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

Diagnosis:  Angioedema.
treatment:  Inpatient stay.

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a female with a history of two episodes of angioedema (no history of intubation) with an allergy to cinnamon and obesity who was admitted for another episode of angioedema secondary to Greek yogurt. The patient presented with symptoms of swelling/edema of the upper lip/cheeks. She was treated with intravenous corticosteroids, antihistamines and an H2 (histamine) blocker with an improvement in her symptoms within 48-hours.

Inpatient Hospital Stay was not medically necessary for this patient.
Based upon the severity of illness, intensity of required therapy and Milliman Care Guidelines (MCG), the inpatient admission was not medically necessary. This patient with a history of two episodes of angioedema (no history of intubation) with an allergy to cinnamon and obesity was admitted for another episode of angioedema secondary to Greek yogurt. On the date of admission, the patient had a blood pressure of 106/70, heart rate of 71 beats per minute, respiratory rate of 18 breaths per minute and oxygen saturation of 97% (percent) on room air. On exam, she had swelling/edema of the upper lip/cheeks but no noted swelling of the tongue/uvula, no swelling on her head, no nasal swelling discharge or bleeding, she was in no respiratory distress, and her chest was clear to auscultation bilaterally without evidence of stridor or wheezing. After initial treatment with intravenous corticosteroids, antihistamines and an H2 blocker, the patient remained hemodynamically stable, had a patent airway without signs of requiring intubation, she did not report fatigue or weakness, edema of the lower extremities or reported malnutrition. She was kept on continuous oximetry monitoring and was breathing comfortable without signs or symptoms of airway compromise with an improvement in her symptoms within 48-hours of admission. Therefore, inpatient hospital admission was not medically necessary, and the patient could have been cared for at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure.
Treatment: Inpatient admission.

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

According to the medical records, the patient is an adult male. He had a witnessed, generalized tonic-clonic seizure (GTC). In emergency medical services (EMS) he was unconscious, post ictal. The seizure was 1 minute. He received 5 mgs (milligrams) Versed. He had been drinking alcohol (ETOH) until a few days ago. Exam in the emergency department (ED) shows normal mental status and no neurologic deficits. Throughout hospitalization he continued with normal mental status. The initial consult shows normal mental status and neurologic exam. He was diagnosed with seizures. The computed tomography scan (CT) of the head shows no abnormalities. The magnetic resonance imaging (MRI) of the brain showed no abnormalities.

There was no evidence of an unstable neurologic condition.

"A generalized tonic-clonic seizure, formerly known as grand mal seizure, is defined as a seizure that has a tonic phase followed by clonic muscle contractions. Among patients, families, and observers, they are most feared of seizure types. They are usually associated with impaired awareness or complete loss of consciousness. The disease etiology and pathophysiology are described along with the evaluation and management of generalized tonic-clonic seizures. This article covers the diagnosis and treatment of generalized tonic-clonic seizures and highlights the role of the interprofessional team in caring for patients afflicted with generalized tonic-clonic seizures." (Kodankandath, TV. et al. 2022).

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

Diagnosis: Plaque psoriasis and psoriatic arthritis. 
Treatment: Sotyktu. 
The insurer denied coverage for Sotyktu. 
The denial is overturned. 
 
The patient has a diagnosis of psoriasis and psoriatic arthritis. The patient has failed excimer light therapy, Otezla, Tremfya, methotrexate, acitretin, Siliq, and Taltz. The patient is currently being treated with the combination of Skyrizi for psoriasis and Sotyktu for psoriatic arthritis with the consideration that the combination would benefit both medical conditions. The request is for continuation for both medications in combination.  

Based on the medical history and provided documentation, the combined use of Skyrizi and Sotyktu for psoriasis and psoriatic arthritis is medically necessary. This patient has failed numerous systemic agents, including numerous biologics. The patient has severe psoriasis and psoriatic arthritis which is difficult to manage. Having failed numerous individual biologics it is reasonable to attempt to obtain disease control with combinations of therapeutics. Skyrizi and Sotyku work through differing mechanisms [interleukin (IL)-23 inhibitor and tyrosine kinase inhibitor respectively] and offer the best possible opportunity to achieve disease remission for the patient's psoriasis and psoriatic arthritis. 

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 Sotyktu is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week. 
The insurer denied Personal Care Services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours per week. 
The health plan's determination is overturned. 

