease status/post (s/p) colectomy who was admitted with complaints of (c/o) a low hemoglobin associated with fatigue and shortness of breath (SOB) with no history of overt bleeding; the patient had not received regular iron infusions due to insurance issues. His vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD). Lab work was notable for a hemoglobin of 4.9. Imaging studies, a computed tomography (CT) scan of the abdomen/pelvis (A/P) showed no evidence of active gastrointestinal (GI) bleed, distal ileitis and pouchitis. The patient was diagnosed with symptomatic anemia and treated with three units of blood transfusion, intravenous (IV) iron, steroids, and antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The hospital stay was not medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o)a low hemoglobin associated with fatigue and shortness of breath (SOB) with no history of overt bleeding. He was found to have a low hemoglobin but had no history of hematochezia, hematemesis, or melena. He received three units of packed red blood cells (PRBCs), symptomatically improved, and was discharged home in stable condition. The patient did not have hemodynamic instability, persistent orthostasis, evidence of active bleeding in the ED (such as frequent episodes of hematemesis, melena, or bright red blood per rectum (BRBPR)), coagulopathy, or known esophageal varices. This patient could have been safely observed and received diagnostic work-up, consultation, steroids, antibiotics, and transfusion at a lower level of care.
The patient did not have hemodynamic instability, active hemolysis, active bleeding that could not be controlled, severe altered mental status (AMS), recurrent syncope, cardiac arrhythmias of immediate concern, acute peripheral ischemia, high-risk low platelet count, acute kidney failure, or severe symptoms not improved with observation care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cancer-related symptoms
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient in this case is an adult female. She was diagnosed with diffuse large B cell lymphoma and follicular lymphoma that was complicated by pleural effusion. Records note that she was initially evaluated for this condition out of state. That evaluation revealed a left-sided pleural effusion along with multiple enlarged lymph nodes and a mass adjacent to the tail of the pancreas. She underwent thoracentesis with Pleurex catheter placement while out of state, along with a lymph node needle biopsy that revealed grade 3A follicular lymphoma. The patient went to
the Urgent Care Center for evaluation because she felt short of breath. Evaluation there revealed a large left-sided effusion and tachycardia. It was noted that the night before she presented, she had drained 175 milliliters from the Pleurex catheter. She was admitted to the hospital. Interventional radiology evaluated her and on the next day they instilled tissue plasminogen activator (tPA), allowing for drainage of 800 milliliters. Records note that shortness of breath improved significantly after that procedure. On day number (#) 3 she underwent left retroperitoneal node
biopsy. Pneumothorax was identified, but this was felt most likely to represent trapped lung given the extent of pleural metastatic disease seen on imaging. On day #4, she was feeling well and continuing to drain pleural fluid daily from the Pleurex catheter. She had no significant symptoms and no hypoxia. She was started on rituximab, cyclophosphamide, hydroxy daunomycin, oncovin, prednisone (R-CHOP) chemotherapy and discharged to home on day #6.

The Inpatient admission was not medically necessary.

This patient was admitted with shortness of breath due to a malignant pleural effusion. Notably, she did not have hypoxia at the time of hospital admission. The pleural effusion was treated with tissue plasminogen activator and following that she was able to drain much more fluid, and her shortness of breath resolved. She had a biopsy done while in the hospital and had chemotherapy treatment with R-CHOP (Rituximab, Cyclophosphamide, Hydroxy daunomycin, Oncovin, Prednisone)
given as well. None of these interventions required acute care inpatient hospital admission. All could have been done safely at a lower level of care setting given her lack of hypoxia and given that all are safe and commonly performed in the outpatient setting. The acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion 
Treatment: braces
The insurer denied braces. 
The health plan's determination is overturned. 

The patient in question is a young male presenting with a skeletal Class I malocclusion and minor crowding. He has an anterior open bite. He is treatment planned for braces to address the crowding and open bite.

Braces are medically necessary for this patient.
Anterior open bite patients are among the most difficult patients to treat. One side effect of anterior open bite is reduced maximum bite force with less muscle activity while chewing than patients without an open bite. Orthognathic surgery or permanent teeth extraction are often the choice of treatment to treat patients with anterior open bite.
Braces are medically necessary for this patient due to the side effects described above and the fact that this is not something that will self-correct without orthodontic intervention.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cerebral palsy.
Treatment:  Durable Medical Equipment: SleepSafe II Bed - Medium with Mesh Windows.
The insurer denied Durable Medical Equipment: SleepSafe II Bed - Medium with Mesh Windows.  The health plan's determination is overturned. 

The patient is a female with spastic cerebral palsy and history of pressure ulcers. A sleep safe bed with mesh windows was ordered by her medical team. It is noted in her medical records, that she is dependent for all care. She is somewhat mobile and has demonstrated ability to pull herself up and possibly over hospital bed bedrails leading to need for 24-hour supervision in a hospital bed.

