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

Diagnosis: Acute viral infection
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is overturned.


The patient is a female child who presented to the emergency department (ED) with a several day history of fevers, congestion, cough, diarrhea, and vomiting. She had been seen in the ED two days prior and discharged with symptomatic treatment. She returned with poor oral intake, vomiting after breastfeeding, and decreased alertness. The examination was significant for ill appearance, pallor, congestion, dry mucous membranes, tachycardia, good perfusion, respiratory distress with normal breath sounds, and non-focal neurologic exam. Coronavirus disease (COVID) testing returned positive. A chest x-ray revealed bilateral perihilar and peribronchial thickening and interstitial opacification, non-specific and possibly representing viral pneumonia.
She was treated with a normal saline bolus and ondansetron prior to admission for further care. Admission orders included maintenance intravenous (IV) fluids, diet for age, pulse oximetry, and Tylenol as needed. She continued to have vomiting and diarrhea overnight but was tolerating some sips of liquids. Her intake improved slowly, she was tolerating Pedialyte, some applesauce (mixed with supplemental potassium chloride) and pudding. The diarrhea had resolved, and she had one episode of vomiting overnight. Her oral intake was steadily improving, with her mom encouraging some fluid intake every hour. She was deemed stable for discharge to continue with hourly fluid intake and follow-up as needed. At issue is the medical necessity of an inpatient stay.
Full hospital admission was medically necessary for this young child.
This child presented to the ED with signs and symptoms consistent with acute viral infection, exposed to dad with similar symptoms, testing positive for COVID 19 in the ED. She had persistent vomiting and diarrhea for almost a week, presenting with significant dehydration and electrolyte imbalance necessitating IV fluid hydration, potassium supplementation, antiemetic medications, and hourly oral fluid administration. Despite appropriately aggressive medical care and active family participation, she was not stable for discharge within the guidelines of a lower level of care. She required the duration of care and level of care most consistent with acute inpatient management to achieve sufficient stability to discharge home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

In the emergency room (ER), the patient was noted to be in moderate distress. The patient had had no tachypnea (20 to 28) and mild wheeze.  Oxygen saturation was greater than 90% and there was no hemodynamic instability. Perfusion was adequate. No chest x-ray (CXR) was done The patient was treated with nebulization, steroids, and magnesium sulfate (MgSo4). The clinical status improved. The patient did not require continuous nebulization. The patient was able to be weaned from every 2 hours (Q2H) of nebulization to every 4 hours (Q4H). 

There was no persistent hypoxia and no need for continuous positive airway pressure (CPAP) support or high flow nasal cannula (HFNC). The pH was not less than 7.3. The patient was only given oral (PO) Decadron in the ER.  There was no severe dehydration. The general exam was documented as non-distressed. The respiratory exam was documented as wheezing. Magnesium sulfate was given and no second line treatment was needed. If one were to take the Pediatric Respiratory Assessment Measure (PRAM) score to assess the pediatric asthma, it would be in the category of mild asthma. If one were to take the Pediatric Early Warning Scoring Tool (PEWS) score, it would have been desirable also indicating an expectant and stable course in the hospital. The patient did not have severe persistent asthma and only had mild intermittent asthma as per underlying asthma diagnosis. The patient was continuing in an expected clinical trajectory while in the hospital.  The patient could have been treated in an observational status.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive Decline. 
Treatment: Personal care assistance (PCA) level 2 services: 12 hours per day - 7 days per week - a total of 84 hours per week. 
The insurer denied coverage for personal care assistance (PCA) level 2 services: 12 hours per day - 7 days per week - a total of 84 hours per week. 
The denial is overturned. 

Documentation submitted shows several comorbidities. There has been progression of physical and mental status decline. There is the report of a recent fall requiring hospitalization. There is documentation of memory loss and decreased mentation. There is limited use of the extremities and incontinence. The patient is clearly not independent with activities. 

The nursing assessment indicates he cannot get out of bed. The patient has memory problems and cannot take their medication when necessary. The patient has had frequent falls. The patient is totally dependent upon personal care assistance (PCA) for all activities. The patient's daughter reports that the patient is frequently incontinent of bladder throughout the day and incontinent of bowel during the day. As noted, there is progression and the patient clearly is not independent for most activities. The documentation clearly supports the request. 

