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

Diagnosis:  Chronic kidney disease and secondary hyperparathyroidism.
Treatment: Cinacalcet.
The insurer denied: Cinacalcet.
The denial is upheld.

The patient is an adult female with chronic kidney disease and secondary hyperparathyroidism. Her treating physician has requested Cinacalcet for this patient.

The requested Cinacalcet is not medically necessary.

There is no evidence-based literature to support Cinacalcet as being safe or effective in patients with chronic disease who are not on dialysis. This request does not meet Medical Society guidelines. The submitted appeal letter states that the patient needs Cinacalcet so that they can be a good or better candidate for dialysis. However, this not consistent with evidence-based literature or any medical society guidelines. Therefore, given the above, the requested Cinacalcet is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, chronic obstructive pulmonary disease (COPD) with oxygen dependence, polyosteoarthritis, dysphagia, urinary and bowel incontinence, falls and sacral pressure ulcer
Treatment: Personal Care Services 24 hours a day split shift (two 12-hour shifts), 7 days a week for a total of 168 hours
The insurer denied coverage for Personal Care Services 24 hours a day split shift (two 12-hour shifts), 7 days a week for a total of 168 hours
The denial is overturned.
 
This is an elderly patient with end-stage oxygen dependent chronic obstructive pulmonary disease (COPD), osteoarthritis and dementia. She lives alone and was admitted to hospice services recently.  Her previously approved personal care services (PCS) were decreased from 24 hours/day (split shift) to 8 hours/day, 7 days/week. The patient is requesting reinstatement of the previously approved PCS 24 hours/day (split shift); which is currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately impaired- Decisions consistently poor or unsafe, cues/supervision required at all times." She is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  Maximal assistance is also needed for bathing and dressing. Extensive assistance is needed for personal hygiene and toilet transfer/use. She is occasionally incontinent of bladder and continent of bowel. Limited assistance is needed for locomotion and ambulation, with an unsteady gait and poor endurance. She is reportedly independent with bed mobility; however, she has a sacral decubitus ulcer and skin tears. The patient should be repositioned while in bed approximately every 2 hours to prevent further decubitus ulcers. The patient's declining clinical condition (requiring hospice care), cognitive and functional deficits are at a level or unpredictable as to require the requested PCS 24 hours a day split shift (two 12-hour shifts).  The patient's health, safety and nighttime ADL needs are more appropriately provided and maintained by the previously approved PCS 7 days/week, 24 hours/day (split shift).

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 Personal Care Services 24 hours a day split shift (two 12-hour shifts), 7 days a week for a total of 168 hours is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hereditary spastic paraplegia. 
Treatment: Personal care aide 1 day x 5 hours, 4 days x 4.5 hours and 1 day x 4 hours. 

The insurer denied coverage for personal care aide 1 day x 5 hours, 4 days x 4.5 hours and 1 day x 4 hours. 

The denial is upheld. 

The medical records fail to demonstrate a change in condition to warrant the additional service. The nursing assessment reported the patient used a walker in an independent manner. She was able to perform several activities with minimal assistance. The most recent Uniform Assessment System (UAS) indicates regarding activities of daily living (ADLs) that she is independent with dressing upper body, limited assistance for lower body, independent for transfer and toilet use, needs set up only for eating, occasionally incontinent of bladder and continent of bowel. 

There was a stair lift in place and she was able to walk a few steps with help. She received assistance from family members who were close by. She continued to receive physical therapy (PT) and occupational therapy (OT) at home. There were no recent falls or hospitalizations. There were no safety issues. Her incontinence was intermittent. There were no reported extenuating circumstances to support the request. 

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 personal care aide 1 day x 5 hours, 4 days x 4.5 hours and 1 day x 4 hours is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This patient is an adult patient with a past medical history significant for Crohn's disease, dyspnea on exertion, lower back pain, mediastinal lymphadenopathy, muscle weakness, obstructive sleep apnea, and Raynaud's disease who presented to emergency department with complaints of fever, back pain, and a recent tick bite. Vitals on presentation included: temperature 39 degrees Celsius, blood pressure 116/58, pulse 73, respiratory rate 22, and oxygen saturation 96% on room air. Laboratory values were notable for the following: white blood cell (WBC) count 5.4, hemoglobin 14.4, hematocrit 47.4, platelet 191, creatinine 0.76, and glucose87, lactic acid 0.9, C-reactive protein 2.2, and a urinalysis which was negative. The chest x-ray was negative.

The patient was admitted for evaluation of fever. The patient was empirically started on antibiotics (intravenous vancomycin, Zosyn, and doxycycline). A Computed Tomography scan of abdomen/pelvis showed no acute findings. Infectious Diseases were consulted; their impression was possible tick-borne infection. The patient remained afebrile, hemodynamically stable, and clinically improved. The patient was discharged to continue outpatient management with oral antibiotics (doxycycline).

According to documentation, the patient presented with fever and body aches following a recent tick bite. The patient had fever, otherwise was hemodynamically stable, with laboratory results showing a normal WBC count. Their clinical impression was a viral syndrome versus a tick- borne etiology (such as Lyme disease). Based on above findings, the patient met criteria for observation level of care. The patient did not meet criteria for an acute hospital admission.

