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

Diagnosis: Cystic fibrosis (CF)
Treatment: Airway Clearance Device 
The insurer denied an Airway Clearance Device.
The health plan's determination is overturned. 

The patient is young male with cystic fibrosis (CF), who among other therapies is using the high frequency chest wall oscillation device for airway clearance. 

The Airway Clearance Device [E0483-RR x 3] is medically necessary for this patient.

CF is a genetic disease characterized, among other things, by the production of abnormally viscous airway secretions. Because of the abnormal viscosity, the airway secretions in CF are difficult to clear. Retained viscous airway, secretions provide a milieu for the growth of infectious microorganisms, including bacteria and fungi. This results in ongoing destruction of the airway and lung parenchyma in CF patients. Multiple studies, including those described in the papers listed in the references section below, have shown that effective airway clearance reduces the destruction of the airway and lung parenchyma mentioned above, improving, duration and quality of life in this patient population. Accordingly, all clinical care guidelines for CF recommend every patient with CF adhere to effective airway clearance technique. High-frequency chest-wall oscillation is a well-known, well-accepted, and quite effective airway clearance technique.

The provided records indicate that the patient has been using high-frequency chest-wall oscillation for airway clearance as per the CF guidelines. The patient's adherence to the prescribed regimen and its effectiveness are also documented in the provided medical records. The letter supplementing the records further indicates that the patient has had good airway clearance and minimal if any effects of retained secretions as a result of using high-frequency chest-wall oscillation. The request for the high frequency chest wall isolation device is consistent with published CF clinical care guidelines and the device is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Atrial arrhythmia.
Treatment:  Inpatient admission.

The insurer denied coverage for inpatient admission.  The denial is overturned.

This is an elderly patient with a past medical history of hypertension and diabetes who presented to the hospital complaining of chest pain and lightheadedness. Symptoms developed while walking and lasted for three hours. Upon arrival vital signs were stable [blood pressure (BP) 112/83, pulse 91]. Physical examination revealed an irregular heart rhythm without other abnormality. 12 lead electrocardiogram (EKG) revealed atrial fibrillation. Serum blood testing was significant for elevated creatinine [1.7 milligrams/deciliter (mg/dl)]. Serum troponin and B type natriuretic peptide levels were not elevated. The patient was admitted to the hospital for treatment of new onset atrial fibrillation and acute renal failure. Oral anticoagulant therapy was initiated along with intravenous (IV) fluids. Renal function normalized, and heart rate was controlled.

Admission for monitoring and treatment was medically necessary. Patients presenting with atrial arrhythmia with rapid ventricular rates require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. (Reference 1) An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen-year period demonstrated an average length of stay of 3 days. (Reference 2) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation. This patient presented to the hospital with chest pain, new onset atrial fibrillation, and acute renal failure.

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Stelara dosed every four weeks
The insurer denied the Stelara dosed every four weeks.
The denial is overturned.

The patient is a female who has severe Crohn's disease (CD). She has previously tried and failed steroids, an anti-tumor necrosis factor (TNF) agent (infliximab) and an anti-integrin agent (vedolizumab). She has had multiple hospitalizations for flares of her Crohn's disease. She was started on Stelara during a hospitalization but has not achieved mucosal healing. Hence, the attending provider is requesting the use of Stelara at the escalated dose of 90 milligrams (mg) subcutaneously (SC) every 4 weeks to treat this patient's severe Crohn's disease.

The requested treatment with Stelara 90 mg every 4 weeks is medically necessary for this patient. The health plan did not take into account that dose escalation in patients with inflammatory bowel disease (IBD) who are on a biological agent and not responding to standard dose of the medication is considered the standard of care. Meserve and colleagues showed that in real world settings, ustekinumab dose escalation was effective in achieving response in patients with CD with inadequate response, or loss of response to standard dose induction and/or maintenance therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal/Abdominal Pain/Stomach Pain
Treatment: Inpatient Hospital Admission
The health plan denied the requested inpatient hospital admission as not medically necessary. 
The health plan's determination is upheld.

