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

Diagnosis: vascular dementia

Treatment: personal care aide (PCA) 7 days x 12 hours x 2 shifts, total of 168 hours per week

The insurer denied coverage for personal care aide (PCA) 7 days x 12 hours x 2 shifts, total of 168 hours per week

The denial is overturned

This is an elderly female with chronic medical problems including vascular dementia, hypertension and is legally blind. She lives alone in a studio apartment. The insurer approved personal care aide (PCA) services, 75 hours/week and the request is for personal care aide (PCA) services 7 days per week, 24 hours per day (split shift), for a total of 168 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as severely impaired. She is reportedly total dependent for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient reportedly requires maximal assistance for bathing, lower body dressing and toilet use. Extensive assistance is reportedly needed for personal hygiene, upper body dressing, toilet transfer, locomotion and ambulation. Limited assistance is reportedly needed for bed mobility and eating. The patient is frequently incontinent bladder and infrequently incontinent of bowel. 

The patient's Activities of Daily Living (ADL) status and self-sufficiency have reportedly declined over the prior 90 days. She fell at home. A subsequent right hip X-ray demonstrated a fracture. She underwent right hip fracture surgical repair. The patient's cognitive and functional ability have also declined. The patient's clinical condition and functional deficits are at a level and unpredictable as to require the increasing personal care aide (PCA)  services 7 days per week, 24 hours per day (split shift). This physician was also persuaded by the letters, treatment notes and hospital records from her treating physicians and medical providers documenting the patient's clinical condition, multiple impairments and functional decline. She requires routine repositioning in bed at least every 2 hours. Based on the clinical records, a live-in personal care aide (PCA) is unlikely capable of consistently obtaining approximately 5 hours of uninterrupted sleep over the course of a 24 hour shift. This physician would also agree that attention to the patient's functional needs are more appropriately provided and maintained by increasing personal care aide (PCA) services 7 days per week, 24 hours per day (split shift), for a total of 168 hours per week.

From a physical medicine and rehabilitation perspective, personal care aide (PCA) 7 days x 12 hours x 2 shifts, total of 168 hours per week is 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 personal care aide (PCA) 7 days x 12 hours x 2 shifts, total 168 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Mental Health 
Mental health outpatient

Diagnosis: Major Depressive Disorder
treatment: Transcranial Magnetic Stimulation (TMS)
The insurer denied Transcranial Magnetic Stimulation (TMS). The health plan's determination is overturned.

The patient is an adult female with history of a mood disorder best characterized as bipolar II disorder with most recent episode, major depressive disorder, severe and recurrent without psychotic features. The patient has a documented history of multiple medication treatments including treatment with Prozac, Celexa, Lexapro, and Cymbalta prescribed over the past ten years. She has received augmentation with Seroquel. Due to adverse effects or lack of efficacy or sustained benefit, the patient has continued to experience severe symptoms of depression and functional impairments scoring 22 on the PHQ-9 (Patient Health Questionnaire) in the severe range of depression. 

Transcranial Magnetic Stimulation (TMS) is medically necessary for this patient.
TMS therapy as a primary or adjunctive therapy for treatment of depression has generally been evaluated in patients who have treatment refractory/resistant depression, as defined by one or more, antidepressant medication treatment failures with or without augmentation. TMS therapy for depressive disorder has been established by the Food and Drug Administration (FDA) as a safe treatment; and the data, as reflected in peer reviewed medical literature, supports this assertion. Specifically, when treatments with antidepressant medication with or without augmentation, or with electroconvulsive therapy, and/or psychotherapy, especially cognitive behavioral therapy, have failed to produce a response or remission, then TMS is an appropriate consideration. This assertion is noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below. Moreover, scientific literature indicates that a course of treatment with TMS therapy is reasonable in cases of treatment resistant depression as defined in the scientific literature.
In this case, at least four alternative therapeutic trials with augmentation together with other therapeutic measures have been provided, and the proposed treatment with TMS therapy is considered clinically appropriate and medically necessary. Additionally, the use of TMS therapy is reasonable, and in the best interest of the patient. The decision to proceed with TMS therapy reflects sound medical judgment based upon the current scientific literature and American Psychiatric Association practice guidelines concerning the assessment and treatment of major depressive disorder. The patient in this case has demonstrated that her depressive disorder is treatment refractory or resistant, and the proposed treatment of recurrent major depressive disorder using TMS therapy with a clinically appropriate number of sessions is warranted in this case scenario and is consistent with prevailing standards of medical practice.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Central Nervous System/Migraines
Treatment: Pharmacy/Prescription Drugs/Qulipta
Insurer Denied: The health plan denied the requested medication, Qulipta, as not medically necessary. The health plan's determination is upheld.