The prior determination of denial of coverage for an acute inpatient admission is upheld.

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lung Infection
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is a female toddler with medical history significant for delayed speech and one episode of wheezing. She presented to the ED (emergency department) with week-long history of cough and runny nose and two-day history of increasing difficulty breathing. She was treated with one albuterol treatment at home. She was weak, not eating but taking water, and had no urine output since the night before.

The patient's vital signs included temperature 37.4, heart rate 128, respiratory rate 42, and 98% (percent) oxygen saturation in room air. Examination was significant for lethargic and weak appearance, unable to sit on her own, dry lips, moist tongue, crying with tears, increased work of breathing with subcostal retraction, bilateral equal air entry, no wheezing, and non-focal neurologic deficit. Lab studies, GenMark (diagnostics exam), and cultures were obtained as well as a chest x-ray. Lab studies were significant for WBC (white blood count) 13.576K (thousand), sodium 132, potassium 5.8 (hemolyzed), glucose 55, CO2 (carbon dioxide) 16. Chest x-ray revealed right middle lobe pneumonia. She was treated with nebulized albuterol, enteral dexamethasone, and parenteral ceftriaxone. She was admitted for IV (intravenous) hydration and antibiotics.

The patient's admission orders included IV fluids, pediatric diet as tolerated, supplemental oxygen as needed for saturations less than 92%, vital signs every four hours, ceftriaxone every 24 hours, Tylenol as needed, follow-up GenMark and cultures, repeat metabolic panel the next morning. The viral panel returned positive for rhinovirus/enterovirus, GenMark was negative. She had no fevers overnight and no need for supplemental oxygen. She was able to tolerate some breakfast, was drinking well, and was more active. Examination revealed no retractions, occasional crackles. Repeat metabolic panel was unremarkable with CO2 23. She was transitioned to parenteral ampicillin, and later in the day was deemed stable for discharge to complete a course of antibiotics with amoxicillin.

The inpatient hospital admission was not medically necessary.

This young female child with history of reactive airways disease presented with URI (upper respiratory infection) symptoms and cough and increasing difficulty breathing. She was dehydrated upon examination, with metabolic acidosis, hypoglycemia, and decreased urine output. Chest x-ray revealed middle lobe pneumonia. While it was reasonable to monitor in the hospital, treating dehydration and providing antibiotics, she was overall hemodynamically stable with no need for supplemental oxygen and no evidence of impending respiratory failure. She did not require acute inpatient hospital admission and could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

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

The patient in question is a male with a Class III malocclusion, moderate spacing of the upper and lower arches and anterior crossbite of teeth # (number) 7-10. He has a supernumerary mandibular right second premolar. Tooth 29 is impacted. Tooth 14 has incomplete eruption. He is treatment planned for 24-30 months of braces to correct his malocclusion. 

Braces are medically necessary for this patient. The patient has significant spacing with teeth #7-10 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. He is already damaging his lower central incisors. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, braces are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea/Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is: Upheld

The patient is a female who presented to the emergency department (ED) with a history of nausea, vomiting and poor oral intake. The patient was status post laparoscopic sleeve gastrectomy performed for the condition of morbid obesity. She carries the diagnoses of hyperlipidemia, sleep apnea, and pre-diabetes. Vital signs at the time of presentation were notable for a heart rate of 83/minute, blood pressure of 120/67 millimeters of mercury (mmHg), and normal temperature. The white blood cell count was 6.1 thousand (K). Hemoglobin was 12.2 grams per deciliter (g/dl). Creatinine was normal at 1.0, serum electrolytes were normal. Computed tomography (CT) scan showed no acute pathology. The patient was evaluated with esophagram that showed normal post-surgical changes of gastric sleeve without obstruction.
The patient was treated with intravenous (IV) fluid, antiemetic, and antacid medication. She was started on a liquid diet and monitored. She tolerated the liquid diet. The patient was discharged from the hospital with improvement of nausea and vomiting.

The health plan's determination is upheld.

No, inpatient hospital admission was not medically necessary. The clinical needs of this patient could have been satisfied without need for full inpatient admission. This patient presented to the hospital emergency department (ED), approximately 2 weeks following a gastric sleeve procedure with compliant of nausea and vomiting and intolerance of diet. She was clinically stable at the time of presentation. The patient had stable vital signs and lab data did not suggest significant dehydration at presentation. Her nausea and vomiting responded favorably to provision of IV fluid and antiemetics. Contrast upper gastrointestinal (UGI) was performed as noted above. Following this diagnostic study, the patient was started on a diet. Once she demonstrated tolerance of a liquid diet and had stable hemodynamic parameters she was discharged from the inpatient setting. This treatment could have appropriately been performed at a lower level of care status.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Low Tension Glaucoma, Bilateral, Severe Stage
Treatment: Formulary exception for Dorzolomide-Timolol PF (preservative-free)
The insurer denied: Formulary exception for Dorzolomide-Timolol PF
The denial is overturned

The patient is an adult female with low tension glaucoma for whom coverage of Dorzolomide-Timolol PF is the subject of review.