The requested durable medical equipment (DME)- SleepSafe II Bed - Medium with Mesh Windows is medically necessary for this patient. The medical team documented the safety risk of the patient in a regular hospital bed. Given her spastic cerebral palsy and need for total care, including incontinence, an adjustable bed is in fact medically necessary. Further, the safety rails of the requested bed will provide the safety for the patient that will allow her to sleep in her own space, instead of in her parent's bed, posing a risk to her and her parents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance Abuse
Treatment: Substance Abuse Inpatient Rehabilitation.
The insurer denied Substance Abuse Inpatient Rehabilitation.
The determination is upheld.

The patient is an adult male who was admitted for inpatient rehabilitation substance use disorder treatment in order to address substance use disorder with alcohol, opioid, and stimulant (cocaine) class substances of abuse.
The patient has a history of a psychiatric disorder and treatment for bipolar disorder with anxiety including a history of psychiatric hospitalization. The patient reported that he was not taking psychotropic medications.
There were no acute general medical issues in this case.
Evaluation on admission for inpatient level services revealed a mental status examination that was free of severe psychiatric symptoms. He was generally motivated for rehabilitation treatment.  
The patient was admitted to inpatient rehabilitation treatment with replacement of vitamins and comfort medications, as well as continued use of methadone at 140 milligrams (mg) per day. He was provided comprehensive evaluation and treatment that included focus on coping skills, relapse prevention techniques with identification of triggers, education about the disease model of addiction, and involvement with groups, as well as peer-supported recovery groups and other therapeutic activities.
Throughout the inpatient stay, the patient was engaged in treatment with intensive services, sober housing, monitoring, and structure provided within the residential treatment program. The patient was discharged against medical advice with plans to immediately return to outpatient level treatment with the methadone program and with recommendation for continued involvement in recovery groups.

At issue is the medical necessity of Substance Abuse Inpatient Rehabilitation.
The requested health service/treatment of substance use inpatient rehabilitation treatment was not medically necessary for this patient.
The patient was admitted to inpatient level rehabilitation treatment. He readily engaged in treatment with continued use of methadone and comfort medications, as well as vitamin replacement therapy. There were no treatment issues or biomedical or co-occurring psychiatric disturbances that would have warranted the admission or the continued inpatient level of care. The application of NY State OASAS LOCADTR Criteria (referenced below) did indicate that the patient was clinically appropriate for treatment with lower-level care in a less restrictive treatment setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Urinary tract infection.
Treatment:  Inpatient stay.

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

The patient is a male, who initially presented to the emergency department with concerns for fever, chills, and bilateral flank pain. Pertinent history included prostate cancer, urinary retention, and diabetes mellitus type 2. Initial vital signs revealed a temperature of 99.3F (Fahrenheit), heart rate (HR) 99, blood pressure (BP) 148/75, respiratory rate (RR) 18, and pulse oximetry 98% (percent) on room air. Initial examination documented the patient as alert, oriented, with bilateral pitting edema, and with right costovertebral tenderness to palpation. Abdominal ultrasound revealed mild to moderate bilateral hydronephrosis and hepatosplenomegaly. Chest x-ray (CXR) was unremarkable. Computed tomography (CT) head was unremarkable. CT abdomen/pelvis revealed bilateral hydronephrosis, periaortic lymphadenopathy, pelvic lymphadenopathy, and left inguinal lymphadenopathy. Empiric antibiotics were initiated. The patient was placed in the hospital thereafter with an impression of urinary tract infection.

The inpatient hospital admission was medically necessary. The patient was admitted with concerns for fever, chills, and bilateral flank pain. Initial examination documented the patient as afebrile, hemodynamically stable, and with costovertebral angle tenderness. Initial evaluation was concerning for a leukocytosis, acute renal failure, and bilateral hydronephrosis with abdominopelvic lymphadenopathy. Urinary retention was confirmed with drainage of significant urine volume following placement of an indwelling Foley catheter. The hospital course was further complicated by development and bacteremia secondary to Proteus mirabilis. Once clinical stability was achieved from an acute renal failure, urinary retention, and urinary tract infection complicated by bacteremia, the patient was promptly discharged.

The patient had a complicated urinary tract infection with bacteremia, acute renal failure, and acute urinary retention (possibly due to both significant uropathy from lymphadenopathy and bladder outlet obstruction from prostate cancer). An inpatient stay was indicated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Renal stone. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The determination is upheld. 

