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

Diagnosis: Parkinson's Disease
Treatment: Home Health Care (HHC) Personal Care Aide (PCA) Increase to 24 hours/day (Split-Shift).
The health plan denied the requested HHC PCA increase to 24 hours/day (Split-Shift) as not medically necessary. 
The health plan's determination is overturned.

The patient is a female with past medical history of Parkinson's disease, dementia, anxiety, depression, urinary incontinence, bowel incontinence, tremor, chronic pain, and gastroesophageal reflux disease (GERD). She had been assigned personal care aide (PCA) services 6 hours/day, 7 days/week, to total 42 hours/week based on telephonic assessment performed, assessing the patient at total assistance with tasks of ordinary housework and shopping, while maximum assistance with tasks of meal preparation, managing finances, and managing medication. With tasks of stairs, transportation, bathing, dressing upper/lower body, and toilet use the patient was assessed at extensive assistance, while limited assistance with tasks of phone use, personal hygiene, walking, locomotion, and transfer toilet. The patient was assessed at independent with tasks of bed mobility and eating. Notes from the assessment stated the patient lived with her spouse. 

The patient's psychiatrist provided a letter stating the patient's medical diagnoses, the patient's medications, the patient has had worsening of her medical condition, the patient has episodes of excess worry, and the patient required additional home health aide (12 + [plus] 12 hours) for better improvement and help with activities of daily living (ADLs). The patient stated due to her medical conditions she was bed bound and due to irritable bowel syndrome and overactive bladder the patient needed to be changed 3-4 times a night because she could not use the bathroom herself.

At issue is the medical necessity for the requested increase in PCA hours.

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

There is documentation from the patient and her family that the patient requires assistance with overnight care needs, specifically transfer toilet and toilet use in the overnight hours 3-4 times per night. The patient's overnight care needs would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs/instrumental activities of daily living (IADLs). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory System
Treatment: Inpatient Hospital Stay

Diagnosis: Respiratory System - Breathing Problem
Treatment: Inpatient Hospital Stay
The health plan denied the inpatient hospital stay as not medically necessary. The health plan's determination is upheld.

The patient is a male who presented to the emergency department (ED) in respiratory distress with a respiratory rate of 45 breaths/minute along with bilateral rhonchi, global retractions, nasal flaring, and grunting. His temperature was 100.7 Fahrenheit (oF), and his heart rate was up to 165 beats per minute (bpm). He was placed on High Flow Nasal Cannula (HFNC) at 16 liters per minute (lpm) and 30 percent (%) oxygen, but quickly weaned to 1 lpm. Laboratory testing noted a venous potential hydrogen (pH) of 7.288, a bicarbonate of 19.9, a lactic acid of 1.8, and anion gap of 13.0. A viral respiratory panel (VRP) was negative. A complete blood count (CBC) was normal for his age.
The patient was admitted for management of acute respiratory failure secondary to bronchiolitis. He received intravenous fluids (IVF) following a bolus of normal saline intravenous (IV). He was also given acetaminophen and famotidine. His diagnoses included the following: lactic acidosis, acute viral bronchiolitis, and acute respiratory failure. A blood culture was obtained, but no antibiotics were started.
The patient showed rapid improvement, was weaned to a nasal cannula, and then to unassisted room air (oxygen saturation greater than (>) 98%). He was tolerating a regular diet, deemed stable, and cleared for release from acute care to home. Outpatient follow-up was arranged.
At issue is the medical necessity of the inpatient hospital services.
The health plan's determination of medical necessity is upheld in whole.
The requested health service/treatment of inpatient hospital services was not medically necessary for this patient.
The patient required short term monitoring that did not exceed 48 hours (hospital stay was approximately 17 hours). He received acute treatment for his respiratory distress that included HFNC and supplemental oxygen that was able to be quickly weaned. He was monitored during this time and showed a rapid improvement. His discharge in less than 24 hours supported that no new condition developed to support an adverse change that would support the need for continued hospital services. The patient met published guidelines for discharge because he was clinically stable, was taking adequate oral fluids, and maintained an oxygen saturation in air over 90% for 4 hours, including a period of sleep [1,2].
There was no documentation of a worsening in the patient's condition to support the continuation of hospital services. The patient's condition improved rapidly and permitted discharge. The patient's condition met criteria for an alternate level of care per the health plan and per published literature as noted below [3]. Therefore, the inpatient hospital services were not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

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

This adult male patient with a history of alcohol abuse, anxiety, depression and diabetes presented from rehab for detox. He had been admitted for alcohol detox and developed tachycardia with a heart rate in the 140's associated with nausea and vomiting after receiving Librium. He has a history for alcohol withdrawal seizures. 

