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

Diagnosis: Dementia, CVA (cerebrovascular accident), osteoarthritis, and hypertension
Treatment: Personal Care Aide (PCA) Services, PCA Services For A Live-in Per Diem, 24 Hours A Day, 7 Days A Week
The insurer denied: Personal Care Aide (PCA) Services, PCA Services For A Live-in Per Diem, 24 Hours A Day, 7 Days A Week
The denial is overturned.

The patient is an elderly female. She has history of dementia, CVA (cerebrovascular accident), osteoarthritis, and hypertension. Denial of personal care aide (PCA) services for a live-in per diem, 24 hours a day, 7 days a week is being appealed. The health plan approved increase from 49 to 70 hours per week. Uniform Assessment System (UAS) evaluation showed moderately impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, shopping, locomotion, and toilet use; maximal assistance with managing medications, phone, bathing, personal hygiene, dressing, walking, and toilet transfer; limited assistance with bed mobility; and supervision with eating. The patient uses a wheelchair for transportation. She has bowel and bladder incontinence. Appeal letters, medical records and advocacy reports are provided. They note that the patient is bedbound/wheelchair bound and needs one to one (1:1) care. It notes that she needs assistance with ADLs (activities of daily living) as already accounted for in the UAS (Uniform Assessment System) evaluation. They note that the patient has scheduled and unscheduled toileting needs and needs overnight assistance with transfers and toileting.

The requested Personal Care Aide (PCA) Services, Live-in, 24 Hours A Day, 7 Days A Week, is 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. Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs (activities of daily living), including toileting, walking, transfers, turning/positioning, or feeding. Denial of personal care aide (PCA) services for a live-in per diem, 24 hours a day, 7 days a week, is being appealed. The health plan approved increase from 49 to 70 hours per week.

The patient has multiple chronic conditions. She is bed bound/wheelchair bound. Uniform Assessment System (UAS) evaluation the patient requires assistance with all ADLs (activities of daily living), except eating. She has bowel and bladder incontinence. Appeal statements note that she has scheduled and unscheduled needs and requires overnight assistance to include transfers and toileting. This patient's physical functioning is significantly impaired. The need for assistance with all ADLs (activities of daily living) cannot be met with the approved PCA (personal care aide) 70 hours per week. The requested increase to live-in per diem, 24 hours a day, 7 days a week is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nonischemic cardiomyopathy
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the hospital for a scheduled procedure that involved extraction of a previously implanted coronary sinus pacing lead and implantation of a new cardiac resynchronization therapy (CRT) system. His medical history was remarkable for nonischemic cardiomyopathy and a left ventricular ejection fraction of 25%. He originally had a CRT device implanted but revision was required due to persistent diaphragmatic stimulation. The coronary sinus (CS) lead was extracted. However, attempts at implantation of a new CS lead were unsuccessful and a lead was implanted for left bundle branch pacing. Toward the end of the procedure, the patient developed hypotension with a mean arterial blood pressure of 60 millimeters of mercury (mmHg). He required a continuous intravenous infusion of phenylephrine for blood pressure support. He was then admitted to the coronary care unit where the infusion was continued and his blood pressure was monitored invasively with an intra-arterial catheter. The phenylephrine was weaned off. The patient remained stable overnight and was discharged. At issue is the medical necessity of an inpatient level of care.

Based on the documentation provided, an inpatient level of care was medically necessary.
This patient became hypotensive during a procedure for coronary sinus lead extraction and implantation of a cardiac resynchronization therapy. He required a continuous infusion of phenylephrine in order to maintain an adequate perfusion pressure. Phenylephrine is an alpha adrenergic agonist that results in arterial and venous vasoconstriction. Potential adverse effects include ischemia due to peripheral and visceral vasoconstriction, reflex bradycardia, and decreased cardiac output, particularly in patients, like this patient, with depressed left ventricular systolic function. Hypertension is a risk and the dose must be individualized. In addition, with intravenous infusion, extravasation can result in tissue necrosis or sloughing. For these reasons, patients receiving intravenous phenylephrine infusions require treatment in an intensive care setting with careful and continuous and dose titration, as necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Inferior cerebellar stroke
Treatment: The insertion of a subcutaneous cardiac monitor
The health plan denied: The insertion of a subcutaneous cardiac monitor
The health plan's determination is: Overturned

The patient is a male who suffered bilateral inferior cerebellar strokes. His medical history was remarkable for remote migraine headache, an episode of transient global amnesia and hyperlipidemia. His electrocardiogram at the time of presentation showed sinus rhythm and was a normal tracing. An echocardiogram showed no evidence of intracardiac shunt or other embolic source. The patient was treated with aspirin, clopidogrel and a statin. External ambulatory electrocardiographic monitoring for 25 days showed no arrhythmias. The patient presented with right-sided numbness that waxed and waned for two days; brain magnetic resonance imaging (MRI) and head and neck magnetic resonance angiography (MRA) were unremarkable. The subject under review is the medical necessity for the insertion of a subcutaneous cardiac monitor.

