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

Diagnosis: Memory Issues
Treatment: Consumer Directed Personal Assistance Services (CDPAS), 56 Hours per Week
The insurer denied Consumer Directed Personal Assistance Services (CDPAS), 56 Hours per Week.
The determination is upheld.

This is a female patient with a medical history notable for dementia, urinary incontinence, hypertensive heart disease with heart failure, rheumatoid arthritis, and mobility issues. The patient is currently approved for 42 hours per week of consumer directed personal assistance services (CDPAS). The patient and her care team requested an increase to 56 hours per week, and this request was denied by the health plan.
The patient's physician provided a letter of medical necessity for this review. The letter describes the patient's declining physical and cognitive status and her extensive medical conditions. The patient wears diapers for urinary incontinence. She requires multiple daytime and night time changes of soiled diapers. There is no discussion of currently unmet personal care needs.
A Uniform Assessment System (UAS) was completed and was available for review. The patient lives alone in her apartment. The patient was alert and oriented times three with appropriate answers to questions. She has some short-term memory issues but is not confused and can call for help when needed. For her Instrumental activities of daily living (IADLs) , she requires total dependence for housework. She requires maximal assistance for meal preparation, stairs, shopping, and transportation. For her activities of daily living (ADLs), she requires maximal assistance for bathing, dressing lower body, toilet transfer, and toilet use. She requires extensive assistance for hygiene, dressing upper body, walking, locomotion, and bed mobility. She is frequently incontinent of stool and urine and uses 4-5 pull ups per day. Her daughter assists with her care as her Consumer Directed Personal Assistance Services (CDPAS) caregiver. A task tool associated with the assessment recommended 44 hours per week to address her personal care needs. At issue is the medical necessity of Consumer Directed Personal Assistance Services (CDPAS), 56 Hours per Week. 

The requested health service of Consumer Directed Personal Assistance Services (CDPAS), 56 Hours per Week has not been demonstrated to be medically necessary for this patient.
The patient has a requirement for hands on assistance with most IADLs and ADLs as outlined by the UAS. The patient was approved for 42 hours per week, which is almost to the level recommended by the task tool. There is no documentation regarding what personal care tasks are not being met at this current level of assistance that would be provided for with an additional two hours per day. Therefore, there is no clear demonstration of medical necessity for the requested increase in personal care hours.
Appeal type: Medical necessity
Decision: Overturned

Digestive system
Pharmacy/prescription drugs

Diagnosis: Crohn's disease
Treatment: Stelara every 4 weeks
The insurer denied Stelara every 4 weeks. The health plan's determination is overturned. 

The patient is a male with severe ileocolonic Crohn's disease complicated by small bowel obstruction status post ileocolonic resection. He has intestinal tuberculosis. He has failed mesalamine, azathioprine, 6-mercaptopurine, Humira, and Entyvio. He started Stelara with initial response. He had a disease flare (associated with missed Stelara doses), with hospitalization. A Colonoscopy showed severe ileal disease. He has had abdominal pain and has required prednisone.

The current medical literature supports the dose escalation of Stelara to 90 milligrams (mg) every 4 weeks as medically necessary for the treatment of Crohn's disease in this patient. In this case, the patient has had disease symptoms and colonoscopy showing inflammation while taking Stelara every 8 weeks. The American College of Gastroenterology guidelines for the treatment of Crohn's disease state that "Those with continued symptoms should have their medication dose adjusted in order to attempt to optimize therapy" (Battat, et al; Lichtenstein, et al). Continuation of the current Stelara dose (every 8 weeks) or discontinuation of Stelara (even if an alternative is attempted immediately) may result in loss of disease control, with complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for surgery, or other complications. For these reasons, the request for Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of this patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pain
Treatment: Vascular Surgery- (revascularization, endovascular, open, or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty)
The insurer denied the requested Vascular Surgery- (revascularization, endovascular, open, or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty).
The health plan's determination is overturned.
 
The patient is a male with lifestyle limiting bilateral lower extremity intermittent claudication who was seen by his provider for follow up. The patient was offered treatment with a right lower extremity angiogram with angioplasty and possible stenting.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient in its determination of medical necessity. The patient has lifestyle limiting claudication that requires treatment. 