Coverage was previously denied by the health plan, as it was not identified that the patient had tried and had an inadequate treatment response, intolerance or contraindication to the required number of formulary alternatives, which include dorzolamide-timolol, latanoprost, and travoprost.

Upon appeal, the provider states that the patient has early onset of severe, chronic open angle glaucoma. She has had a significant visual field defect for many years and has experienced bleeding in tear ducts with drops with preservatives as well as general irritation. As such, it is medically necessary for the patient to have preservative-free drops.

The health plan should cover the Formulary exception for Dorzolomide-Timolol PF (preservative-free).

While the formulary drugs have not been found to be ineffective for this patient or be less effective than the requested non-formulary drug, they would be expected to have adverse effects for this patient who requires glaucoma drops without preservatives. All three formulary alternatives are identified as having preservatives. The requested formulation of dorzolomide-timolol is preservative free (PF). Therefore, the requested formulary exception for Dorzolamide-Timolol PF (preservative free) is established as medically necessary.
Appeal type: Medical necessity
Decision: Overturned

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

The patient is a baby who presented for lethargy and pallor. He had diarrhea for 3 days in addition to increased crying and agitation. He had no fever or vomiting. He started making some abnormal breathing sounds and the paramedics were called. At the emergency room he was noted to have delayed capillary refill and clinical evidence of dehydration. He was given intravenous fluid boluses and blood and urine cultures were sent. He was started on intravenous antibiotics pending the cultures and was admitted to the pediatric floor.

The requested health service and treatment of an inpatient admission was medically necessary for the baby. He presented with lethargy and pallor. He had clinical signs consistent with dehydration. He had a delayed capillary refill time and a low bicarbonate level. He also had a decreased temperature, which can suggest sepsis.
According to Ershad, Muhammed, et al: "Vital sign derangements include both hypothermia and fever. Fever is more common in term babies whereas preterm babies more often demonstrate hypothermia. There may be tachycardia or bradycardia, signs of poor perfusion including cool and pale extremities, and a rapid thready pulse." The baby required a sepsis workup, with a blood and urine culture and was started on intravenous antibiotics. He required intravenous fluids until his oral intake was deemed adequate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Polyarthritis, coronary artery disease and hypertension
Treatment: Home Care / Personal Care HHC - level 2 personal care services, per 15 minutes increase to 42 hours per week
The insurer denied coverage for Home Care / Personal Care HHC - level 2 personal care services, per 15 minutes increase to 42 hours per week.
The denial is upheld.

This is an elderly patient with chronic medical problems including polyarthritis, coronary artery disease and hypertension. The patient lives in a 2-bedroom home with her sons and is currently approved for personal care services (PCS) 35 hours/week and requesting 42 hours/week.  

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is "Modified independence." The patient requires extensive assistance for bathing and lower body dressing. They are otherwise independent for personal hygiene, eating, bed mobility and toilet transfer/use. The patient is occasionally incontinent of bladder and continent of bowel. The patient uses a cane indoors and walker outdoors with supervision. Functional ability has declined compared to the prior UAS report, specifically for bathing and lower body dressing. At that time, the patient was receiving PCS 28 hours/week. There is also a note from the patient's treating physician, indicating "needs 24 hour, round the clock care which is provided by her son." However, the physician does not provide any supporting clinical documents for his assertion of the patient's reported functional incapacity, which is contrary to the UAS report. The patient's condition and functional needs are not at a level or unpredictable as to require the requested 42 PCS hours/week.  Based on the enclosed documents reviewed, the patient's health and safety is appropriately provided and maintained by the currently approved PCS, 35 hours per week.  

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

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 Home Health Care / Personal Care HHC - level 2 personal care services, per 15 minutes increase to 42 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: maxillary and mandibular crowding
Treatment: D8080 braces, D8670 monthly visits
The insurer denied  D8080 braces, D8670 monthly visits.
The health plan's determination is upheld. 

The patient is a female with maxillary and mandibular crowding. Tooth 6 is erupting to the labial and tooth 11 is unerupted. The orthodontist mentioned in the diagnosis that tooth #11 is impacted and will require surgical exposure. The narrative states that the primary maxillary canines are retained. The patient is treatment planned for 30-36 months of comprehensive orthodontics.

Braces and monthly visits are not medically necessary for the patient at this time. She is in the process of losing her remaining primary teeth as they are replaced with permanent teeth. Research indicates the following risk factors for impacted canines in patients over 10 years of age:
1. If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does have this, But it is due to the retained primary teeth rather than a true lack of space.)
2. The canines cannot be palpated and occlusal development is advanced (occlusal development is not advanced - the second molars are far from eruption.)
3. The lateral incisor is proclined and tipped distally (teeth 7 and 10 are not tipped distally at all)
4. On a panoramic radiograph of the late mixed dentition if the incisal tip of the canine overlaps the root of the lateral incisor. (Neither canine overlaps the root of a lateral incisor on the panoramic radiograph provided.)

The patient does have maxillary and mandibular crowding and treatment may be indicated in the future. However, the patient does not exhibit any of the criteria to suspect her canines are, in fact, impacted.  For this reason, braces are not medically necessary.