The patient is a female with a medical history of hypertension, hyperlipidemia, and gastric sleeve revised to gastric bypass. She presented to the emergency department with six days of epigastric pain, nausea, and vomiting with one episode of blood in her emesis. She had two recent emergency department visits with the same symptoms. Vital signs were notable for elevated blood pressure of 141/85 millimeters of mercury (mmHg). Physical examination was notable for a soft, nondistended abdomen with epigastric tenderness. Labs showed an elevated white blood cell count of 12.5 and an unremarkable comprehensive metabolic panel. A chest x-ray showed no acute pulmonary disease. A computed tomography scan of the abdomen and pelvis showed mild edema around the stomach secondary to gastritis or peptic ulcer disease, a few prominent small bowel loops with possible mild adynamic ileus or enteritis, no complete small bowel obstruction, and indeterminate adrenal gland nodules. She was treated with intravenous fluids,and started on proton pump inhibitor and Sucralfate. Labs showed an elevated white blood cell count of 13.0 . A surgery consultation noted symptoms and imaging consistent with peptic ulcer disease in the setting of recent proton pump inhibitor cessation; the recommendation was intravenous fluids, proton pump inhibitor with Maalox, and outpatient follow-up including an endoscopy. Later, she had no new complaints, and was on a clear liquid diet. The patient had well-controlled abdominal pain, and was tolerating a clear liquid diet without nausea or vomiting. Labs showed low hematocrit of 34 with a normal hemoglobin, and an unremarkable comprehensive metabolic panel. She was discharged on Sucralfate and Mylanta, with a plan for bariatric surgery follow-up.
At issue is the medical necessity for the inpatient hospital admission.

No, the inpatient level of care is not supported as medically necessary.
In this case, the patient presented with epigastric pain, nausea, and vomiting with one episode of hematemesis in the setting of a Roux-en-Y gastric bypass. Proton pump inhibitor and Sucralfate were appropriately initiated, and esophagogastroduodenoscopy was planned as outpatient. [1-5] Her hemoglobin remained stable after presentation; there was no hemodynamic instability or ongoing gastrointestinal bleeding. Her diet was advanced, and discharge was then deemed appropriate.
The care provided, including intravenous fluids, proton pump inhibitor therapy, and surgery consultation, could have been provided without the inpatient level of care, at an alternate level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Ocular Hypertension (left eye).
Treatment:  Formulary exception for Pred Forte 1% Suspension.

The insurer denied: Formulary exception for Pred Forte 1% Suspension.  The denial is overturned.

The patient is an adult female with uveitic glaucoma for whom a formulary exception for coverage of Pred Forte 1% Suspension is the subject of review. Coverage was previously denied by the health plan, as it was not identified that the patient had failed or could not use the generic (prednisolone acetate). Formulary alternatives are identified as dexamethasone sodium phosphate, difluprednate, loteprednol, and prednisolone acetate. Upon appeal, the provider states that the patient has already tried and failed or is intolerant to alternatives, and branded Pred Forte is needed to prevent loss of vision in this patient with macular edema. Reportedly, the patient has been under care for uveitic glaucoma and macular edema of the right eye and ocular hypertension of the left eye for 10 years. The patient has been stable on Pred forte for a period of time after having failed or being intolerant to alternatives in the past including Durezol, difluprendate, and prednisolone (redness).

The health plan should cover the Formulary exception for Pred Forte 1% Suspension.

Coverage was previously denied, as it was not identified that the patient had failed or could not use the generic (prednisolone acetate). Upon appeal, the provider reports intolerance to the preferred formulary alternatives, generic prednisolone and Durezol (difluprednate). While the patient has not used dexamethasone, it would be expected to not be as effective as the requested non-formulary Pred Forte, as dexamethasone has less bioavailability.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is an adult female with a past medical history of hypertension, diabetes, and childhood asthma, who presented to the emergency department for evaluation of progressively worsening shortness of breath associated with a decrease in her exercise tolerance, pleuritic chest pain, and lower extremity edema. On arrival, the patient was afebrile, heart rate was 99 beats per minute, blood pressure was 177/111, respiratory rate was 20, and oxygen saturation (SPO2) was 96% on room air. Initial labs were notable for white blood cell (WBC) count of 6.8, hemoglobin of 12.5, platelet count of 300, sodium of 137, potassium of 4.4, creatinine of 0.93, brain natriuretic peptide (BNP) of 80, and troponin of less than 0.012. The patient's eosinophils and basophils were elevated. Electrocardiogram (EKG) showed normal sinus rhythm with nonspecific ST changes. The patient tested negative for COVID. Computed tomography angiogram (CTA) of the chest was obtained which did not demonstrate evidence of pulmonary embolism. The patient was admitted to the inpatient unit and received one dose of Decadron, nebulizers, and loratadine with improvement of her symptoms. The patient was subsequently started on oral prednisone 40 milligrams, montelukast, Symbicort, albuterol, Claritin, and a nicotine patch. She was ultimately discharged with outpatient follow-up with a transthoracic echocardiogram.

