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

Diagnosis: Urinary tract infection
Treatment: Full Hospital Admission
The insurer denied: Full Hospital Admission
The denial is: Upheld

The patient is a female with a history of asthma, diabetes, and hypothyroidism. She presented to the emergency room with a one-day history of hematuria, dysuria, urinary frequency and urgency, and generalized malaise. The vital signs were normal, and she was alert and in no acute distress. The physical exam was normal. Labs were remarkable for a white blood cell (WBC) count of 14,900, glucose 229, many red blood cells (RBCs) and WBCs per high powered field on urinalysis, and a minimally elevated lactic acid level. The abdominal plain film, renal ultrasound, and abdominal computed tomography (CT) scan were non-contributory. The electrocardiogram (EKG) was negative for acute ischemia or significant arrhythmia. Intravenous antibiotics were administered in the emergency. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with continuation of the intravenous antibiotics and intravenous fluids. The next day the WBC count was down to 8000 and the lactic acid level was almost normal. The infectious disease consultant evaluated the patient and noted that the urine culture grew out non-resistant Escherichia (E.) coli. Switching to an oral antibiotic was recommended. The patient was discharged.

The inpatient admission was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. She was afebrile, and there was no hemodynamic instability, mental status changes, or severe metabolic disarray. Upon presentation she was able to tolerate a diet and oral medication; there was no evidence that she failed appropriate outpatient therapy for a urinary tract infection (UTI). She responded quickly to straightforward treatment. The services provided - intravenous antibiotics, oral medications, consultations - were not at the acute inpatient level of intensity.
Therefore, based on the standard of care, as well as the peer reviewed literature and Milliman Care Guidelines (MCG) Health Recovery Guidelines, the acute inpatient level of care was not medically necessary, and the patient could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

This adult female patient with no significant history had presented to the emergency room with four days abdominal pain, subjective fevers, chills and a loss of appetite. The white count was 15.9. The patient had abdominal pain, tenderness and emesis. A computed tomography scan of the abdomen and pelvis showed focal thickening of the sigmoid colon, with evidence of an inflamed diverticulum. There was a small amount of free intraperitoneal air adjacent to this diverticulum. There was also noted to be adjacent mesenteric infiltration. The diagnosis was perforated sigmoid diverticulitis with a perforation.
The patient was started on Zosyn intravenous and given Toradol intravenous, morphine intravenous, normal saline intravenous fluids, dextrose and normal saline. She also received infusion, Colace, heparin injections, Tylenol, acetaminophen intravenous and Pepcid intravenous. Her diet was advanced as tolerated. The plan was nonoperative management and surgery if no improvement. The patient improved and was discharged for follow-up as an outpatient.

The proposed inpatient hospital admission was not medically necessary.

The care as provided could have been rendered as an observation level. The patient improved significantly with intravenous antibiotics and oral intake, and discharge was allowed on the second day. The care as provided could have been rendered in its entirety at a lower level of care. The patient had an infection; yet she did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for a prolonged nothing by mouth status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Muscle Weakness
Treatment: Physical/occupational therapy 
The insurer denied coverage for physical/occupational therapy. 
The denial is upheld.

This is a child with reported "muscle weakness" and "lack of coordination." Treatment included physical/occupational therapy, which is currently under review.  

The physical/occupational therapy treatment notes made available for review are inadequate and do not provide sufficient objective clinical information to support the medical necessity for the dates of service under review. The clinical records do not establish the medical necessity of continuing a structured out-patient physical/occupational therapy treatment program for the time period under review. There are no impairment ratings, quantitative assessments or documented measurable response to treatment. The therapy notes simply list non-specific goals such as "increase attention span and focusing skills needed for academic functioning by 50% [percent]" and "attend/filter out auditory and visual distractions with gestural prompts with 75% accuracy" without establishing a credible baseline, interval measurements or reasonable time-line for anticipated improvement. In addition, the lack of credible documented quantitative functional improvement renders the provided treatment as not medically necessary.