The insertion of a subcutaneous cardiac monitor is medically necessary.
Implantation of a subcutaneous cardiac monitor has been recommended to evaluate the possibility that this patient's unexplained stroke was a result of intermittent episodes of atrial fibrillation (AF). Use of implantable loop recorders (ILRs) in patients with unexplained stroke has proven superior to external monitoring methods in detecting asymptomatic AF. The Crystal AF study randomized patients with cryptogenic stroke to monitoring with an ILR versus conventional follow-up with intermittent external monitoring. By 6 months, atrial fibrillation had been detected in 8.9% of patients in the ILR group versus 1.4% of patients in the control group (hazard ratio, 6.4; probability [P] less than [<] 0.001). By 12 months, atrial fibrillation had been detected in 12.4% of patients in the ILR group versus 2.0% of patients in the control group. Since the detection of AF in this population mandates a change in therapy with institution of anticoagulation to prevent further embolic events, it is a highly significant clinical finding. Thus, long-term cardiac monitoring with a ILR is medically necessary in this instance.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ulcerative Colitis
Treatment Stelara 90 milligrams (mg) every 4 weeks
The health plan denied the Stelara 90 milligrams (mg) every 4 weeks.
The determination is overturned.

The patient has a history of ulcerative colitis (UC), severe atopic dermatitis and inflammatory arthritis. She has tried and failed numerous therapies, including infliximab, Entyvio and corticosteroids. She was started on Stelara at the standard dose, however, she continued to have active disease. Xeljanz was then added but was deemed ineffective and was stopped. She was then started on Rinvoq (upadacitinib) for her atopic dermatitis and arthritis and the Stelara was escalated to every 4 weeks. The requested service is continuation of Stelara at 90 milligrams (mg) every 4 weeks.
Continuation of the Stelara as requested is medically necessary.
Stelara is Food and Drug Administration (FDA) approved for the treatment of Crohn's disease and ulcerative colitis in adults. Despite the lack of FDA approval for pediatric patients, there are many peer reviewed publications supporting the efficacy and safety of Stelara in children with inflammatory bowel disease.
A report by Dayan JR et al, showed that ustekinumab (Stelara) is efficacious and safe in pediatric patients with inflammatory bowel disease.
According to Dhaliwal, Jasbir, et al: " Ustekinumab (UST) demonstrated efficacy in this paediatric cohort with otherwise treatment-refractory UC".
Therefore, the use of Stelara in treating refractory pediatric ulcerative colitis is appropriate. However, some patients do not respond adequately to the standard dose. Dose escalation is often required in biologics in order to achieve therapeutic levels and clinical remission. There are many peer reviewed literature reports showing that low Stelara levels were associated with poor clinical response. The requested dose of 90 mg every 4 weeks is proven to be effective in patients who fail the standard dose.
According to Dalal, R., et al: " UST dose escalation resulted in clinical remission in greater than (>) 50 percent (%) of UC patients and was more effective in those with loss of response compared to no/minimal response after induction. "
This patient has a history of refractory ulcerative colitis and has failed anti-tumor necrosis factor alpha, Entyvio, Xeljanz and conventional therapy. The patient also failed to respond to Stelara standard dose (90 mg every 8 weeks) and continued to have severe symptoms. She responded well to Stelara at 90 mg every 4 weeks. Discontinuation of Stelara at this time will put this child at risk of a colectomy. There are no suitable treatment alternatives for this child. Therefore, continuation of Stelara at 90 mg every 4 weeks is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Necrotizing wound.
Treatment: Skilled Nursing Facility.
The insurer denied the Skilled Nursing Facility.
The determination is overturned.