The patient is a female with migraines. Treatment with Qulipta is the subject of this review. The drug was denied because the patient has not tried and failed the formality alternatives of Ajovy, Aimovig, Emgality, Vyepti, and Nurtec ODT. The provider appealed the determination.

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

The patient has tried and failed Aimovig. There is no documentation that the patient has tried and failed Ajovy, Emgality, Vyepti, and/or Nurtec ODT. There is no reason to believe that the remaining formulary alternatives would not be as effective as the nonformulary drug for treatment of migraines. All of the remaining formulary alternatives are Food and Drug Administration (FDA) approved for prevention of migraines. All of the drugs have been shown to be safe and effective in controlled trials. These drugs are not expected to have any significant adverse side-effects, as all of the drugs have similar mechanisms of action on the calcitonin gene-related peptide (CGRP) pathway. Qulipta has not been compared head to head with any of the formulary alternatives, so it cannot be said that Qulipta is more effective than these drugs.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Skin Disorders/Plaque Psoriasis
Treatment: Pharmacy/Prescription Drugs/Taltz autoinjector (2 pack) 80 mg/ml
The health plan denied the requested medication Taltz autoinjector (2 pack) 80 mg/ml as not medically necessary. The health plan's determination is upheld.

The patient is a female with moderate to severe psoriasis (25% body surface area involvement) on the back, forearms, hands, abdomen, legs, ankles, scalp, and ears. The patient has tried and failed topical Vtama 1% (percent) cream.
The medical necessity of Taltz is under review.

Health plan determination of Taltz coverage is recommended to be upheld.

No. The patient has no documented treatment failure with, or true medical contraindication to, either Methotrexate, Acitretin, Otezla, Taltz, Enbrel, Humira, Cimzia, Cosentyx, Skyrizi, Stelara, or Tremfya, all of which are of similar potency and efficacy to the requested Taltz. These alternative medications are as medically appropriate for the treatment of this patient's particular clinical condition as is the requested Taltz. Therefore, as per the patient's health plan policy language, [1] the requested Taltz is not medically necessary.
Modern dermatology literature [2-5] supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized, and this literature recommends the use of these preferred agents as appropriate for this patient's clinical scenario. The provider is prescribing and requesting Taltz out of convenience and/or preference of the provider and/or patient, and neither convenience nor preference are the same as true medical necessity. The formulary alternatives are overall no less effective, and without any significantly greater incidence of adverse effects, compared to the requested Taltz. Therefore, as per current medical standards of care, Taltz is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person: 168 hours per week
The insurer denied coverage for Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person: 168 hours per week.
The denial is overturned.
 
The patient is an elderly woman currently receiving 77 hours per week of Personal Care Worker (PCW) services. There is a request for Personal Care Worker (PCW) services to increase to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week. She has a diagnosis of dementia. There was a request for more hours. She was reported to have had falls, be unable to toilet on her own. There is also reported frequent urination and constipation. According to the documentation the patient "has frequent urination and bowel movements often using the bathroom multiple times an hour and at least 4-5 times per night.  This is thought to be caused by diverticulitis.  She cannot transfer to the toilet without physical assistance of an aide.  It would not be possible for an aide to obtain 5 hours of uninterrupted sleep.

