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

Diagnosis: Status post stroke, heart disease 
Treatment: Personal Care Aide (PCA) 7 days x (times) 12 hours, a total of 84 hours/week 
The health plan denied PCA 7 days x 12 hours, a total of 84 hours/week. 
The health plan's denial is upheld. 

The patient is an elderly female. Her medical history includes stroke, hypertension, hyperlipidemia, coronary artery disease, diabetes, atrial fibrillation, heart failure, hypothyroidism, and GERD (gastroesophageal reflux disease). She has a recent hospitalization for cardiogenic shock. Hospice care was started two months ago. Denial of personal care aide (PCA) 7 days x (times) 12 hours, a total of 84 hours/week is being appealed. The health plan partially approved from 47 to a total of 62 hours/week. 

The patient's Uniform Assessment System (UAS) evaluation completed three months ago shows modified independent cognition and functional status; total dependence with meal preparation and housework; maximal assistance with bathing and lower body dressing; extensive assistance with managing finances, personal hygiene, upper body dressing, walking, locomotion, toileting, and bed mobility; and limited assistance with managing medications and eating. She has bowel and bladder incontinence. 

A letter from the patient's provider notes that the patient is dependent with ADLs (activities of daily living). She had a recent decline in function. She was hospitalized late last year with a stroke that resulted in weakness and decreased vision. She was hospitalized earlier this year with cardiogenic shock. She is currently receiving home hospice. She requires maximal to total assistance with walking, bathing, dressing, personal hygiene, toileting, and transferring. 

This patient has multiple chronic conditions, including a recent stroke with residual weakness and impaired vision. The appeal statement notes the patient had a recent decline in function and requires maximal to total assistance with walking, bathing, dressing, personal hygiene, toileting, and transferring. The patient is receiving hospice care. Based on the available information, the plan's increase from 47 to 62 hours/week is appropriate to meet this patient's needs for assistance with ADLs. PCA services are not indicated for management of medical conditions or when no tasks are being performed. The requested increase of PCA services to 84 hours/week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Eczema, Atopic Dermatitis.
Treatment: Dupixent.
The health plan denied Dupixent. 
The denial is overturned.

The patient is a male child with severe atopic dermatitis, treated with topical steroids and well controlled on Dupixent. The provider is requesting continuation of Dupixent. The health plan denied coverage of the request, as it requires use of topical calcineurin inhibitors. The denial is being appealed.

It is generally considered medically necessary to continue a patient on a therapy to which they have favorably responded. Dupixent is appropriate for a patient with large body surface area involvement, which makes topical calcineurin inhibitors less appropriate.

The FDA (United States Food and Drug Administration) also approved dupilumab for the treatment of patients above a certain age with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. This approval followed a phase 3, randomized, double blinded placebo-controlled trial that enrolled 367 patients to evaluate the safety and efficacy of dupilumab in children for treatment of atopic dermatitis (Paller et al). Significantly and clinically meaningful improvements in patients' signs and symptoms of atopic dermatitis as well as quality of life were reported. As seen in adults, treatment in pediatric population was reportedly well tolerated, with the most commonly reported side effects including injection site reactions and conjunctivitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: D8080 Braces and D8670 monthly visits x 12
The health plan denied the D8080 Braces and D8670 monthly visits x 12.
The denial is overturned.

The patient in question is a female with buccal (reverse) crossbite on teeth 13 and 14. She presents with a skeletal Class II malocclusion with moderate maxillary and severe mandibular crowding. Tooth 20 is impacted. She has a slight anterior open bite. She is treatment planned for 30-36 months of orthodontics with the extraction of four premolars to correct her malocclusion.

At issue is the medical necessity for the requested service/treatment of braces and monthly visits.

I overturn, in whole, the health plan's determination of medical necessity.