This is a male patient with a past medical history remarkable for kidney stones and cerebrovascular accident (CVA), who presented for left flank pain. The patient has a known history of kidney stone and hydronephrosis. The review of systems was negative for additional clinical symptoms. 
The physical examination was unremarkable for positive clinical findings. The neurologic examination was reported as normal. 
The patient was admitted for a renal stone. A computed tomography (CT) scan of the abdomen and pelvis revealed 0.4 centimeter (cm) renal calculus with mild hydronephrosis. The patient was treated with intravenous (IV) fluids and pain control. The stone was determined to be chronic, and the patient was advised to follow up with his primary care physician (or provider) (PCP) and outpatient urology. There was no urinary tract infection (UTI). 
At issue is the medical necessity of an inpatient stay. 
The requested health service/treatment of inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level of care for IV hydration and syncope workup. 
The patient was admitted for a 0.4 cm renal calculus with mild hydronephrosis; this was chronic in nature and the patient did not require urologic interventions. The patient was hemodynamically stable with stable renal function. He did not have signs of infection or sepsis. Inpatient level of care was not necessary for surgical intervention and urgent relief of urinary obstruction. 
Renal stones are common problems that result in ED (emergency department) admissions, and many cases may end up requiring only conservative therapy and outpatient management. However, there are certain cases where nephrolithiasis can result in renal obstruction, which could cause permanent renal damage if treated inadequately. In patients with laboratory/imaging findings consistent with acute kidney injury and moderate to severe hydronephrosis, urgent urologic intervention is typically warranted especially if the patient has urosepsis and acute kidney injury. 
Subsequent therapy and treatment after urologic intervention is necessary based on the patient's comorbidities, imaging findings, and clinical status. In this case, the patient had no clinical evidence of sepsis or acute kidney injury. The care could have been safely rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eosinophilic Esophagitis.
Treatment: Dupixent.

The insurer denied Dupixent.  The denial is overturned.

This patient is a teenage male. He has been diagnosed with celiac disease and eosinophilic esophagitis. He had been doing well with gluten free diet and Flovent (fluticasone). Recent biopsy 2 months ago showed active eosinophilic esophagitis. The patient's doctor requested Dupixent. The reason for the prior denial was that the request was not medically necessary, since the patient has not tried budesonide. The reason for appeal is that the patient tried and failed a proton pump inhibitor (PPI) and fluticasone and Dupixent is indicated.

The requested health service is medically necessary.

One published phase clinical trial of Dupixent (dupilumab) for eosinophilic esophagitis in adults and adolescents showed that subcutaneous dupilumab administered weekly improved histologic outcomes and alleviated symptoms of the disease (1). Patel et al. (2022) reported 3 children that all achieved clinical and histopathologic remission on dupilumab (2). In a recent published study, 45 children with eosinophilic esophagitis were treated with dupilumab and a total of 28 patients had improvement of symptoms, with 24 patients reporting complete resolution of symptoms after dupilumab initiation (3). Dupilumab (Dupixent) has been approved by the Food and Drug Administration (FDA) for eosinophilic esophagitis in children 12 years of age or older with weight at least 40 kilograms (kg). Current medical literature and diagnostic/treatment guidelines support the use of dupilumab in children (including children less than 12 years of age) with refractory eosinophilic esophagitis (1-4). As documented in the clinic note and appeal letter, this patient has been diagnosed with eosinophilic esophagitis. The patient has tried and failed a proton pump inhibitor (PPI) and one topical steroid, fluticasone. The last biopsies 2 months ago showed persistent eosinophilic esophagitis with greater than 100 eosinophils per high power field (hpf). The patient is considered to have refractory eosinophilic esophagitis. Trial of another topical steroid, budesonide, is unlikely effective. The next treatment option would be to try Dupixent, as supported by current literature. Thus, the requested Dupixent is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: excess chest and breast skin
Treatment: Outpatient Procedure to Lift Chest and Fat Tissue Removal Procedure (Liposuction) 
The insurer denied Outpatient Procedure to Lift Chest and Fat Tissue Removal Procedure (Liposuction) 
The health plan's determination is upheld. 

The patient in this case is a male who has lost weight following bariatric surgery. He has excess chest and breast skin. He complains of difficulty exercising and back pain due to his breast and chest skin.

The Outpatient Procedure to Lift Chest and Fat Tissue Removal Procedure (Liposuction) is not medically necessary for this patient.
The patient reports a history of rashes under his breasts, but only one note documents a prescription for a steroid/anti-fungal cream, and the note does not provide any details on the duration or location of the patient's rash. The patient reports back pain, but the records do not document a work-up for back pain. Photos showing excess skin are not provided. Ultrasound shows benign breast tissue and fat. There is no documentation of an endocrine evaluation and exclusion of an endocrine cause. There is no documentation of a concern for breast malignancy. He is reported to have pain, but the records do not document a need for treatment with analgesics or problems with activities of daily living due to his enlarged breasts. The requested procedure will primarily improve appearance and self-esteem and therefore is cosmetic and not medically necessary. Observation, reassurance and use of analgesics as needed are reasonable management approaches for this condition. The patient is likely to derive emotional benefit from the surgery, but his physiologic health will not be improved.