The patient was admitted to a Skilled Nursing Facility (SNF) for necrotizing wound care status/post (s/p) vacuum-assisted closure (VAC), physical and occupational therapy. She is s/p debridement of the wound.
At issue is the medical necessity of skilled nursing facility care.
The requested services are medically necessary. The patient needs to work on strength, activities of daily living (ADLs), mobility, transfers, and wound care. She has not maximized function.
This patient was admitted to SNF. She continues to have wound care needs with a VAC and drainage from the wound site. She is slowly progressing in physical therapy (PT) and occupational therapy (OT). She still requires assist for transfer and ambulation using a rolling walker (RW). She had been independent with a cane prior to admission. She was independent with activities of daily living (ADLs) and still requires assist at this time. 
The patient's long-term goal of independent ambulation with a single point cane (SPC) with safe clearance has not been met by discharge notes. The priority for this patient is safety.
Continued SNF care is medically appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. Lymphedema.
Treatment: Pharmacy/Prescription Drugs. 
The insurer denied Vasculera TABS.
The denial is upheld. 

The patient is a female with a past medical history of chronic venous insufficiency, lymphedema of bilateral lower extremities, and lipedema. She has been experiencing a variety of symptoms including heavy/achy limbs and consistent pain result of her lower extremity disease. Reportedly, despite conservative measures such as diet,  as compression of legs with compression garments, and leg elevation, she has remained symptomatic. Consequently, Vasculera tablets (TABS) have been prescribed "to alleviate her symptoms and prevent progression of her disease."
At issue is the medical necessity of Vasculera TABS.

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

The requested health service/treatment of Vasculera TABS is not medically necessary for this patient.

This is a patient with history of chronic lower extremity venous disease which has included lipedema and lymphedema. Reportedly, this has resulted in a significant amount of pain and has been a hindrance to her quality of life. Treatment of lipedema can certainly be challenging and complex in some cases. Per the current guidelines and generally accepted practices, conservative therapy is important and should be the initial treatment for patients with lower extremity lymphedema and lipedema. This includes postural and core exercises, muscle strengthening exercises, gait training and neuromuscular re-education. Other standard conservative therapy includes nutritional guidance, manual therapy, compression garments, pneumatic compression device therapy, and a home exercise plan. Only if this is ineffective, non-conservative measures such as surgical intervention or medical therapy should be pursued especially given that the data regarding therapy with medications is limited. In this case, there is insufficient data to suggest the patient received treatment with aggressive conservative measures.
Therefore, the requested health service/treatment of Vasculera TABS is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems/Arrhythmia/Irregular Heart Rhythm
Treatment: Inpatient Hospital
The health plan denied the requested inpatient admission. The health plan's determination is upheld.

The patient is a man with a past medical history of hypertension, hyperlipidemia, diabetes, and history of inguinal hernia with repair. He was at his physician's office for a routine visit when he developed dizziness and palpitations. He was tachycardia with a heart rate in the 160's beats per minute (bpm) and his 12-lead electrocardiogram (EKG) demonstrated evidence of atrial flutter (AF) with a rapid ventricular response. Consequently, he was sent to the emergency department for further evaluation. On arrival to the emergency department (ED), he was afebrile, and his blood pressure was 121/79 millimeters of mercury (mmHg). His respiratory rate was 20/minute, and his oxygen saturation was 100% on room air. On arrival, his atrial flutter self-resolved and his EKG demonstrated normal sinus rhythm. However, during evaluation in the ED triage, the patient had another episode of atrial flutter with a heart rate in the 160's bpm which again self-resolved. His initial laboratory work up was notable for hyponatremia with a serum sodium of 124, a potassium of 5.2, and a creatinine of 1.5. His white blood cell count (WBC) count was 7.2, with a hemoglobin of 9.2, and platelets of 225. The patient was admitted to the inpatient unit for treatment of hypovolemic hyponatremia and paroxysmal atrial flutter. He was evaluated by cardiology and no further episodes of atrial flutter were noted on telemetry monitor. He was hydrated with intravenous (IV) fluids and his serum sodium was stable. He was asymptomatic from a hyponatremia standpoint. The patient was ultimately discharged on anticoagulation (for stroke prevention in the setting of AF) with outpatient follow up.
At issue is the medical necessity for an inpatient stay.

I uphold the health plan's determination of medical necessity.

This patient presented with atrial flutter with a rapid ventricular response and hyponatremia. He was hemodynamically stable and was saturating well on room air. His episodes of atrial flutter self-resolved in the emergency department. There was no evidence of acute infection, acute ischemia, or heart failure. He did not require cardioversion, anti-arrhythmic therapy, or Digoxin loading. Although he had hyponatremia, he was asymptomatic from this. He did not have neurologic deficits and/or seizures. Consequently, based on the provided documentation, there is insufficient clinical data to support the medical necessity for an inpatient level of care. An alternate level of care would have been appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever, neck pain
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is upheld.