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 continued physical therapy (PT), 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain and dyspnea. 
Treatment: Full hospital admission. 
The insurer denied coverage for full hospital admission. 
The denial is upheld. 

This is an adult patient that presented to the hospital complaining of dyspnea for one day. Past medical history was relevant for asthma. Upon arrival to the hospital vital signs were stable (Blood Pressure 120/82, Pulse 74). Physical exam revealed no abnormality. 12 lead electrocardiogram (ECG/EKG) demonstrated normal sinus rhythm without ST-segment or T wave abnormalities. Serum blood testing revealed no abnormality (no elevation in cardiac enzymes). The patient was admitted to the hospital for monitoring and treatment. Cardiac catheterization was performed and revealed no significant coronary artery obstruction. The patient was discharged the next day. 

This patient presented with atypical chest pain and a past medical history of asthma. The patient's pretest probability of coronary artery disease was low. (Reference 1) Utilizing the HEART (History, EKG, Age, Risk factors, and troponin) score, the patient was considered low risk. (Reference 2) Utilizing the TIMI (Thrombolysis in Myocardial Infarction) risk score the patient also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (Reference 3) Risk assessment of patients presenting with chest pain and no significant ST-segment changes on ECG was reviewed by Hedayati et al (Reference 3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events [defined as myocardial infarction (MI), need for percutaneous coronary intervention (PCI), need for coronary artery bypass grafting (CABG), or death] in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, admission to the hospital to treat an acute cardiac event was not medically necessary. This patient could have been treated at a lower level of 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 the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Knee pain
Treatment: Hyaluronan Injections
The insurer denied Hyaluronan Injections. 
The health plan's determination is upheld.

This case describes a female patient with a complaint of bilateral knee pain. The provided medical records document that she had plain radiographs obtained which demonstrated moderate bilateral knee osteoarthritis. The patient subsequently underwent a right knee cortisone injection followed by a course of injections. The patient's health plan denied coverage for the Hyaluronan Injections. 

The Hyaluronan Injections are not medically necessary in this case. The recent, peer-reviewed literature has concluded that viscosupplementation injections do not provide statistically better improvements in pain from knee osteoarthritis than other routine treatments. Tammachote and colleagues conducted a prospective, randomized controlled trial in which knee arthritis patients were injected with either Hylan or triamcinolone acetonide. Their results were published in the Journal of Bone and Joint Surgery in 2016. These authors concluded that "Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with Hylan at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week." A second article published by Jevseavr and associates in the Journal of Bone and Joint Surgery in 2015 was a meta analysis and systematic review of the evidence regarding viscosupplementation done for osteoarthritis of the knee. These authors concluded that "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of hyaluronic acid treatment over placebo."
Thus, based upon this peer-reviewed evidence, the efficacy and medical necessity of viscosupplementation injections such as Hyaluronan Injections are not established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, arthritis, diabetes. 
Treatment: Increase Personal Care Aide to 84 Hours Per Week. 

The insurer denied: Increase Personal Care Aide to 84 Hours Per Week. 
The denial is overturned. 

This elderly female patient has conditions including dementia, hypertension, arthritis, diabetes, and varicose veins. She is appealing denial of an increase in personal care aide (PCA) to 84 hours per week. An appeal request form notes the patient cannot do laundry or make a shopping list. She falls. She needs her clothes changed more than once daily due to incontinence. The health plan approved consumer direct, 35 hours per week. 

Uniform Assessment System (UAS) evaluation completed 8 months ago shows moderately impaired condition and functional status: total dependence with housework, managing finances, and shopping; maximal assistance with meal preparation, managing medications, and transportation; limited assistance with stairs, bathing, personal hygiene; supervision with dressing, walking, locomotion, and toileting; and independent with eating. She has frequent bladder incontinence. Uniform Assessment System completed 4 months ago shows a decline in function with meal preparation, managing medications, and shopping. 

A letter from her Provider notes the patient needs increased home care hours due to medical and safety reasons. She has cognitive impairment, dementia, and unsteady gait. She has a history of multiple falls. A letter from another Provider notes the patient has end-stage dementia, is unable to perform activities of daily living (ADLs) and is a danger if left unaccompanied. 