The patient's vital signs revealed: temperature 99.6, pulse 100, respiratory rate 20, blood pressure 139/94 and oxygenation saturation 100%. His exam was remarkable for mild tremors and facial droop. Labs revealed: white blood cells (WBCs) 4.4, hemoglobin/hematocrit (H/H) = 13.9/41.1, platelet (Plt) 158, sodium (Na) 135, potassium (K) 3.8, blood urea nitrogen/creatinine (BUN/Cr) = 7/0.8, glucose 246, and potential hydrogen (pH) 7.45. Urinalysis was positive for ketones and glucose. Electrocardiogram (EKG) showed no arrhythmia. 

The patient was admitted with alcohol withdrawal. His plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) and Ativan. On the next day the patient's vital signs were stable. The patient's tachycardia had resolved. His Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was 12. He was on Ativan detox. The following day the patient's vital signs were stable. Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was one. He was not in acute distress. The patient was on an Ativan taper. On day 3, the patient's vital signs were stable. He felt improved. His Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was one. He was continued on Ativan detox. The patient was discharged the next day. 

The proposed inpatient hospital admission was not medically necessary. 

This patient with a history of alcohol abuse and withdrawal was admitted after presenting with alcohol withdrawal. He had a history of alcohol withdrawal seizures. He was not acutely intoxicated. The patient was hemodynamically stable and afebrile. He had mild tachycardia but no arrhythmia. He had findings of alcohol withdrawal that responded to treatment in the emergency department. Admission physical exam was unremarkable for mild tremors. The patient had an elevated blood glucose, but no acidosis. He did not have comorbid conditions. The patient was admitted with a plan for Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. During his hospital stay, the patient did not have findings of acute alcohol withdrawal. On day #3, his Clinical Institute Withdrawal Assessment (CIWA) was one. He was being managed with oral medication assisted treatment. The patient was clinically stable and did not have findings of severe alcohol withdrawal. He had not failed a lesser level of care. He did not have symptoms that required an acute inpatient level of care. The acute inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast cancer.
Treatment: Genetic testing.
The insurer denied genetic testing. 
The health plan's determination is upheld. 

This is a female with newly diagnosed recurrent, metastatic breast cancer. Genetic testing was obtained and is under review.

The Laboratory Services: Genetic Testing is not medically necessary for this patient. Simply having a potentially targetable mutation does not guarantee that the patient will benefit from a therapy that presumably targets that mutation. Another potential pratfall is if targeted testing identifies a potentially actionable genetic abnormality for which a molecularly targeted treatment is available but not yet approved. Based on the paucity of supporting data, neither the National Comprehensive Cancer Network (NCCN) nor the authors of UpToDate recommend the use of the Guardant360 assay in this clinical scenario. Treatment based on published literature and guideline recommendations has been encouraged. For these reasons, the use of this assay in this scenario is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: psoriatic arthritis
Treatment is Cosentyx
The insurer denied coverage for Cosentyx.
The denial is upheld.

The patient is an adult with a diagnosis of psoriatic arthritis, psoriasis, and fibromyalgia. The patient is being treated with Cosentyx and Otezla for her psoriatic arthritis. The patient was initially treated for her psoriatic arthritis with Otezla, without complete resolution. Cosentyx was introduced and led to clinical improvement. The Otezla was not discontinued. The insurer has denied the combination of Otezla with Cosentyx. The request is for combination therapy for the patient's psoriasis and psoriatic arthritis with simultaneous Cosentyx and Otezla treatment.

Based on the submitted documentation, the continuation of Otezla while on Cosentyx is not medically necessary. The patient has failed therapy with Otezla.  The standard of care would be to discontinue Otezla and treat with Cosentyx. Cosentyx is FDA (Food and Drug Administration) approved for monotherapy of psoriasis and psoriatic arthritis. There is insufficient evidence for using the combination of Cosentyx with Otezla. Furthermore, the patient has not been treated with Cosentyx monotherapy to determine whether it will be effective. Finally, Menter et al in the guidelines for treatment of psoriasis using biologics under the section for secukinumab (Cosentyx) supports its use as monotherapy but does not mention combining it with apremilast (Otezla). 

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 Cosentyx services is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension
Treatment: Edarbyclor 40/25mg (milligrams) Tablet
The insurer denied the Edarbyclor 40/25mg (milligrams)Tablet
The denial is upheld

The patient is a male with hypertension. No complaints of chest pain, palpitations, shortness of breath or dizziness. Also diagnosis of prediabetes. Appeal noted poor responses to ARB/HCTZ agents (Angiotensin receptor blockers/Hydrochlorothiazide) such as Benicar/HCTZ (hydrochlorothiazide), AMLODIPINE, AND MICARDIS. Presently uses combination of Azilsastin and Chlorthaidone, known as Edarbyclor. 