Based on the above, the insurer's denial must be reversed. 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 personal care assistance (PCA) level 2 services: 12 hours per day - 7 days per week - a total of 84 hours per week is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy 1.7 milligrams (mg) injection
The insurer denied coverage for Wegovy 1.7 milligrams (mg) injection
The determination is overturned

The patient is a female who sought medical treatment for obesity. The request is for the prescription medication Wegovy 1.7 milligrams (mg) injection. The patient has comorbid health conditions of hypertension, diabetes, gastroesophageal reflux disease (GERD), sleep apnea, and hyperlipidemia. She has a history of a prior sleeve gastrectomy. She was started on Wegovy due to Saxenda not being covered by her health plan. She is currently engaged with a reduced calorie diet and exercise program. The documentation states that she has been prescribed Wegovy 1 mg/0.5 ml subcutaneously by pen injector once per week.
The clinical note describes calorie reduction, recommended exercise, and use of Wegovy as an adjunct to diet and exercise for weight reduction.
The treatment plan is for Wegovy 1.7 milligrams (mg) /0.5 milliliters (ml) auto-injectors subcutaneous (SQ) once weekly, continued calorie restriction and follow up with the bariatric program. The health plan's denial rationale is that the appropriate clinical documentation confirming the member's condition, past treatment history, and the current medication requested including dose and frequency has not been submitted.
Wegovy (Semaglutide) is clinically appropriate for the patient's condition of obesity in the setting of her engagement with a medical weight loss program. This drug is a prescription weight loss medication that activates glucagon-like-peptide-1 (GLP-1) receptors in the brain, regulating appetite and caloric intake. It is indicated for the long-term treatment of obesity for patients with a body mass index of at least 30 kilograms per square meter (kg/m2) or 27 kg/m2 with weight-related comorbidity in conjunction with an ongoing diet and exercise program.
There is evidence of active enrollment in an exercise and calorie reduction program. Follow up is planned with a bariatric program. The patient has been appropriately counseled on diet and ongoing nonsurgical weight loss. The patient is not currently taking another GLP-1 receptor agonist.
Wegovy is a proven effective medication that is used as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial Body mass index (BMI) of 30 kg/m2 or greater or a BMI of 27 kg/m2 or greater in the presence of at least one weight related comorbid condition (hypertension, type 2 DM, dyslipidemia, etc). 
Wegovy would be expected to be health beneficial for this patient in conjunction with a reduced calorie diet and exercise program based on evidence-based literature.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: polycystic ovarian syndrome, insulin resistance, and morbid obesity. 
Treatment: Zepbound.
The insurer denied Zepbound.
The determination is overturned.


The patient is a female diagnosed with polycystic ovarian syndrome, insulin resistance, and morbid obesity. This request is for Zepbound. Her weight was 239.8 pounds (lb), and her body mass index (BMI) was 43.9. She is on topiramate, metformin, and Wegovy. She has tried weight management and lost 50 pounds but plateaued and overmedicated with phentermine and Topamax. She failed phentermine due to palpitations and insomnia. She tried Saxenda as well as Ozempic but stopped after 1-2 months with no weight loss. She was intolerant to Qsymia. Her weight in August was 256 pounds and her hemoglobin A1c was 5% (percent).

At issue is the formulary exception for Zepbound.

The health plan's determination is overturned as a whole.

The formulary drugs Orlistat, Qsymia, Saxenda, and Wegovy have been ineffective and have had side effects on this patient compared to the non-formulary drug, Zepbound (tirzepatide).
Tirzepetide in the form of Zepbound is Food and Drug Administration (FDA) approved for obesity treatment (1). It is safe and effective in the treatment of obesity (2,3). The standard of care based on multiple societal guidelines recommends treatment with FDA-approved treatments for obesity. (4-9) Standard of care requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia.
The patient is diagnosed with obesity. She is reported to have failed Qsymia and Saxenda. Orlistat will not be as effective as the requested Zepbound. The patient was recently on Wegovy but is unable to obtain it since Wegovy is currently in shortage.
The request meets the standard of care and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lightheadedness and syncope. 
Treatment: Inpatient level of care. 
The insurer denied coverage for inpatient level of care.  
The denial is overturned. 

This is an adult male who presented to the hospital with lightheadedness and syncope.  He reported being unconscious for several minutes.  Past medical history was significant for deep vein thrombosis. On arrival at the hospital he was hypertensive with a blood pressure of 164/79 mmHg (millimeters of mercury) and a pulse of 82 beats per minute. Physical examination was positive for left leg swelling. 12 lead electrocardiogram (EKG) demonstrated sinus rhythm without ischemic ST or T wave changes.  Serum blood testing revealed an elevated high sensitivity troponin level of 48.9 ng/L (nanograms/liter).  Toxicology screen was positive for marijuana. Computed tomography (CT) of the head was unrevealing. The patient was admitted to the hospital for additional testing and treatment. He signed out against medical advice (AMA) prior to echocardiographic imaging. 