This female patient complained of three days of fever associated with neck pain, stiffness, rash, headache, and lethargy.  The patient's vital signs included temperature = 101.8, pulse = 103, respiratory rate = 18, blood pressure = 104/67 and oxygenation saturation = 100%.  The patient's exam was remarkable for strawberry tongue, inflamed pharynx, and diffuse macules.  Labs revealed white blood cells (WBC) = 3.8, hematocrit = 34, sodium (Na) = 135, potassium (K) = 3.9, and blood urea nitrogen/creatinine (BUN/Cr) = 7/0.7.  The patient's urinalysis was negative.  Her cerebrospinal fluid analysis was normal.  The patient's electrocardiogram (EKG) was normal.  Her chest x-ray had no acute pathology.  Her head computed tomography (CT) showed possible sinusitis.  

The patient was admitted.  The plan of care included empiric intravenous antibiotics.  Infectious disease was consulted with impression of strep throat or viral exanthem, or infectious mono.  The recommendation was to evaluate for Epstein Barr Virus (EBV) and consider dermatology consult.  On day two the patient was feeling better and was afebrile.  Her rash had improved.  COVID and influenza were negative. The patient was cleared for discharge on oral antibiotics.


No, the proposed inpatient hospital admission was not medically necessary.
This patient was admitted after presenting with fever, neck pain, and rash.  The patient was hemodynamically stable and did not have a high fever. She had mild tachycardia, but no tachypnea.  She did not have altered mental status.  She did not have bacteremia.  The patient's work up for meningitis was negative.  Her evaluation did not reveal a source of infection.  She did not have end organ dysfunction.  Inpatient admission was not medically necessary.  Empiric intravenous antibiotics did not require inpatient admission.  The patient had not failed an observation level of care.  The proposed inpatient hospital admission was not medically necessary.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
The proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder/ Stroke.
Treatment: Skilled Nursing Facility.
The insurer denied Custodial Care (long term care).
The denial is upheld. 

The patient is a male, who has a diagnosis of stroke. The patient was admitted to a nursing rehabilitation center with a primary diagnosis of stroke which was from an occlusion of the left internal carotid artery which resulted in right sided weakness and aphasia at time of admission. His past medical therapy is significant for a prior stroke, substance use disorder, and hyperlipidemia.
Per Care Plan Activity Report, the plan was for the patient to, "return to community upon improvement in functioning and ability to re-enter the community as resident has no next of kin [nok] and lacks community support at this time." At that time the care team was referring the patient to other Skilled Nursing Facility (SNF) at patient request to be in a facility that allowed smoking; however, the patient was referred to over 50 SNFs in the metro area but facilities that allow smoking were not available and the patient was unwilling to consider cessation of smoking. Documentation by physical therapy indicated that the patient was independent in bed mobility, ambulating 40 feet with minimal assistance using a circumduction gait, transferred and sit to stand were contact guard assistance. 
At issue is the medical necessity of Custodial Care (long term care).

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

No, the requested health service/treatment of Custodial Care (long term care) is not medically necessary for this patient.
Custodial care is non-medical care that helps individuals with their activities of daily living (ADL), such as eating and bathing. This patient does have impairments of movement, speech, and cognition, and would be expected to require home services including home health aide, occupational therapy, speech therapy, and physical therapy. However, per the documentation, his level of impairment does not require long term custodial care. In addition, there is no documentation of occupational or speech therapy function that would warrant custodial care for the time period in question.
Therefore, the requested health service/treatment of Custodial Care (long term care) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis. 
Treatment: Skyrizi. 
The insurer denied treatment with Skyrizi. 
The denial is upheld.

The patient is a male with psoriasis. The patient also has joint pains in the wrists, fingers, and elbows. He is currently on Otezla and Skyrizi. He has also failed Humira, Stelara, and Siliq. The medication under review is the medical necessity for Skyrizi.

The health plan's determination is upheld.

The requested health treatment of Skyrizi is not medically necessary for this patient. Scientific evidence has not been established via well-designed, controlled studies with adequate follow-up that demonstrate the safety and efficacy of the proposed treatment. There are no randomized-controlled studies that show the efficacy of safety of Otezla when administered concomitantly with Skyrizi. Combination therapy of Otezla with Skyrizi is not generally accepted medical practice and management of psoriasis and psoriatic arthritis in the United States (1-4). Further studies are necessary to determine the role and utility of co-administration of these medications for plaque psoriasis and psoriatic arthritis patients.