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

Diagnosis: Gastroesophageal reflux disease (GERD), Nasogastric tube.
Treatment:  Private duty nursing (PDN) for 24 hours per day, 7 days per week.

The insurer denied private duty nursing (PDN) for 24 hours per day, 7 days per week.  The determination is upheld.
 
This is a male patient with a congenital diaphragmatic hernia, pulmonary hypoplasia, pulmonary hypertension, gastroesophageal reflux disease (GERD), feeding tube (nasogastric [NG]) dependence, and oral aversion. His home medications include bethanechol solution, omeprazole suspension, erythromycin ethylsuccinate suspension, and cholecalciferol liquid. Per the medical records provided, he is on condensed NG feeds. It is unclear whether supplemental oxygen is still required, as the most recent neonatal intensive-care unit (NICU) note indicates 1/2 liter (L) supplemental oxygen but plans for room air trial and wean. There is no discharge summary or recent medical records which gives details of the current regimen or necessary medical support. At issue is whether private duty nursing (PDN) is medically necessary for 24 hours per day, 7 days per week. The child has been previously approved for private duty nursing (PDN) services 8 hours per day, 56 hours per week for 90 days.

Based on the medical records provided, the requested private duty nursing service of 24 hours per day/7 days a week is not medically necessary for this patient. This patient is noted to be medically stable. There is no intravenous (IV) access or respiratory instability. There is no indication of other medical conditions requiring a skilled nursing level care.

The patient has a repaired diaphragmatic hernia and oral aversion who requires NG feeds. Per the most recent NICU note provided, feeds were condensed over 2 hours and supplemental oxygen was still being supplied. There was a plan for a possible gastrostomy (G)-tube. Medications are supplied either orally or via NG tube. The skills needed for feeding and monitoring for aspiration can be accomplished by the currently approved private duty nursing care of 8 hours daily. There is no indication of respiratory instability, seizures, or need for more complex care beyond 8 hours a day.
Appeal type: Medical necessity
Decision: Overturned



Diagnosis: ulcerative colitis.
Treatment: Stelara 90 mg every 4 weeks.
The insurer denied Stelara 90 mg every 4 weeks.
The health plan's determination is overturned. 

The patient is a male with Ulcerative Colitis. He presented with abdominal pain and diarrhea. He failed mesalamine, Xeljanz, and Humira with balsalazide. He was started on Stelara with a good response. A colonoscopy showed mild inflammation in the rectum. Recently, he had recurrent Ulcerative Colitis symptoms, with increased loose bowel movements, urgency, and abdominal pain in the 1-2 weeks before Stelara doses; fecal calprotectin was elevated at 503. 

Stelara 90 milligrams (mg) every 4 weeks is medically necessary. The patient has failed Humira and Xeljanz; he then had improvement on Stelara.  In this case, the patient has Ulcerative Colitis, and had active disease symptoms and objective evidence of active disease on colonoscopy with biopsies while on Stelara every 8 weeks, as well as markedly elevated fecal calprotectin. In such cases, the use of Stelara 90 mg every 4 weeks can lead to remission. Continuation of the current dose of 90 mg every 8 weeks or a discontinuation of Stelara (even if an alternative is immediately attempted) may result in ongoing symptoms and complications such as toxic megacolon, dysplasia leading to colorectal cancer, hospitalization, or need for surgery. For all of these reasons, Stelara 90 mg every 4 weeks is supported as medically necessary for the treatment of this patient's Ulcerative Colitis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive Impairment
Treatment: Personal Care Aide 10 hours (hrs) per day, 7 days a week.
The insurer denied Personal Care Aide 10 hours (hrs) per day, 7 days a week.
The determination is overturned.

This is a male with a medical history notable for cognitive impairment and age-related physical debility. The patient is approved for 6 hours per day, 7 days per week of personal care assistant services. The patient and his care team requested an increase to 10 hours per day, 7 days per week for a total of 70 hours per week, and this request was denied by the health plan.