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. The patient with multiple chronic conditions, including dementia. She is noted to have falls. She is appealing denial of increase personal care aide (PCA) to 84 hours per week. The health plan approved consumer direct, 35 hours per week. Uniform Assessment System (UAS) evaluation completed 4 months ago shows she needs assistance with housework, managing finances, shopping, meal preparation, managing medications, transportation, stairs, bathing, and personal hygiene. She needs supervision with dressing, walking, locomotion, and toileting. Compared to Uniform Assessment System evaluation complete 8 months ago, there has been a 
decline in function with meal preparation, managing medications, and shopping. She has frequent bladder incontinence. This patient's physical functioning is significantly impaired. She is only independent with eating. The approved consumer direct, 35 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living. 

The proposed increase in personal care assistant to 84 hours per week is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension, cardiac arrhythmias, asthma, arthritis, general weakness, gait abnormalities, and overactive bladder

Treatment: increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.

The insurer denied coverage for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.

The denial is overturned

This is an elderly patient with chronic medical problems including hypertension, cardiac arrhythmia and osteoarthritis. The insurer approved consumer directed personal assistant services (CDPAS) 42 hours/week. The request is for increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as minimally impaired.  Maximal to extensive assistance is needed for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing. Extensive assistance is needed for personal hygiene, dressing, locomotion, ambulation (uses walker or cane) and toilet transfer/use.  She is frequently incontinent of bowel and bladder. The patient is independent with bed mobility and eating. The patient fell in her bathroom and was able to activate Life Alert and obtained assistance. She also fell again and was sent to the emergency room (ER). The computed tomography (CT) scan was negative, and she was not admitted to the hospital.  The patient was more recently admitted to the hospital and treated for pneumonia. She was subsequently discharged.     

The patient's medical condition, functional ability and mobility are at the level as to require the requested consumer directed personal assistant services (CDPAS) services 24 hours/day, 7 days/week (live-in). She is frequently incontinent, has fallen in the bathroom along  with recent falls and hospitalization, support an increase CDPAS services 12 hours/day, 7 days/week (total 84 hours/week).  Given her recent hospitalization for pneumonia and likely self-sufficiency deterioration, an updated Uniform Assessment System (UAS) report may be indicated.  Based on the records reviewed, the patient's health and safety would be more appropriately provided and maintained by increasing CDPAS services to 24 hours/day, 7 days/week (live-in).

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 increase of hours in consumer directed personal assistant services (CDPAS) from 42 hours per week to 7 days per week, 24 hours a day live in services is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Menopause
Treatment: Prometrium (progesterone)
The insurer denied coverage for Prometrium (progesterone)
The denial is upheld
 
This patient is an adult with a diagnosis of menopausal symptoms maintained on estrogen and progesterone therapy. The patient has been doing well on Divigel but in order to protect the endometrium from hyperplasia or endometrial cancer she was started on progesterone in the form of generic Prometrium. The patient stated that the generic Prometrium is causing her hot flashes that she cannot tolerate. The provider and patient are requesting coverage for brand-name Prometrium.

Endometrial hyperplasia and cancer can occur after as little as six months of unopposed estrogen therapy; as a result, a progestin should be added in women who have not had a hysterectomy. The most common progestin preparations are micronized progesterone which is bioidentical to the progesterone secreted by the human ovary and medroxyprogesterone acetate which is the most commonly prescribed synthetic progestin. Both have proven efficacy for preventing endometrial hyperplasia and endometrial cancer. Many women have difficulty tolerating progestins, most commonly because of adverse effects on mood. There are some alternative options, like the use of Levonorgestrel-releasing intrauterine device.

Micronized progesterone is available as a brand-name Prometrium or as generic. Generic medicines are copies of brand-name medicines. Generic medicines have the same active ingredient as the brand-name medicine they copy. Makers of generic medicines must follow the same government rules about strength, quality, and purity as makers of brand-name medicines. In the United States, the government requires careful testing of generic copies to make sure they will work as well as the brand medicines. As per the Food and Drug Administration (FDA), generic medicines are as good as brand name.