This is a case review for an elderly male with medical history notable for Alzheimer's dementia, heart failure, and arthritis. The patient's physician provided a letter of support for this appeal. The letter states that the patient's medical conditions include benign prostatic hyperplasia, osteoarthritis of multiple joints, gait instability, combined systolic and diastolic congestive heart failure, history of falls, and Alzheimer's dementia. The letter reports increasing debility in the patient due to his dementia. He requires frequent toileting due to his heart failure medications and his prostate condition. The physician states that without assistance he is at risk for falls, incontinence, and infections. The physician requests 24-hour care to assist him with these activities. 

The Personal Care Services (PCS): 24 Hours per Day x 7 Days per Week (Split Shift) - Total of 168 Hours per Week is medically necessary for this patient. 
The patient is of advanced age and suffers from dementia and osteoarthritis-related mobility issues. He is unable to complete personal care tasks independently. His night time care logs demonstrate the requirement for personal care assistance every 2-3 hours throughout the night for tasks such as toileting and repositioning in bed. Because his personal care needs are continuous and unscheduled in nature, he requires split-shift 24-hour care. Failure to provide for his personal care needs could result in additional falls or other adverse health consequences.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Severe Dementia. 
Treatment: Consumer Directed Personal Assistance Services - 24 Hours per Day 7 Days per Week (Monday-Sunday) Split Shift for a Total of 168 Hours per Week. 

The insurer denied: Consumer Directed Personal Assistance Services - 24 Hours per Day 7 Days per Week (Monday-Sunday) Split Shift for a Total of 168 Hours per Week. 

The denial is upheld. 

This elderly female patient has dementia. The denial of consumer directed personal assistance services 24 hours per day 7 days per week, split shift, for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week. Uniform Assessment System evaluation completed three months ago shows severely impaired cognition and functional status. 
The patient needs total dependence with all activities of daily living (ADLs), except maximal assistance with eating. She is bedbound. She is incontinent of bowel and bladder. A letter from her Provider notes the patient has severe dementia and chronic kidney disease. She is dependent with all activities of daily living, bedbound, and incontinent. She needs prompt changing of diapers during the night to avoid bedsores. She is a fall risk. She cannot stand or transfer on her own. She needs assistance with liquids every few hours. 

The proposed treatment is not medically necessary. 

Personal care service is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift personal care services is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This patient has dementia. Denial of consumer directed personal assistance services 24 hours per day 7 days per week, split shift, for a total of 168 hours per week is being appealed. The health plan approved 84 hours per week. Uniform Assessment System evaluation completed 3 months ago shows the patient requires assistance with all activities of daily living. She is incontinent of bowel and bladder. An appeal statement supports that the patient needs assistance with all activities of daily living as well as nighttime assistance with changing diapers. The information provide show that this patient has significant limitations in functioning. The information does not support that the patient has continuous needs, such as turning/repositioning every two hours. The information does not support the proposed increase in consumer directed personal assistance services to 24 hours per day 7 days per week, split shift. The proposed increase is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malignant pleural effusion
Treatment: Personal Care Aide (PCA) Level II Live-in Per Diem, 7 Days per Week - for a Total of 7 Days per Week
The insurer denied: Personal Care Aide (PCA) Level II Live-in Per Diem, 7 Days per Week - for a Total of 7 Days per Week
The denial is overturned.

This elderly female patient has a malignant pleural effusion secondary to lymphoma, congestive heart failure, osteoarthritis, cervical and lumbar radiculopathy, diabetic retinopathy, macular edema, and insomnia. The patient lives alone. Denial of personal care aide (PCA) live-in, 7 days per week is being appealed. The health plan approved 7 hours per day, 7 days per week for a total of 49 hours per week. A letter from her Provider notes the patient is unable to perform activities of daily living (ADLs) due to her multiple medical problems. Aide logs show the patient receiving frequent assistance with activities of daily living 24 hours per day.

The proposed treatment is medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. This patient has multiple chronic conditions. The denial of personal care aide (PCA) live-in, 7 days per week is being appealed. The health plan approved 7 hours per day, 7 days per week, for a total of 49 hours per week. Appeal statements note the patient lives alone and needs additional assistance with activities of daily living. Aide logs support the patient's needs for frequent assistance around-the-clock with activities of daily living. The patient lives alone and does not have informal support. The information provided show that this patient has significant limitations in functioning. The approved personal care aide 49 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 
live-in is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atrial fibrillation. 
Treatment: Transcatheter Ablation Procedure. 