Because teeth 13 and 14 are in buccal crossbite, they have no antagonists. As a result, it is extremely likely that these teeth will over erupt. Once this overeruption occurs, it is very difficult to treat. [1] Buccal crossbite (also known as scissor-bite in the literature) can also negatively affect mandibular growth and should be treated as early as possible to eliminate the potential growth disturbance. [2]

If left untreated, the damage that will likely occur to the patient's teeth will be much more time consuming and costly to correct than the patient's existing orthodontic problem. For these reasons, treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting. 
Treatment: Inpatient admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The patient had a history of cyclic vomiting and methadone therapy and presented with nausea and vomiting. The blood pressure was initially 227/135. She responded to treatment for hypertension. Intravenous (IV) fluids and antiemetics were given. After admission, IV access was no longer able to be obtained. She was placed on a liquid diet. The following day there was a systolic blood pressure in the 80s which was treated with oral hydration. 

Clinical indications for admission for Vomiting (Milliman Care Guidelines MCG M-370) include having hemodynamic instability. This is defined as a tachycardia or hypotension that persists despite appropriate therapy. In this case, the patient had hypertension that responded to therapy and mild hypotension that also resolved. Other indications include having a severe metabolic derangement, severe electrolyte abnormalities, bacteremia, acute renal failure, and an inability to maintain oral hydration after observation care. She did not have these indications. 

This patient had cyclic vomiting and required treatment with IV fluids and antiemetics. This could have been given in the ER (emergency room) with observation status. The hypertension responded to treatment. She was able to tolerate a liquid diet after being treated in the ER. She did not meet MCG criteria for admission for Vomiting. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient hospital stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission
The denial is overturned

This adult patient presented to the hospital complaining of severe chest pain. Past medical history was significant for ischemic heart disease and a recent non-ST [interval on an ECG (electrocardiogram)] elevation myocardial infarction with a stent three weeks prior to presentation. Following percutaneous intervention, the patient reported persistent chest pain that never completely resolved. Outpatient treatment for angina and pericarditis failed to alleviate symptoms. This included treatment with nitrates and colchicine. On arrival to the hospital the patient was hypotensive (96/59) and bradycardic (pulse 54). Physical exam revealed no significant abnormality. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic ST (interval on an ECG) or T wave (interval on an ECG) changes. Serum blood testing demonstrated no elevation in troponin level or erythrocyte sedimentation rate. The patient was admitted to the hospital for observation and treatment. The echocardiogram revealed a Left ventricular ejection fraction (LVEF) of 60%(percent) without evidence of pericardial effusion. A gastroenterology evaluation was performed, and delayed emptying of the esophagus was noted. Diltiazem was initiated to treat esophageal dysmotility but was discontinued after worsening bradycardia was noted. The patient was discharged home on therapy for gastroesophageal reflux.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with persistent chest pain three weeks following non-ST elevation myocardial infarction (NSTEMI) and percutaneous coronary intervention. The patient's pretest probability of coronary artery disease is high and careful evaluation for complications following revascularization is indicated. Although the patient had no elevation of serum troponin and an intermediate HEART (history, electrocardiography, age, risk factors, troponin) score, careful evaluation for the etiology of recalcitrant chest pain was indicated. Following attempts to treat this patient for angina with nitrate therapy and pericarditis with colchicine therapy, symptoms persisted and an inpatient admission for an additional work up was medically necessary to rule out serious complications following NSTEMI and percutaneous intervention. The patient was ultimately diagnosed with esophageal dysmotility, and gastroesophageal reflux disease and other etiologies associated with major adverse cardiac events were ruled out. In conclusion, admission to the hospital for assessment of recalcitrant chest pain several weeks following non-ST elevation myocardial infarction and subsequent percutaneous intervention was 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 a full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission

The denial is overturned

This adult patient presented to the hospital complaining of severe chest pain. Past medical history was significant for ischemic heart disease and a recent non-ST (interval on an ECG) elevation myocardial infarction with a stent three weeks prior to presentation. Following percutaneous intervention, the patient reported persistent chest pain that never completely resolved. Outpatient treatment for angina and pericarditis failed to alleviate symptoms. This included treatment with nitrates and colchicine. On arrival to the hospital the patient was hypotensive (96/59) and bradycardic (pulse 54). Physical exam revealed no significant abnormality. A 12-lead electrocardiogram revealed normal sinus rhythm without ischemic ST (interval on an ECG) or T wave (interval on an ECG) changes. Serum blood testing demonstrated no elevation in troponin level or erythrocyte sedimentation rate. The patient was admitted to the hospital for observation and treatment. The echocardiogram revealed a Left ventricular ejection fraction (LVEF) of 60% without evidence of pericardial effusion. A gastroenterology evaluation was performed, and delayed emptying of the esophagus was noted. Diltiazem was initiated to treat esophageal dysmotility but was discontinued after worsening bradycardia was noted. The patient was discharged home on therapy for gastroesophageal reflux.