The patient's physician provided a letter of support. The letter states that the patient has urinary incontinence and requires help with incontinence care management. He requires assistance with nearly all activities of daily living and instrumental activities of daily living. He is at risk for falls even when using an assistive device for ambulation and requires hands-on assistance for that as well. He has mild Alzheimer's dementia and resulting cognitive impairment.
The patient's eye doctor provided a letter of support. It states that the patient has neovascular age-related macular degeneration in his left eye. He is legally blind in his left eye with little hope for recovery of vision. He has impaired vision in his right eye of 20/70.
A Uniform Assessment System (UAS) was completed. The patient was alert and oriented but had frequent episodes of forgetfulness. He is able to describe an emergency plan and call 911 in an emergency. For his instrumental activities of daily living, he requires total dependence for housework. He requires extensive assistance for transportation, shopping, stairs, phone use, medications, finances, and meal preparation. For his activities of daily living, he requires extensive assistance for bathing, dressing upper body, and dressing lower body. He requires limited assistance for hygiene, walking, locomotion, toilet transfer, and toilet use. He is independent for bed mobility and eating. He is occasionally incontinent of urine and is continent of stool. At issue is the medical necessity of Personal Care Aide 10 hours (hrs) per day, 7 days a week.

The requested health service of Personal Care Aide 10 hours per day, 7 days a week is medically necessary for this patient.
The patient's condition, as described by his numerous healthcare providers, appears to be worse than the UAS indicates. He has also apparently had a functional and cognitive decline since his wife passed away. He requires hands-on assistance for all activities of daily living. He has evidence of unmet personal care needs, with his physician stating that he had falls, dehydration, and hospitalizations when not under proper supervision of a personal care aide. Therefore, the requested increase to 10 hours per day is medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Upheld

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

This is the case of a gentleman that presented to the hospital complaining of palpitations that awoke him from sleep. Past medical history was significant for paroxysmal atrial fibrillation. He was previously treated with metoprolol therapy but discontinued several months prior to presentation. On arrival to the hospital, the patient was hemodynamically stable and tachycardic: 136/99, Pulse 175. Physical examination was significant only for an irregularly, irregular pulse. 12 lead electrocardiogram demonstrated atrial fibrillation with rapid ventricular rate. The patient was treated with intravenous diltiazem to control heart rate. He was admitted to the telemetry and rhythm reverted to normal sinus overnight. Dronaderone antiarrhythmic therapy was initiated, and the patient was discharged home the day after presentation. 

This patient presented with symptomatic atrial fibrillation and was effectively treated with atrial ventricular (AV) nodal blocking agents. Following evaluation and additional testing, the patient reverted to normal sinus rhythm and was released from the hospital. Bellew, et al studied patients presenting to the hospital with rapidly conducted atrial fibrillation and compared outcomes between those admitted to the inpatient service and those that were observed in the emergency department. In this study of almost 600 patients, there was no difference in outcome. American Heart Association (AHA) guidelines note that admission to the hospital for management of atrial fibrillation is not necessary in patients that achieve rate control. [2] This patient reverted to normal sinus rhythm several hours after presentation. In conclusion, admission to the hospital for treatment of paroxysmal atrial fibrillation was 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 the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

This patient is an adult female. She presented came to the emergency room with right-sided pain. Her past medical history included asthma, Mycobacterium avium complex (MAC) infection, and endometriosis. In the emergency room, the patient's vital signs were pulse 93; blood pressure 121/62; respiratory rate 16; temperature 97.5, and oxygen saturation 100% (percent). Lab results revealed sodium 141, blood urea nitrogen 16.5, and creatinine 1.03; glucose 110; white blood cells 13.67, 
hematocrit 38.4, and hemoglobin 12.5. The patient was admitted with pneumonia. Computed tomography (CT) of the chest reported no pulmonary embolism (PE), but positive for bilateral infiltrate with bronchiectasis in right middle lobe (RML). Respiratory culture was positive. She was treated with intravenous antibiotics. She was discharged on day #3.

The inpatient admission was not medically necessary.

The patient presented to the emergency room with chest pain. The chest computed tomography scan did not show a pulmonary embolism, but revealed infiltrate that could be consistent with 
pneumonia. She had no high-grade fever or hypoxia and was not hemodynamically unstable. She did not require high oxygen, positive airway pressure (PAP), or ventilator. The patient's pneumonia score measured by CURB 65 (confusion, blood urea nitrogen, respiration rate, blood pressure, Age 65+) was 0, and her pneumonia severity index (PSI) score was 33 points. Both of these scores recommend outpatient treatment. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Recurrent perianal abscess
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with a history of obesity, human immunodeficiency virus (HIV), and prior left perianal abscess who presented to the emergency department with a brief history of recurrent left sided perianal pain. Exam was confirmatory of a recurrent perianal abscess. The patient was tachycardic but afebrile with a mildly elevated white blood cell (WBC) count. A computed tomography (CT) scan was confirmatory of an 8-centimeter abscess. The patient was started on intravenous antibiotics in the emergency department and admitted to 
acute inpatient care. He was taken to surgery the next day for drainage of his abscess and discharged to home later that same day on Augmentin and Percocet to be followed in the clinic.
The health plan has denied the inpatient admission as not medically necessary. The provider has appealed the decision.