The insurer denied Transcatheter Ablation Procedure. The health plan's determination is overturned. 

The patient is a man with a history of hypertension, hyperlipidemia and a markedly elevated coronary calcium score (>1000). In the beginning of this year, his Apple watch indicated that he was in atrial fibrillation (AF). An electrocardiogram confirmed this. An echocardiogram showed biatrial enlargement and normal left ventricular systolic function. A Zio patch worn and showed his rhythm was AF throughout the recording with an average ventricular rate of 75 beats/minute. 

A Transcatheter Ablation Procedure is medically necessary for this patient.
This patient has hypertension, coronary atherosclerosis and minimally symptomatic early persistent atrial fibrillation (AF). AF is associated with an increased risk for multiple adverse outcomes including stroke, heart failure and cognitive decline. Data from observational studies suggest that catheter ablation in patients with AF, even when asymptomatic, may mitigate these risks. In the Early Rhythm Control in Patients with Atrial Fibrillation Trial (EAST) which included 2789 patients with atrial fibrillation of less than one years duration and at least one cardiovascular condition, early rhythm-control therapy with either catheter ablation or antiarrhythmic drug therapy was associated with a significantly lower incidence of the primary outcome (a composite of death from cardiovascular causes, stroke (either ischemic or hemorrhagic), or hospitalization with worsening of heart failure or acute coronary syndrome) as compared to patients assigned to usual care which was initial rate control. The 2017 expert consensus statement on catheter and surgical ablation of atrial fibrillation, assigns catheter ablation a IIb rating in patients with asymptomatic persistent AF, meaning the weight of evidence/opinion is in favor of its usefulness/efficacy and the expected benefit is equal to or greater than the risk.
Appeal type: Medical necessity
Decision: Overturned

Respiratory
Inpatient hospital

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

This is the case of a young male with mild intermittent asthma who presented to the emergency department (ED) with cough and wheeze for 1 day. The cough is dry and barky in nature, with associated difficulty sleeping and shortness of breath (SOB). The review of symptoms (ROS) was positive for rhinorrhea, congestion, and chest tightness.

An inpatient hospital stay is medically necessary for this patient. The patient required nebulizers, steroids, magnesium sulfate, and antibiotics. In addition, the patient needed intravenous fluids (IVF) and supplemental oxygen which meet the need for inpatient level of care.

This patient presented to the ED with respiratory distress and was found to have both acute asthma exacerbation and pneumonia. He had persistent symptoms despite steroids and Duonebs in the ED, requiring supplemental oxygen and increased medical care. Based on expert guidelines, his status required inpatient level of support and care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 


This is an adult male who presented to the hospital complaining of chest pain. Pain was exacerbated with deep inspiration and relieved when sitting up and leaning forward.  On arrival to the emergency room (ER) Blood Pressure was 105/71 mmHg and pulse was 78 beats per minute, and the patient was afebrile.  Physical examination revealed a pericardial friction rub.  12 lead electrocardiogram (ECG) demonstrated normal sinus rhythm with diffuse ST segment elevations.  Serum blood testing demonstrated no elevation in troponin (0.01ng/ml) and B-Type Natriuretic Peptide (BNP) was normal. The patient was admitted to the hospital for monitoring and treatment.  He was evaluated for borderline hypotension. Echocardiogram demonstrated normal left ventricle function without pericardial effusion. The patient was ultimately treated with non-steroidal anti-inflammatory agents and colchicine. 

Acute inpatient admission was not medically necessary in this case.  This patient presented with chest pain, and an abnormal electrocardiogram with diffuse ST segment elevation consistent with acute pericarditis. His pretest probability of coronary artery disease was low. (Reference 1). The Troponin was normal as was left ventricular function. This makes myocarditis highly unlikely. Such patients can be observed and managed as an outpatient.  This patient did not manifest high risk features as discussed in Up to Date. As such, out patient management was appropriate. 
  
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: Formulary Exception
Decision: Overturned

Diagnosis: Obesity
Treatment: Formulary exception for Wegovy
The insurer denied: Formulary exception for Wegovy
The denial is overturned.

The patient is an adult female with hypercholesterolemia and obesity. She has a body mass index of 35.7. The request for Wegovy is under review. The prior request was denied coverage by the health plan, as they require trial of two preferred alternatives: phentermine, benzphetamine, diethylpropion, and phendimetrazine. The denial is being appealed. The patient has tried and failed phentermine for two months. She has tried Weight Watchers and Jenny Craig in the past. She has osteoarthritis with bilateral knee replacements and would benefit from significant weight loss to preserve her joints.