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 an increase in Personal Care Worker (PCW) services to 7 days per week, 24 hours per day, continuous care by more than 1 person; 168 hours per week services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Respiratory System
Pharmacy/Prescription Drugs

Diagnosis: Asthma
Treatment: Tezspire

The health plan denied: Tezspire
The determination is: Upheld

The patient is a female who is seeking approval for Tezspire. It was denied as the patient has not tried any formulary alternatives such as Dupixent, Fasenra, or Nucala. A doctor's visit note documented moderate persistent asthma, and her symptoms were not controlled on Dulera and albuterol. Her inhaler was changed to Trelegy from Dulera, and a complete blood count (CBC), immunoglobulin E (IgE), and a radioallergosorbent test (RAST) panel were obtained. Computed tomography angiography (CTA) of the chest noted multifocal COVID pneumonia. The patient is also obese. Another visit noted she is doing better with Trelegy and nebs. It appears Nucala was also prescribed previously, but she is no longer using it. The most recent visit noted prescribing Tezspire. Blood work was obtained, and Singulair was started.
At issue is whether the formulary drug will be or has been ineffective, or would not be as effective as the non-formulary drug, Tezspire.
The health plan's determination is upheld in whole.
There is no documentation that the formulary drugs will be ineffective, not as effective as the non-formulary drug, or would have adverse effects. Lab work results were not included in this review. The patient has tried Nucala in the past, but there is no documented trial of Fasenra or Dupixent. It is reasonable to trial Fasenra or Dupixent prior to Tezspire, in accordance with health plan policy.
Appeal type: Medical necessity
Decision: Upheld

Blood Disorder/ Anemia
Inpatient Hospital

Diagnosis: Low blood counts (anemia), abnormal uterine bleeding.
Treatment: Inpatient emergency admission.
The insurer has denied the inpatient emergency admission.
The health plan's determination is upheld.

The patient is a female with abnormal uterine bleeding, weakness, and fatigue with abdominal pain. Her hemoglobin was 5.6. She was diagnosed with symptomatic anemia and was admitted as an inpatient. She was provided three units of packed red blood cells (PRBCs), and her hemoglobin increased to 8.6 with symptomatic improvement. She was discharged.

At issue is the medical necessity of an inpatient emergency admission.
I uphold, in whole, the health plan's determination of medical necessity.

The requested health service/treatment of inpatient emergency admission is not medically necessary for this patient.

The patient had symptomatic anemia and transfusion was appropriate; however, inpatient admission was not medically necessary. She was hemodynamically stable, and there was no profuse, active bleeding. Old clots were found in the vagina. In addition, she had no syncope, altered mental status, or cardiac arrhythmias. She had no significant comorbid condition including pulmonary, renal, or hepatic concerns. She was not in disseminated intravascular coagulation (DIC) or renal failure. Her transfusion could have been performed as an outpatient with less than a 24-hour admission or extended monitoring. Inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female with no major medical history who presented to the hospital with acute on chronic cholecystitis. An ultrasound (US) demonstrated evidence of cholelithiasis without evidence of cholecystitis. Her white blood cell count (WBC) was 13 and she was afebrile. The patient underwent laparoscopic cholecystectomy. She was discharged tolerating a diet, and 
pain was well controlled.

The proposed treatment was not medically necessary.

Inpatient admission was not warranted given the uncomplicated nature of the laparoscopic cholecystectomy, no evidence of post-operative complications, and meeting discharge milestones. Also, on admission, the patient was not demonstrating any signs that necessitated inpatient level of care. Therefore, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This patient is an adult male with prior colon resection surgery due to trauma who presented with lower abdominal pain, loose watery stool, inability to tolerate oral intake (POs) for 2 days. 
The patient was hemodynamically stable. The white blood cell (WBC) count was 10.1. Computed tomography (CT) of the abdomen / pelvis showed dilated loops of small bowel with no definitive transition point indicating partial small bowel obstruction. The patient was treated with nothing by mouth (NPO), intravenous fluids, and Ketorolac. Surgery consult opined that there would be no surgical intervention required. On day #3, the patient felt better, abdominal pain resolved, and the patient had 2 loose bowel movements. Clear liquids were tried and the patient was discharged. 

The proposed treatment was not medically necessary. 

Acute inpatient level of care was not appropriate for this patient. A lower level of care would have been a more efficient setting, since the patient did not require any procedural or surgical intervention, did not require to be nothing by mouth for a prolonged duration of time, did not require prolonged treatment with intravenous hydration or intravenous medications, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, and did not have any complications such as intra-abdominal abscess or a surgical abdomen. The medical records do not support that the acute inpatient admission was medically necessary. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. Therefore, based on review of the submitted medical records, the requested inpatient level of care was not medically necessary for the dates of service in question as it exceeded in scope and intensity the level of care necessary to provide safe, adequate and effective treatment for this patient's condition.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion. 
Treatment: Braces and Monthly Visit. 
The insurer denied Braces and Monthly Visit. 
The denial is overturned. 