The proposed treatment was not medically necessary.

The patient was hemodynamically stable and was not hypoxic. There was no evidence of sepsis, no mental status changes and no end organ malperfusion. There was no evidence of acute coronary syndrome or acute heart failure. Consequently, based on the provided documentation, there is insufficient clinical data to support medical necessity for inpatient level of care. 

Observation level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weakness, low blood pressure.
Treatment: Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female, who was admitted for worsening weakness and was found to have low blood pressure. Her chest x-ray (compared to previous x-ray) noted cardiomediastinal silhouette was stable but incompletely evaluated. She was noted to have elevated creatinine and was started on intravenous fluids. The patient's condition responded appropriately, and she was discharged.

The proposed inpatient hospital admission was not medically necessary.

During this admission, the patient was hemodynamically stable with normal oxygenation and negative cultures and did not have significant electrolytes disturbance or irreversible kidney failure. The patient did not have cardiac arrhythmias, no altered mental status or persistent nausea and vomiting. There was no documentation of refractory pain, and the patient was able to tolerate oral diet and did not need total parenteral nutrition; her condition responded to intravenous fluids within hours. Therefore, the request service was not medically necessary; observation was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

Diagnosis: appendicitis
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is upheld. 

This patient is a previously healthy woman who presented to the emergency department (ED) with the complaint of abdominal pain of 3-days duration. Examination revealed right lower abdominal tenderness. Vital signs were normal at the time of presentation. The white blood cell (WBC) count was elevated at 15.6. Surgical consultation was obtained. A computed tomography (CT) scan was completed showing findings of acute appendicitis. 

The Inpatient hospital admission was not medically necessary as the care and treatment provided could have appropriately rendered with a lower level of care. This patient presented with abdominal pain. The evaluation with examination, lab data, and computed tomography (CT) scan supported the diagnosis of acute appendicitis. She underwent uncomplicated appendectomy. The vital signs and lab data were normal. She was tolerating a diet. Pain medications were transitioned to oral medications. She was discharged from the hospital.
The patient was clinically stable at the time of presentation and remained so during the course of care. A lower level of care designation would have provided for presurgical assessment, operative treatment and post-surgical monitoring and antibiotics. This lower level of care would have also allowed for overnight monitoring (if needed).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld.

The patient is a female who initially was directed to the emergency department by her primary care physician for concerns of anemia. Review of symptoms was negative for signs of bleeding. Pertinent history included erosive gastropathy and duodenal arteriovenous malformations (AVM), chronic kidney disease, deep vein thrombosis on Eliquis, congestive heart failure, cerebrovascular accident (CVA) with residual aphasia, hypertension, and diabetes mellitus. 

The inpatient level of care was not medically necessary. In this particular situation, the patient was directed to the emergency department following an abnormal blood draw in the outpatient setting. The attending physician documented asymptomatic acute on chronic anemia without a baseline provided. Treatment plan included transfusion of packed red blood cells. Gastroenterology consultation was obtained, who documented no signs of overt gastrointestinal bleeding or indication for urgent endoscopic intervention. In addition to being hemodynamically stable, the patient did not have documented active hemolysis, active bleeding, altered mental status, syncope, cardiac arrhythmia of immediate concern, decompensated heart failure, or other severe signs or symptoms secondary to anemia.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intractable vomiting with sudden onset left sided numbness of her arm, leg and abdomen
Treatment: Inpatient Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is an adult female who was admitted to hospital. She was initially on her way to the hospital due to intractable vomiting and inability to take anything by mouth when she developed sudden onset left sided numbness of her arm, leg and abdomen. Examination was significant for weakness and numbness. Stroke code was called, and she was admitted to rule out CVA (cerebrovascular accident), TIA (transient ischemic attack) and CVT (cerebral venous thrombosis) in the setting of pregnancy as well as to manage poor PO (oral) intake. The inpatient admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient Admission was medically necessary.