In summary, the generic progesterone contains the same ingredients as the brand product Prometrium. It has the same side effects, safety and efficacy as the brand name and is approved by the FDA with the same indication and warnings and therefore brand name Prometrium for this patient is not medically necessary as she could use the generic form.

The formulary drug is unlikely to cause the patient an adverse reaction.

The formulary drug(s) have not been ineffective based on the patient's clinical history.

The not formulary drug is not expected to be more effective that the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Prometrium (progesterone) is upheld.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially underwent a planned left total knee arthroplasty. Pertinent history included anemia, obstructive sleep apnea, irritable bowel syndrome, and breast cancer. No history of coronary artery disease, chronic obstructive pulmonary disease, cerebrovascular disease, or significant anesthesia problems is noted. Post-operatively, the patient noted chest tightness, heart rate (HR) 60, blood pressure (BP) 134/61, respiratory rate (RR) 33, and peripheral capillary oxygen saturation (SpO2) 100%.

Based on the clinical documentation provided, evidence based literature and standards of care, the inpatient hospital admission was not medically necessary. This patient had a history of severe left knee osteoarthritis who presented for a planned left total knee arthroplasty. Post-operatively, the patient was noted to have chest discomfort. The electrocardiogram (EKG) did not reveal acute ischemic changes no significant change from prior reading. Cardiac enzymes were negative. This had occurred with prior surgeries and felt to be gastrointestinal related. The patient felt it was gastrointestinal as did the medical consultation. Following observation care, the attending physician documented pain was controlled with a regimen performable at the next level of care, spontaneous voiding was observed, and epigastric discomfort had resolved. Moreover, clinical indications for admission to inpatient care were not met. The patient did not undergo bilateral arthroplasty or revision of prior arthroplasty, did not have comorbidities that require more prolonged postoperative treatment or monitoring, and was not documented to have insufficient outpatient care and support to allow early outpatient recovery. A lower level of care was appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Eosinophilic Esophagitis.
Treatment: Budesonide ER (extended release) 9mg (milligrams) OR (oral) TB (tablet) 24.
The insurer denied: Budesonide ER (extended release) 9mg (milligrams) OR (oral) TB (tablet) 24.
The denial is upheld.

This patient is a preschool aged male. He has been diagnosed with eosinophilic esophagitis, eosinophilic gastritis and eosinophilic duodenitis. He has been treated with proton pump inhibitors (PPIs), dietary therapy and Flovent (fluticasone). Repeat endoscopy and biopsies showed persistent eosinophilic gastritis and duodenitis. The patient's doctor requested budesonide nine milligrams daily to treat eosinophilic gastritis and eosinophilic duodenitis (or eosinophilic gastroenteritis). 
The reason for the prior denial was that the requested budesonide is not considered medically necessary for the patient's conditions.

The proposed treatment is not medically necessary.

Eosinophilic gastrointestinal disease (EGID) includes eosinophilic esophagitis, eosinophilic gastritis, eosinophilic duodenitis, eosinophilic enteritis and eosinophilic colitis. In the past it was also called eosinophilic gastroenteritis. There have been no specific treatment recommendations for eosinophilic gastrointestinal disease (EGID). Steroids including budesonide have been used for eosinophilic gastrointestinal disease or 
eosinophilic gastroenteritis. The one study published and cited by the appealing physician is a letter to the editor to describe their experience of eight children with eosinophilic esophagitis and eosinophilic gastritis treated with budesonide (1). Another retrospective case review reported seven children with eosinophilic gastroenteritis treated with dietary elimination and budesonide (2). However, there have been no large well controlled clinical studies to show the effectiveness of budesonide for eosinophilic gastrointestinal disease in children. There have been no clinical treatment guidelines to recommend budesonide for eosinophilic gastrointestinal disease in 
children. Thus, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.