Appeal letter states that no other medication on formulary can control blood pressure as well as Edarbyclor.

Formulary alternatives are: candesartan, candesartan-hydrochlorothiazide, irbesartan, irbesartan-hydrochlorothiazide, losartan, losartan-hydrochlorothiazide, olmesartan (generic Benicar), olmesartan-hydrochlorothiazide (generic Benicar HCT), telmisartan, telmisartan-hydrochlorothiazide, valsartan, valsartan-hydrochlorothiazide.

No, the health plan should not cover the proposed treatment.

There is no evidence in the literature to suggest that this fixed combination anti-hypertensive, Edarbyclor, would be superior to  other medications is this clinical situation. This could also included other ARB (angiotensin-receptor blockers), ACE (angiotensin converting enzyme) and diuretic. 

Also, there is no documented evidence of failure of other formulary drugs in the medical records. It would be reasonable to try other formulary drugs in various dosages prior to the exclusive use of Edarbyclor.

Many of the formulary medications should be effective in blood pressure control.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine Headache.
Treatment: Reyvow 50MG (milligram) OR TABS (oral tablets), pre-service.
The insurer denied the Reyvow 50MG (milligram) OR TABS (oral tablets), pre-service.
The denial is overturned.

Patient is a woman with intractable migraines who is currently on Ubrelvy. Provider wishes to prescribe Reyvnow in conjunction with Ubrelvy. The request was previously denied by the plan as it was concerned with combination therapy of both given the lack of data with these two therapies together.

Yes, Reyvow is medically necessary as patient has intractable migraines that has not been responsive to multiple abortive and preventative medications. Combination therapies with different mechanisms of actions do not necessitate research. There was also a concern for drug interaction between Reyvow and Ubrelvy however they will not be used concurrently with each other and Ubrelvy will be used with less severe headaches and Reyvow would be used for more severe headaches. Given the poor quality of life due to migraines in this patient, Reyvow is medically necessary and is standard of care.

Given these two medications have different mechanisms of action and would be taken at different times, it is medically necessary. Plan refusal would force patient to have continued decreased quality of life which could lead to increased healthcare utilization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infection of Finger. 
Treatment: Inpatient Hospital Stay. 

The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a patient with a history of intravenous drug use who presented to the emergency department (ED) with cellulitis of the right ring finger with purulent drainage from the finger. She was diagnosed with a paronychia. Drainage of the paronychia was attempted in the emergency department (ED) but with no return of pus. She was admitted for intravenous (IV) antibiotics. She developed drug withdrawal and was treated for her symptoms. The patient self-discharged. At issue is the medical necessity of an inpatient stay. 

The inpatient stay was not medically necessary. The patient had a finger infection and was admitted for IV antibiotics. According to Milliman Care Guidelines (MCG) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations." This patient was medically stable and needed only IV antibiotics and management of her withdrawal symptoms. She could have been safely managed at a lower level of care than inpatient. Had she failed to respond to IV antibiotics, she could have been admitted but she left the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Chest Pain. 
Treatment: Inpatient Admission. 

The health plan denied the requested inpatient admission as not medically necessary. 
The health plan's determination is upheld. 

This case involves a male with a history of mild left ventricular (LV) systolic dysfunction, colon cancer, diabetes mellitus, deep vein thrombosis (DVT), and hypertension, who presented to the emergency department (ED) for evaluation of chest pain. The patient developed substernal chest pain described as pressure that awoke him from sleep that radiated down right arm associated with abdominal pain, emesis and left upper extremity numbness. In the ED, the patient was hypertensive, 143/95 millimeters of mercury (mmHg). An electrocardiogram (ECG) showed normal sinus rhythm and left ventricular hypertrophy (LVH). The patient was admitted to telemetry under an inpatient level of care for evaluation of chest pain and acute coronary syndrome (ACS) rule out. An echocardiogram demonstrated mild LVH and a normal left ventricular ejection fraction (LVEF). An abdominal X-ray demonstrated moderate stool throughout the colon. A cardiology consultation was obtained, and a stress test was performed that was negative for ischemia but did demonstrate mild global left ventricular (LV) systolic dysfunction, LVEF 48%. The patient was subsequently discharged home. 
At issue is the medical necessity for the inpatient admission. 

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

No, an inpatient level of care was not medically necessary in this case because the patient ruled out for ACS with negative cardiac troponins, there were no ischemic changes on ECG and stress testing was normal. Based on the well-validated HEART pathway and the 2014 American College of Cardiology (ACC)/American Heart Association (AHA) guideline for the management of patients with non-ST-elevation acute coronary syndromes, observation level of care would have been medically appropriate and safe for the evaluation of chest pain in this case. 