The health plan should cover the formulary exception for Wegovy.

This request is for Wegovy for the treatment of obesity. The prior request was denied because approval on criteria requires trial of two preferred alternatives: phentermine, benzphetamine, 
diethylpropion, and phendimetrazine. The patient has tried and failed phentermine. The remaining formulary alternatives have the same mechanism of action and modest weight loss effect. Given that the patient has failed phentermine, she can reasonably be expected to also fail the other formulary alternatives. Wegovy functions via an alternative mechanism via glucagon-like-peptide-1 agonism and has a much more potent weight loss effect. The remaining formulary alternatives are not appropriate substitutes in this clinical situation. Without Wegovy, this patient will be at increased risk of the complications of untreated obesity, including type 2 diabetes. This patient has already experience hypercholesterolemia and osteoarthritis. Therefore, yes, the health plan should cover the formulary exception for Wegovy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: depression
Treatment: transcranial magnetic stimulation (TMS)
The insurer denied transcranial magnetic stimulation (TMS).
The health plan's determination is overturned. 

The patient is a young adult female with a history of major depressive disorder, recurrent and moderately severe without psychotic features and panic attacks. The patient has a documented history of multiple failed medication treatments for depression including treatment with more than two disparate classes of medication (Lexapro, Prozac, Luvox, Zoloft, Cymbalta, and Pristiq), as well as augmentation with Buspar. Additionally, the patient has received treatment with lorazepam and clonazepam targeting associated symptoms of anxiety and panic related to the mood disorder and comorbid generalized anxiety disorder. She has been treated with an evidence-based psychotherapy without a response or remission of depressive symptoms. She has not received electroconvulsive therapy (ECT) or VNS (vagus nerve stimulation) therapy. At the time of evaluation for transcranial magnetic stimulation (TMS) therapy, the PHQ-9 (Patient Health Questionnaire) scale score was 15 in the moderately severe range for symptoms of depression associated with severe impairment of functioning.

Transcranial Magnetic Stimulation (TMS) is medically necessary for this patient.

TMS therapy as a primary or adjunctive therapy for treatment of depression has generally been evaluated in patients who have treatment refractory/resistant depression, as defined by one or more, antidepressant medication treatment failures with or without augmentation. TMS therapy for depressive disorder has been established by the Food and Drug Administration (FDA) as a safe treatment; and, the data, as reflected in peer reviewed medical literature, supports this assertion. Specifically, when treatments with antidepressant medication with or without augmentation, or with electroconvulsive therapy, and/or psychotherapy, especially cognitive behavioral therapy, have failed to produce a response or remission, then TMS is an appropriate consideration. This assertion is noted in the American Psychiatric Association Practice Guideline for the assessment and treatment of major depressive disorder, referenced below. Moreover, the scientific literature indicates that a course of treatment with TMS therapy is reasonable in cases of treatment resistant depression as defined in the scientific literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back injury

Treatment: pain management injection (62323 x 1)

The insurer denied coverage for pain management injection (62323 x 1).

The denial is overturned

 
This young adult woman sustained an injury to her back several years ago. She has tried Physical therapy and a Home Exercise Program. Her medication trials have included Mobic and Lidocaine patches. Her magnetic resonance imaging (MRI) clearly shows a lumbar (L)5- sacral (S)1 disc protrusion abutting the S1 nerve roots. She had an Epidural Steroid injection performed. 

The American Society of Interventional Pain Physicians (ASIPP) published evidence based clinical guidelines which (1) state:

"The evidence recommendations are as follows:

Disc herniation: Based on relevant, high-quality fluoroscopically guided epidural injections,
with or without steroids, and results of previous systematic reviews, the evidence is Level I_for caudal epidural injections, lumbar interlaminar epidural injections, lumbar transforaminal epidural injections, and cervical interlaminar epidural injections with strong recommendation for long-term  effectiveness."

Similarly, practice parameters from a multi-specialty group state:

"Transforaminal epidural steroid injection (TFESIs) and interlaminar epidural steroid injections (ILESIs) are clinically effective for short-term and long-term relief of radicular pain and radiculopathy [51,62-64], although the paucity of high-quality randomized trials literature continues to confound the evidence."

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 pain management injection (62323 x 1) is substantiated.