Inpatient admission was medically necessary due to intractable vomiting, which is an indication for admission in the MCG (Milliman Care Guidelines) guidelines for inpatient admission for vomiting. Furthermore, there was concern for stroke, and according to MCG (Milliman Care Guidelines) guidelines for stroke, admission is indicated when there is a need for frequent neurological checks and telemetry monitoring, which was the case here. That the patient was pregnant increased risk of hypercoagulable state, and therefore the admission was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dementia
Treatment: Consumer Directed Personal Assistance Services (CDPAS) 168 hours per week split shift. 
The insurer denied: Consumer Directed Personal Assistance Services (CDPAS) 168 hours per week split shift.
The denial is upheld.

The patient is a female with medical history notable for dementia, incontinence, blindness, and right leg amputation. The patient was receiving 80 hours per week of Consumer Directed Personal Assistance Service (CDPAS). The patient's care team requested an increase to 168 hours per week of CDPAS. The health plan partially denied this service and increased her hours to 91 hours per week.

A Uniform Assessment System (UAS) was completed and was available for review. She lives alone in an apartment and receives assistance from her niece who is the only relative that lives nearby. The patient was non-verbal at the time. From a functional standpoint, she required total dependence for meal preparation, housework, finances, phone use, and shopping. She required maximal assistance for medications. For her activities of daily living (ADLs), she required total dependence for bathing, hygiene, dressing upper/lower body, locomotion, toilet use, and bed mobility. She required maximal assistance for eating. She was unable to walk even with assistance. She required turning and repositioning every 2 hours. She is incontinent of both urine and stool and wears diapers.

An updated UAS was completed. The evaluation took place in the skilled nursing facility. She had increased awareness and was alert and oriented times 1-2 and was able to speak during this evaluation. There was a slight increase in functional capacity, with the patient now requiring maximal assistance for bathing, dressing lower body, and toilet use. She requires extensive assistance for dressing upper body and toilet transfer. She requires limited assistance for hygiene, bed mobility, and eating. She still requires total dependence for locomotion. She is still incontinent of urine and stool. The subject under review is the medical necessity for Consumer Directed Personal Assistance Service (CDPAS) 168 hours per week split shift.

The health plan's determination is upheld.

The requested health service/treatment of Consumer Directed Personal Assistance Service (CDPAS) 168 hours per week split shift has not been demonstrated to be medically necessary for this patient.

The patient showed functional improvement in the time between the initial UAS, which was completed right after her hospitalization, and the more recent one, which was completed in the skilled nursing facility following her rehabilitation. She has since moved back home. Increasing her CDPAS services to 91 hours per week was appropriate by the plan given her current functional status. If this increase results in care deficits or unmet personal care needs that would need to be investigated. She previously required turning and positioning every 2 hours, but the notes do not indicate that that is an ongoing need at this time. She has incontinence that will need to be managed, 91 hours per week that has been offered by the plan is appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism Spectrum. 
Treatment: Additional 10 Hours per Week Applied Behavior Analysis (ABA). 

The insurer denied: Additional 10 Hours per Week Applied Behavior Analysis (ABA). 
The denial is overturned. 

The patient is a school-aged male with known ADHD (attention deficit hyperactivity disorder), ODD (oppositional defiant disorder) and impulse and aggression control. The patient has received therapy for over seven years. He is appropriately showing progress as per his therapy team. He continues to have issues with inappropriate touching and self-control, but that is to be expected with this diagnosis. The patient continues to require this therapy and support when transitioning from one therapy session to another. 

The requested Additional 10 Hours per Week Applied Behavior Analysis (ABA) is medically necessary. 

The patient is unable to appropriately interact with peers, friends or family members in a safe way. The patient does not have the appropriate awareness of safety around fire, and other general bodily safety measures. The patient does not transition well from one setting to another, creating unsafe environments and situations for not just the patient but others, especially as it is noted that the patient inappropriately touches others. As the patient has demonstrated some improvement but a strong continued need for the prescribed therapy, any decrease in the therapy will only result in a negative clinical outcome that will put the patient at risk for self-injury and the possibility of injuring others or creating unsafe environments for the patient. As such, the full prescribed time of therapy is still medically necessary for the patient's well-being. The patient requires continued therapy to improve his behavior and awareness in basic life functional settings. The patient is followed by multiple specialists in the field for assessing and treating the need safety and self-awareness.