The patient presented with chest pain in the intermediate risk category based on calculated HEART score (=5). The patient ruled out for ACS with negative cardiac troponins and ECG did not demonstrate acute ischemic changes. According to the well-validated HEART pathway, admission under observation level of care to complete ACS rule out and undergo stress testing and echocardiogram imaging would have been medically appropriate and reasonable. [1,2] Additionally, observation level of care for ACS rule out and completion of stress testing in this case is supported by the 2014 ACC/AHA guideline for the management of patients with non-ST-elevation acute coronary syndromes.[3] 

An inpatient level of care was not medically necessary in this case for ACS rule out and completion of stress testing. Rather, observation level of care would have been medically appropriate and safe for evaluation of this patient's chest pain syndrome.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Recurrent Major Depression, Autism Spectrum Disorder, Ulcerative Colitis.
Treatment: Intravenous (IV) Ketamine.
The insurer denied: Intravenous (IV) Ketamine.
The denial is overturned.

The patient is an adolescent male diagnosed with treatment-resistant depression. He has tried and failed fluoxetine, Lexapro, and nortriptyline. He has also tried and failed Abilify, Wellbutrin, and Lamictal. The current request is for IV (intravenous) ketamine.

The health plan should cover the requested intravenous ketamine.

The patient is diagnosed with treatment-resistant depression. IV (intravenous) ketamine is frequently used to treat treatment resistant depression. It is a reasonable option in trying to alleviate his depressive symptoms. IV (intravenous) Ketamine has been shown to be a safe and effective treatment for depression.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Binge Eating Disorder, Anxiety, Attention Deficit Hyperactivity Disorder (ADHD)
Treatment: Vyvanse
The insurer denied: Vyvanse
The denial is: Overturned

The patient is a female with diagnosed binge eating disorder, anxiety and attention deficit hyperactivity disorder (ADHD) inattentive type. She is being followed by a child and adolescent psychiatrist. The psychiatrist prescribed Vyvanse, but it was denied. The following review is evaluating the medical necessity of the use of Vyvanse to treat the patient's condition.

The health plan's determination is overturned.

Yes, Vyvanse is medically necessary. Vyvanse is the only Food and Drug Administration (FDA) approved treatment for binge eating disorder and ADHD. The patient has both of these conditions. It has great efficacy in the treatment of both ADHD and binge eating disorder. The plan alternatives recommended are not FDA approved to treat binge eating disorder, and thus are not appropriate for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection/UTI
Treatment: Inpatient Hospital Stay
The health plan denied the requested inpatient hospital stay as not medically necessary. 
The health plan's determination is overturned.

The patient is a female who was admitted to the hospital with a history of chronic kidney disease (CKD), bilateral nephrostomy tubes, breast cancer, and uterine cancer. She developed 10/10 pain a week after having bilateral nephrostomy tubes placed. She had a fever to 100.5 Fahrenheit (oF). She had nausea/vomiting. She had pain in spite of oxycodone and morphine sulfate. Her creatinine (Cr) was 3.5 from 3.1. Her white blood cell count (WBC) was 5.8. Her heart rate (HR) was 100 beats per minute (bpm). Infectious disease was concerned over possible sepsis. A computed tomography (CT) scan revealed new moderate right hydronephrosis despite the nephrostomy tube. The urine culture grew Pseudomonas and Klebsiella. She was on intravenous (IV) antibiotics. She underwent a nephrostomy tube exchange in interventional radiology the day after admission. She had continued low grade fevers. The patient was admitted for acute kidney injury (AKI)/hydronephrosis. Her WBC was 5.2, and she received IV morphine. On day 3, her Cr was 3.3, and she received IV morphine.  The day before discharge, the Cr was 3.1 with a WBC of 5.2. The indication for continued admission the day before discharge was not clear (she did receive IV morphine at 12:40 on this day). On the day of discharge, there were normal vital signs. She was eventually discharged home.
At issue is the medical necessity of the inpatient admission.
The health plan's determination of medical necessity is overturned in whole.
The requested health service/treatment of inpatient admission was medically necessary for this patient.
Based on the Milliman Care Guidelines (MCG) Guidelines for Renal Colic and Kidney stones (this patient had renal colic), admission is indicated for any of the following (all of which the patient had): bilateral obstruction, severe pain requiring acute inpatient management, and urinary tract infection. As far as the continued hospitalization goes, the patient required continued IV morphine throughout her hospital stay, until she was discharged. The patient had severe flank pain requiring IV narcotics, hydronephrosis, and evidence of a urinary tract infection. As such, the entire inpatient admission was medically necessary.