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient presented with persistent chest pain three weeks following non-ST elevation myocardial infarction (NSTEMI) and percutaneous coronary intervention. The patient's pretest probability of coronary artery disease is high and careful evaluation for complications following revascularization is indicated. Although the patient had no elevation of serum troponin and an intermediate HEART (history, electrocardiography, age, risk factors, troponin) score, careful evaluation for the etiology of recalcitrant chest pain was indicated. Following attempts to treat this patient for angina with nitrate therapy and pericarditis with colchicine therapy, symptoms persisted and an inpatient admission for an additional work up was medically necessary to rule out serious complications following NSTEMI and percutaneous intervention. The patient was ultimately diagnosed with esophageal dysmotility, and gastroesophageal reflux disease and other etiologies associated with major adverse cardiac events were ruled out. In conclusion, admission to the hospital for assessment of recalcitrant chest pain several weeks following non-ST elevation myocardial infarction and subsequent percutaneous intervention was 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 a full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cholecystitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

Acute cholecystitis and biliary complaints are a common inpatient diagnosis. Acute cholecystitis is also estimated to attribute to millions of ambulatory visits each year and is a leading cause of hospital admissions. Studies have shown that ambulatory laparoscopic cholecystectomy is safe and avoids an overnight hospital stay. Factors that contribute to admission after laparoscopic cholecystectomy include drain placement, conversion to open surgery, persistent abdominal pain, nausea, and vomiting. In patients without abnormalities of the bile duct or abnormal liver function tests (elevated alkaline phosphatase and total bilirubin), ambulatory laparoscopic cholecystectomy is safe and feasible. A 50% (percent) increase in the liver function tests can be labeled as mild elevation and is considered negligible by many. 

Per clinical documentation, this patient presented to the emergency department (ED) with chest pain. Vital signs in the ED were within normal limits. An ultrasound demonstrated a normal gallbladder. White blood cell count was 10.7. Liver function tests were elevated with an alkaline phosphatase of 206 and total bilirubin of 1.7. The patient underwent a laparoscopic cholecystectomy with intraoperative cholangiogram. There were no reported complications. The patient was discharged. Per Milliman Care Guidelines (MCG) criteria, an inpatient hospital admission for acute cholecystitis is indicated for patients with all of the following: right upper quadrant pain, mass, or tenderness; systemic signs of inflammation; or a cholecystectomy is not anticipated during the current hospital stay. The patient did not have any systemic signs of inflammation and the ultrasound was equivocal for acute cholecystitis. Surgery was planned during the current admission. MCG criteria indicated that the inpatient hospital admission was not necessary in this patient. Per provided clinical documentation, an inpatient hospital admission was not medically necessary for acute cholecystitis. An observation stay would be more appropriate for chest pain. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: dementia.
Treatment: home health care.
The insurer denied Personal Care Assistant Services: 24 Hours per Day, 2 x 12 Hours (Split-Shift) - Total of 168 Hours per Week. 
The health plan's determination is upheld. 

The patient is a female with past medical history of osteoporosis, dementia, peripheral vascular disease, breast cancer, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), hypertension, hyperlipidemia, glaucoma, depression, urinary incontinence, insomnia, varicose veins, and peripheral edema who was hospitalized due to Covid 19(Coronavirus Disease 2019) infection and subsequently transferred to rehabilitation. As part of the discharge process there was a request to increase PCA (personal care assistant) services.

Personal Care Assistant Services: 24 Hours per Day, 2 x 12 Hours (Split-Shift) - Total of 168 Hours per Week are not medically necessary for this patient.
There is no documentation of specific nighttime and overnight assistance needs that would require split-shift services. There are no specific overnight logs documenting specific activities of daily living (ADL) care needs in the overnight hours that would not allow a PCA 5 hours of uninterrupted care. There is no documentation of medical necessity of turning and repositioning every two hours overnight. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Assistant Services: 24 Hours per Day, 2 x 12 Hours (Split-Shift) - Total of 168 Hours per Week are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Status asthmaticus.