This patient presented to the hospital with syncope and persistently elevated serial serum troponin levels. These findings are concerning and point to a possible cardiac etiology for syncope. Although patients presenting to the hospital with syncope can often be risk stratified and rapidly discharged from the emergency department (ED), those with cardiac syncope are at high risk of future events that result in increased morbidity and even mortality. 

Admission to the hospital for work up with subsequent close follow up by a cardiac electrophysiologist was medically necessary. 

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 inpatient level of care is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral infarction.
Treatment: increase in Customer Directed Personal Assistance Services from 63 hours per week to 7 days per week to 2-12 hours split shift (168 hours per week).
The insurer denied an increase in Customer Directed Personal Assistance Services from 63 hours per week to 7 days per week to 2-12 hours split shift (168 hours per week).
The determination is upheld.

This is a female patient with a medical history notable for prior cerebral infarction. The patient was approved for 63 hours per week of personal care services. The patient and her care team requested an increase to 24-hour split shift personal care, 7 days per week, for a total of 168 hours per week. The health plan partially approved the request, approving a 7-day-per-week live-in personal care aide.
A physician describes the patient's medical history, which includes a prior cerebrovascular accident (CVA), dysphagia, hypertension, Lewy body dementia, osteoarthritis, and Parkinsonism. The letter states that the patient requires constant supervision and assistance. There is no discussion regarding overnight care needs. There were no other letters or overnight care logs provided as part of this appeal.
A Uniform Assessment System (UAS) was completed.  The patient lives with her daughter and her daughter's family in a private home. Her cognition was severely impaired; she could not make her needs known or direct her care. For her instrumental activities of daily living, the patient requires total dependence for all. At issue is the medical necessity of an increase in Customer Directed Personal Assistance Services from 63 hours per week to 7 days per week to 2-12 hours split shift (168 hours per week). 

The requested health service of an increase in Customer Directed Personal Assistance Services from 63 hours per week to 7 days per week to 2-12 hours split shift (168 hours per week) has not been demonstrated to be medically necessary for this patient.
The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, there is an issue as to whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.
The patient's personal care needs are extensive as outlined in the UAS. Her care needs can be expected to be continuous and unscheduled throughout the day and occasionally at night as well. She does require 24-hour assistance as recommended by her physician. A live-in personal care assistant was approved by the health plan. There is insufficient evidence that the patient requires split-shift personal care assistance. There was no documentation regarding care needs overnight.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Arm Infection

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

This is a patient with a past medical history significant for a dog bite to their left arm who presented to the emergency department with complaints of pain, erythema, and swelling to same arm. 

Vitals on presentation included: Temperature (T) 98.1 Fahrenheit (F), blood pressure (BP) 131/102, heart rate (HR) 75, respiratory rate (RR) 18, and oxygen (O2) saturation 98%. Laboratory values were notable for the following: white blood cell (WBC) count 7.8, hemoglobin (Hgb) 15, hematocrit (Hct) 44, creatinine 0.66, glucose 72, and lactic acid 0.7.

The patient was admitted for a hand infection following a dog bite. The patient was started empirically on antibiotics (vancomycin and Zosyn). Infectious Diseases consulted and recommended continuation of antibiotics. Tetanus prophylaxis was given. Surgery evaluated and deemed no surgical intervention was required. The patient remained afebrile and hemodynamically stable. The patient was discharged to continue outpatient intervention. 

According to documentation, the patient was admitted for left arm cellulitis following a dog bite. 
Otherwise, the patient was afebrile, hemodynamically stable, with unremarkable laboratory results including a normal WBC. The patient had no co-morbid conditions, no evidence of a disseminated infection, and no surgical intervention was required. Based on the above findings, the patient met criteria for observation level of management. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: ileocolonic Chron's disease

Treatment: Stelara 90 milligrams (mg) every six weeks

The insurer denied coverage for Stelara 90 milligrams (mg) every six weeks.

The denial is overturned.