The requested health service/treatment of vascular surgery- (revascularization, endovascular, open, or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with transluminal angioplasty) is medically necessary for this patient with lifestyle limiting claudication. The lower extremity arterial studies that were performed demonstrated occlusion of the right superficial femoral artery and high-grade stenosis of the left superficial femoral artery with blunted pulse volume recording (PVR) wave forms consistent with arterial occlusive disease. 

The patient has failed maximum medical therapy and continues to have less than one block, lifestyle limiting claudication. The treatment is the standard of care for the treatment of lifestyle limiting claudication. The patient will benefit from the treatment.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a past medical history (PMH) of deep vein thrombosis (DVT), symptomatic bradycardia status/post (s/p) pacemaker (PM), major depressive disorder (MDD), asthma, neuropathy, hyperlipidemia, and gastritis who was admitted with complaints of (c/o) a two-week history of bilateral lower extremity discoloration associated with shortness of breath (SOB). The vital signs were unremarkable. The physical exam was notable for no apparent distress (NAD), speaking full sentences, positive (+) lower extremity (LE) edema. Lab work was notable for brain (or B-type) natriuretic peptide (BNP) 97. Imaging studies included a chest x-ray (CXR) which showed no evidence of acute pulmonary disease, computed tomography (CT) scan of the abdomen/pelvis (A/P) which showed no evidence of an acute intra-abdominal or pelvic abnormality. The patient was diagnosed with lower extremity (LE) swelling, and there was clinical concern for a pulmonary embolism (PE) / deep vein thrombosis (DVT), and a full work-up was pending while receiving anti-coagulation. The patient was discharged against medical advice (AMA) 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 two-week history of bilateral lower extremity discoloration associated with shortness of breath (SOB). While there was some clinical concern for a pulmonary embolism and/or DVT, these were never proven. However, even if the patient had a pulmonary embolism (PE), there was no history of cancer, heart failure, or chronic lung disease, there was no hypotension, tachycardia, tachypnea, fever, altered mental status (AMS) or hypoxia. The pulmonary embolism severity index (PESI) score was consistent with class I, which is very low risk, with a 0-1.6 percent (%) 30-day mortality. The simplified pulmonary embolism severity index (sPESI) was also indicative of low-risk. In addition, there was no respiratory distress, hemodynamic instability, recent bleeding, or serious comorbid conditions. Patients with a PESI score less than 65 are very low risk for 30-day mortality (0%), and those with a score less than 85 are low risk for 30-day mortality (1%); patients in these categories can be considered for outpatient management. This patient was monitored and received anticoagulation, which could have been provided safely at an observation level of care. Overall, this patient was hemodynamically stable and without respiratory distress, with a negative work-up (that was accomplished), and could have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis
Treatment: Inpatient Hospital Admission
The health plan denied: Inpatient Hospital Admission
The determination is: Upheld

The patient is a female with history of Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome on non-steroidal anti-inflammatory drugs (NSAIDs) for arthritis who had been treated with antibiotics for appendicitis, who presented to the hospital with right sided abdominal pain a few months later. The patient also had associated nausea and vomiting. Her vital signs were essentially normal. The abdominal exam demonstrated tenderness and guarding. The white blood cell (WBC) count was 15.6. A computed tomography (CT) scan demonstrated significantly dilated appendix without significant peri-appendiceal fat stranding or fluid collection. The patient was admitted to General Surgery. The patient was made nothing by mouth (NPO) status and started on intravenous (IV) fluids. The patient was given IV antibiotics. The patient underwent an uncomplicated laparoscopic appendectomy. The patient was hospitalized again overnight due to the chronic/recurrent nature of her appendicitis. The patient met discharge criteria that morning and was discharged home. Pathology demonstrated acute appendicitis and peri-appendicitis.
At issue is the medical necessity of the full hospital admission.
The health plan's determination of medical necessity is upheld in whole.
No, the full hospital admission was not medically necessary for this patient. 
While the patient appears to have had suppurative appendicitis with phlegmonous changes in the right lower quadrant found at surgery, the patient does not appear to have utilized hospital services at the inpatient level of care.
The patient easily met discharge status criteria, did not experience complicated appendicitis, and did not have clinically active comorbidities. The patient did not experience complications of wound dehiscence, wound infection, or enterocutaneous fistula. The patient did not experience ileus. The patient did not experience postoperative bleeding. The patient did not experience complications or conditions such as anemia, arrhythmia, electrolyte disorder, fever, gastrointestinal bleed, hyperglycemia or complicated diabetes control, mental status change, psychiatric disorders, respiratory insufficiency, urinary complications, thrombotic complications, or wound and skin care complications. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Antepartum bleed.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is upheld.