Treatment: Inpatient admission.

The insurer denied coverage for inpatient admission.

The denial is overturned.
 

The patient is a toddler with a history of recent frequent emergency room (ER) visits for wheezing. She had been admitted to the hospital one month before this admission with a respiratory illness related to a Respiratory syncytial virus (RSV) infection. She had a respiratory illness with congestion, cough and fever for 2 days. She had been prescribed albuterol for home use in the past, but the mother did not have albuterol in the home. When she was noted to have labored breathing her mother brought her to the ER for medical evaluation.

In the ER she was noted to have a fever of 103 degrees F (Fahrenheit) and respiratory distress with increased work of breathing. On physical examination she had increased work of breathing and bilateral wheezing. Her oxygen saturation was 96% (percent) on room air. There were two episodes of post tussive vomiting. She was treated with 2 back-to-back albuterol and Atrovent treatments and Decadron. When the child continued to have wheezing and increased work of breathing following treatment in the ER the decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with albuterol, every 2 hours. 

The patient was treated appropriately in the ER for a cough, fever, tachypnea, and wheezing. The medical record indicates that the child had been seen frequently in the ER and treated with three courses of steroids for wheezing in the past 2 months. Although the child had been prescribed albuterol for home use the mother was not able to obtain the medication from the pharmacy. The decision to admit to the hospital for ongoing treatment with albuterol every 2 hours was consistent with the standard of care for status asthmaticus. There was also concern that the mother had not obtained the albuterol treatments previously prescribed from the pharmacy for home use. This child who had recurrent visits to the ER and treatments with steroids for wheezing in the past two months could not have been safely discharged home.

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 the inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rhinovirus. 
Treatment: Inpatient Admission. 

The insurer denied coverage for inpatient admission. 

The denial is upheld. 

The infant presented to the emergency department (ED) with parent with complaints of fussiness for 2 days, decreased oral intake (PO), and an acute onset of fever. Diagnostic labs demonstrated low white blood cell (WBC) and mildly low hematocrit/hemoglobin (Hct/Hgb). The patient's respiratory viral panel was positive for rhinovirus. The patient was admitted for neonatal fever and 36-hour rule out for neonatal sepsis. The patient was started on ampicillin and gentamicin. The patient's condition improved. The patient was discharged. 

The viral panel was positive for rhinovirus while the blood, urine, cerebrospinal fluid (CSF) cultures were all negative. No evidence of respiratory distress nor respiratory involvement. Patient did not have rash. No increased lactate, no acidosis. Mild decreased oral (PO) intake and intravenous (IV) fluids started. Patient did not have risk factors such as prematurity and chronic lung disease. No congenital heart disease. No need for multiple boluses, no need for continuous positive airway pressure (CPAP). Hospital trajectory tracked the desirable clinical course and the clinical status improved. No need for pressors, procalcitonin was only 0.25. If one were to take the Pediatric Early Warning Score (PEWS), the score would have been always 2 or less which is desirable. Due to the above factors, patient could have been observed. No need for inpatient level care. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for inpatient admission is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Asthma
Treatment: Formulary exception for Pulmicort Flexhaler 180 mcg (micrograms) Aerosol Powder 
The insurer denied the Formulary exception for Pulmicort Flexhaler 180 mcg Aerosol Powder.
The denial is overturned.

The patient is an adult female. She has a diagnosis of persistent asthma. The request is for Pulmicort Flexhaler. The prior denial reason was that formulary alternative requirements not met. The denial is being appealed.

The health plan should cover the formulary exception for Pulmicort Flexhaler.

The patient has previously used Symbicort. The treating physician is requesting Pulmicort Flexhaler (budesonide), as the patient is currently pregnant. The formulary drug would not be more ineffective for the patient or be more effective that the 
requested non-formulary drug. However, based on medical literature, the requested drug would have fewer adverse effects for this patient because Budesonide is a Category B medication, whereas the formulary medications are in categories deemed to be not as safe during pregnancy. Therefore, given the above, the health plan should cover the formulary exception for Pulmicort Flexhaler, and it should be for the standard duration of approval.