The patient is an adolescent female. The request is for orthodontic benefits with monthly visits. She has a Class III skeletal malocclusion with mild upper and moderate lower crowding. She has a right posterior crossbite. The health plan's prior denial of coverage was due to the patient scoring a handicapping score of 17. The denial is being appealed. 

The Braces and Monthly Visit are medically necessary. 

The patient has multiple teeth in anterior crossbite (reverse bite, teeth 22-27). There is clinical attachment loss and recession of the gingival margins present. These are multiple automatic qualifiers for orthodontic benefits. The monthly visits are also needed to make sure treatment is properly progressing. This case has medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low Back Pain, Depression. 
Treatment: Consumer Directed Personal Assistance Services. 
The insurer denied Consumer Directed Personal Assistance Services. 
The determination is upheld. 

This is a male patient with a medical history notable for low back pain and depression with anxiety. The patient and his care team requested Consumer Directed Personal Assistance Services (CDPAS), and the request was denied by the health plan. 

The patient's psychiatry team provided a letter for this appeal. The letter states that the patient was diagnosed with schizoaffective disorder and cannabis use disorder. He is receiving medications and weekly telehealth sessions. There is no discussion regarding his personal care needs. 

In the appeal request for personal assistance hours, the physician notes the following: "Patient has chronic health conditions such as mood disorder, depression with anxiety, underweight and low back pain. Patient is unable to care for self and requires assistance with daily living activities." No further detail was provided. The documentation from the patient's family states the following: "My son has severe back pain, but this pain is causing his mental health issues to get worse... my son is at the point where he got diagnosed with schizophrenia, PTSD (post-traumatic stress disorder), severe depression, anxiety, bipolar disorder and he is underweight." 

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. He lives alone in a studio apartment. He has a history of hospitalization for overdose several years ago. His cognition was minimally impaired. He has a supportive relationship with his mother who visits daily and spends 3 hours providing help. The patient requires total dependence for meal preparation and housework, which his mother is currently assisting with. He requires maximal assistance for medications and shopping and extensive assistance for finances. He is independent for activities of daily living (ADLs). He was observed getting up and walking with a slightly unsteady gait. He is continent of stool and urine. 

At issue is the medical necessity of CDPAS. 

The requested health service CDPAS has not been demonstrated to be medically necessary for this patient. 

The patient requires some assistance with instrumental activities of daily living (IADLs) 
but is independent for ADLs. He is currently receiving support from family for his IADLs. There is no documented evidence of unmet personal care needs. There is no documentation regarding the etiology and expected prognosis of the patient's back pain. Personal care aides cannot be authorized for safety monitoring or companionship and are only medically necessary when needed to perform personal care tasks. There is insufficient evidence that the patient currently has any unmet personal care needs that would warrant approval of personal assistance services at this time.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Durable medical equipment

Diagnosis: right posterior plagiocephaly and torticollis
Treatment: Cranial Remolding Helmet 
The insurer denied Cranial Remolding Helmet. The health plan's determination is overturned. 

This is the case of a young male with right posterior plagiocephaly and torticollis. His head shape did not improve despite treatment of the torticollis. Initial evaluation occurred at 5 months old. At that time, a helmet was deferred and physical therapy was initiated for torticollis. He was prescribed a cranial remodeling helmet at follow-up at 7 months old with good result.

Based on the medical documentation provided, as well as the consensus guidelines cited, the requested treatment of Cranial Remodeling Helmet is considered medically necessary for this patient.
This infant was referred due to severe posterior positional plagiocephaly with torticollis. He was first managed with physical therapy to treat the muscular issues and then recommended helmet therapy which provided good result. This sequence of treatments is considered standard of care for this condition as supported by professional guidelines and practice standards.
This child was treated according to established practice standards and current medical literature. Physical therapy was first used to correct the patient's torticollis, then remodeling helmet applied due to continued flattening in the moderate to severe range.