This adult pregnant patient presented with vaginal bleeding. Ultrasound ruled out placenta previa. Examination did not show any cervical changes. Hematocrit was stable and on examination there were no signs of active bleeding. There was also no evidence of preterm labor, premature rupture of membranes, fetal jeopardy or maternal disease warranting admission.

Clinically speaking and after ascertaining that there was no evidence of active bleeding and that the fetus was doing well, the patient could have been sent home. 

Milliman Care Guidelines (MCG) list the following clinical indication for antepartum admission:
Condition requiring premature delivery, Delivery, Fetal distress or demise, Preterm labor and positive fetal fibronectin (fFN), Significant maternal disease, infection or comorbidity as cause; significant vaginal bleeding or any vaginal bleeding with known placenta previa, vasa previa or placenta accreta, continued fetal monitoring, Tocolytric therapy that requires inpatient care, Complications of tocolytic treatment, the patient did not have any of the above indications.

In summary, admission for this patient was not medically necessary. The patient could have been observed for a few hours hydrated and once the provider ascertained that the fetus was doing well, and there was no evidence of worrisome vaginal bleeding, the patient could have been sent home with adequate outpatient follow-up. Admission for monitoring was not medically necessary.

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 admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Idiopathic short stature (ISS)
Treatment: Genotropin
The insurer denied Genotropin.
The health plan's determination is overturned. 

This is a female diagnosed with idiopathic short stature (ISS). This request is for Genotropin 12 mg/mL (milligrams/milliliter) Cartridge. 

Genotropin 12 mg/mL Cartridge is medically necessary for this patient.

Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines. The Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height standard deviation score (SDS) less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

This patient had a pretreatment height less than or equal to -2.25 SDS. The patient's height velocity would not allow the patient to reach a normal adult height. The request therefore met idiopathic short stature criteria at the initiation of growth hormone.

The request is for continuation of growth hormone. The patient is continuing to grow as her height velocity on growth hormone continues to be above 2 centimeter (cm) per year. Continuation is consistent with the standard of care. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity

Treatment: Saxenda 18 milligrams (mg) / 3 milliliter (ml) injections

The insurer denied coverage for Saxenda 18 milligrams (mg) / 3 milliliter (ml) injections

The denial is overturned

 
The patient has a history of obesity, knee pains, and lower back pain. The knee pains are exacerbated by putting weight on her lower limbs. An office visit states that her Body Mass Index (BMI) is 31.9. 

UpToDate has an article titled "Obesity is adults: Drug therapy." The article states that candidates for drug therapy include those individuals with a BMI greater than 30 or a BMI of 27 with weight related comorbidities. Both semaglutide and liraglutide are FDA approved treatments that have been shown to be beneficial for weight loss. They are both GLP-1 receptor agonists and have been shown in large trials to be more effective than placebo in promoting weight loss. 

The insurance company has denied Saxenda asserting that it is not medically necessary since the patient did not meet the Food and Drug Administration (FDA) indications for the drug. However, the physician's progress note indicates that the patient has a BMI over 30 and is having difficulty putting weight on her lower extremities.

This patient has met the FDA recommendations for treatment with a GLP-1 agonist. 

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 Saxenda 18 milligrams (mg) / 3 milliliter (ml) injections is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 2 Diabetes Mellitus
Treatment: Formulary exception for Mounjaro 2.5 mg (milligrams)/0.5 ml (milliliters) Pen
The insurer denied the formulary exception for Mounjaro 2.5 mg/0.5 ml pen.
The denial is upheld.