 
The patient has ileocolonic Chron's disease. He has been on multiple prior biologic agents including Humira, infliximab, and Entyvio. Stelara was started several years ago. He has also been treated with Rinvoq for rheumatoid arthritis. A recent colonoscopy showed chronic enteritis and colitis. The Rinvoq dose was increased but he could not tolerate it and the dose was lowered. He has recently been treated with Stelara every 6 weeks along with a lower dose of Rinvoq. His physician reported that on this regimen he is currently doing well. The physician has included medical literature supporting the use of dual biological therapy for the treatment of irritable bowel disease (IBD). 

Clinical Gastroenterology and Hepatology 2021 Jan 19 (1): 104-110 has an article titled "Effectiveness of Ustekinumab Dose Escalation in Patients with Crohn's Disease." Data was studied from patients who initially received Ustekinumab (Stelara) every 8 weeks and then had their interval shortened to every 4 weeks. The conclusion was that shortening the Ustekinumab dose to every 4 weeks, in patients who did not respond to dosing every 8 weeks, improved clinical and biological indices of disease activity. It was noted that dose interval shortening was effective and safe. 

Advanced Therapeutics 2023 40:2051-2081 has an article titled "Dose Escalation Patterns of Advanced Therapies in Crohn's Disease and Ulcerative Colitis: A Systematic Literature Review." The article states that dose escalation strategies are widely documented in the literature. Among the drugs that have been studied for dose escalation was Ustekinumab with changing doses to every 4 weeks. 

This patient has severe Crohn's disease and has failed multiple biologic therapies. It is reported that he has improved on the current regimen with Stelara every 6 weeks. The dose escalation of Ustekinumab (Stelara) is well supported in the medical literature. Stelara 90 milligrams (mg) every 6 weeks is medically necessary.

Based on the above, the insurer's denial must be reversed. 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 Stelara 90 milligrams (mg) every six weeks is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: primary open angle glaucoma
Treatment: Vyzulta 0.024% (percent) Solution
The insurer denied Vyzulta 0.024% (percent) Solution.
The health plan's determination is upheld.

The patient is a male with primary open angle glaucoma, mild stage, for whom coverage of Vyzulta 0.024% (percent) is the subject of review. Reportedly, the patient was diagnosed with glaucoma. Vyzulta was started due to right optic nerve thinning noted on optical coherence tomography (OCT) and a visual field defect in the left eye while the patient was already using latanoprost and dorzolamide/timolol. Coverage of Vyzulta was denied per policy in the absence of documented failure, contraindication, or intolerance to the required number (3) of formulary alternatives. 

A formulary exception is not indicated in this case. 
It is not established that all the formulary drugs will be or have been ineffective or would not be as effective as the non-formulary drug (Vyzulta) or would have adverse effects. In this case, the patient has tried and failed latanoprost in the right eye. While Vyzulta is considered more effective at lowering intraocular pressures than latanoprost, travoprost and tafluprost, it is not identified as safer or more effective than the remaining formulary alternative Lumigan (bimatoprost) 0.01% (percent).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: Personal Care Aide (PCA) Services: 7 Days per Week, Live-In Per Diem 
The insurer denied Personal Care Aide (PCA) Services 7 Days per Week, Live-In Per Diem. 
The health plan's determination is overturned.

This is a case review for a female with medical history notable for dementia, mobility issues, and incontinence. The patient was approved 4 hours per day, 4 days per week, and 5 hours per day, one day per week for a total of 21 hours per week of personal care services.The patient's care team requested Personal Care Aide (PCA) Services: 7 Days per Week, Live-In Per Diem. 
The patient's physician provided a letter for this appeal. The letter states that the patient has severe dementia which has been worsening and leading to aggressive behavior. She experiences sundowning with increased confusion and agitation during the evening and night time hours. This has resulted in wandering and other unsafe behaviors. The physician states that 24-hour supervision is necessary to ensure the patient's safety.

The requested Personal Care Aide (PCA) Services: 7 Days per Week, Live-In is medically necessary for this patient.
The patient's overall health status is declining, and all of her conditions are complicated by her severe dementia. She is not able to direct her own care. She is not able to complete any activities of daily living without assistance. Although supervision is not an allowable function of a personal care assistant, supervision can be provided if it is done in conjunction with performing personal care tasks. The nature of the personal care needs of the patient are that they would be continuous and unscheduled throughout the day and occasionally at night as well. She will require assistance with toileting and managing incontinence care, which she is not able to do independently or even direct on her own. The patient has had falls and issues with managing incontinence care which are evidence of unmet personal care needs. Therefore, the requested services are medically necessary for the patient.