The patient is an adult male with type 2 diabetes. The request for Mounjaro is under review. The prior request was denied coverage by the health plan, as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This denial is being appealed. The patient has tried Ozempic, which caused nausea. The patient is being treated with metformin. The patient's A1C (glycated hemoglobin) is 6.0% (percent).

The health plan should not cover the formulary exception for Mounjaro.

This request is for Mounjaro for the treatment of type 2 diabetes. The health plan's formulary alternatives include Ozempic, Rybelsus, Trulicity, and Victoza. The patient has tried and was intolerant to Ozempic due to nausea. The documentation does not indicate that the patient has tried and failed the remaining alternatives or that the patient has a contraindication to these alternatives. The patient's A1C was 6.0%. He is being treated with metformin. The patient does not have a prior documented A1C that was elevated to document a need for additional glucose lowering medication. The American Diabetes Association clinical guidelines do not support the use of Mounjaro in this clinical situation. Mounjaro has risks, including nausea and vomiting. Therefore, no, the health plan should not cover the formulary exception for Mounjaro.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Multiple Sclerosis.
Treatment: Formulary exception for Vumerity.
The insurer denied: Formulary exception for Vumerity.
The denial is Upheld.

The patient is an adult female with multiple sclerosis (MS). She has been treated with natalizumab and ocrelizumab. The provider has requested Vumerity. The requested medication was denied coverage by the health plan, as the patient has not tried and failed generic dimethyl fumarate and two additional preferred medications.

The health plan should not cover the Formulary exception for Vumerity.

There is no documented reason the patient cannot be treated with the preferred formulary medications. All of the preferred agents are FDA (United States Food and Drug Administration) approved for his condition based on high-quality clinical trials published in the peer-reviewed medical literature (McGinley et al., 2021). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Vumerity relative to the preferred agents. There is no evidence that switching to a preferred agent would jeopardize his clinical stability.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cryptogenic Strokes
Treatment: CADASIL (Notch3) Genetic Testing
The insurer denied: CADASIL (Notch3 Genetic Testing)
The denial is: Overturned

The patient is a female with multiple cryptogenic strokes. The patient does not have a clear vascular, embolic, or other cause for the strokes. The pattern of strokes on the magnetic resonance imaging (MRI) of the brain is concerning for the genetic condition Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, (CADASIL). Genetic testing was obtained for this condition and denied by the plan. Medical necessity for this service is the subject of this review.

The service is medically necessary. The patient is under the care of a neurologist that specializes in strokes. The neurologist indicated that the patient had multiple ischemic strokes with no identified embolic, atherosclerotic, or vasculitic cause. As a result, genetic testing was performed for CADASIL (also known as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy). This is a rare inherited disorder that occurs when the thickening of the walls of small- and medium-sized blood vessels. This leads to ischemic strokes. The need for the testing was based upon the patient's clinical history, MRI appearance, and negative initial testing. Additionally, a positive test would change management goals for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Abdominal pain.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is upheld.
 
The patient had diabetes and presented with abdominal and back pains. She was afebrile and the vital signs were stable. The abdominal exam was benign. The stool was heme negative. The white blood cell (WBC) count was 11.0. An abdominal computed tomography (CT) scan and ultrasound showed a gallstone with a normal appearing gallbladder. The glucose was 154, but she had glucose in the urine with trace ketones. 

Clinical indications for an admission for Undiagnosed Abdominal Pain Milliman Care Guidelines(MCG M-05) include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, bacteremia, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions. 

The patient was found to have a gallstone. Neither the CT scan or ultrasound showed evidence of acute cholecystitis. In addition, the abdominal exam was not consistent with acute cholecystitis. No surgical interventions were needed for the biliary tract. 

This patient presented with abdominal pain and an elevated glucose. She did not have diabetic ketoacidosis. She was able to tolerate a liquid diet. No acute interventions were required. The workup for the abdominal pain could have been done with observation status. She did not meet MCG criteria for admission for Undiagnosed Abdominal Pain. 

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 an admission is not substantiated.