The requested health service was not medically necessary.

The patient presented to the emergency department with a recurrent perianal abscess. He completed a diagnostic workup in the emergency department, and antibiotic therapy was initiated. The patient remained stable throughout his stay in the emergency department. He was seen in consultation by Colorectal Surgery while in the emergency department, taken to surgery the following day for a drainage procedure, and discharged home later that same day on oral antibiotics and analgesics. The patient's condition and services rendered did not rise to the level of acute inpatient care. Appropriate management of the patient's condition could be achieved on an observational level of care. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, diabetes, sleep apnea, coronary artery disease, and low back pain.
Treatment: Increase Consumer and Self-Directed Personal Assistance Services (CDPAS) to 84 Hours per Week
The insurer denied: Increase Consumer and Self-Directed Personal Assistance Services (CDPAS) to 84 Hours per Week
The denial is overturned.

This is an elderly female patient that has conditions that include hypertension, diabetes, sleep apnea, coronary artery disease, and low back pain. The denial of an increase in consumer and self-directed personal assistance services (CDPAS) to 84 hours per week is being appealed. The health plan approved 42 hours a week. Uniform Assessment System evaluation completed 3 months ago shows minimally impaired condition and functional status: maximal assistance with meal preparation, housework, shopping, and transportation; extensive assistance with bathing, lower body dressing, walking, locomotion, and toileting; limited assistance with managing finances and medications, personal hygiene, upper body dressing, and bed mobility; and independent with eating. She uses a walker indoors and a wheelchair outdoors. She has frequent bladder incontinence. She has had at least six falls in the last 90 days. A letter from the Provider notes the patient has rapidly deteriorating cognitive and physical functioning. She lives alone and is homebound. She is a fall risk. She needs assistance with activities of daily living (ADLs).

The requested health service 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 an increase in consumer and self-directed personal assistance services (CDPAS) for 84 hours per week is being appealed. The 
health plan approved 42 hours a week. Uniform Assessment System evaluation completed 3 months ago shows the patient requires assistance with all activities of daily living ADLs except 
eating. She has frequent bladder incontinence. She has had at least six falls in the last 90 days. Appeal statements note there has been a deterioration in the patient's cognitive and physical functioning. She lives alone and is homebound. She needs assistance with activities of daily living and is a fall risk. The information provided shows that this patient has significant limitations in functioning. Due to her limited mobility and need for assistance with all activities of daily living, the approved consumer directed personal assistance services (CDPAS) of 42 
hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 84 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: 70 hours per week, Consumer Direct, 1 Client. 
The insurer denied 70 hours per week, Consumer Direct, 1 Client. 
The determination is upheld. 

This is a female patient with a medical history notable for dementia, weakness, fatigue, and depression. The patient is approved for 36.75 hours per week of consumer directed personal care aide. The patient and her care team requested an increase to 70 hours per week, and this request was denied by the health plan. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient has dementia, weakness, dizziness, unsteadiness, history of falls, chronic low back pain, hypertension, hypothyroidism, heart disease, and urinary incontinence. Her overall condition has deteriorated and she has had six falls in the past year. She is unable to perform activities of daily living due to her weakness. She needs "constant help and support during the day." Specifically, the physician requests help with dressing, meal preparation, hygiene, and cleaning. 

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted via teleconference. The patient lives alone in her apartment. She was alert and oriented to person and place only with periods of forgetfulness. She is able to direct her own care but requires reminders. A mini-mental state examination score was 18/30 which is consistent with moderate dementia. For her Instrumental activities of daily living (IADLs) she requires maximal assistance or extensive assistance. For her activities of daily living (ADLs), she requires extensive assistance for bathing and dressing lower body. She requires limited assistance for hygiene, dressing upper body, walking, locomotion, toilet transfer, and toilet use. She is frequently incontinent of urine and continent of stool. Compared to a prior assessment, she showed a decline in cognitive status but stable functional status. At issue is the medical necessity of 70 hours per week, Consumer Direct, 1 Client. 

The requested health service of 70 hours per week, Consumer Direct, 1 Client is medically necessary for this patient. 
The patient's ability to perform personal care tasks appears worse than indicated by the UAS. The UAS was most recently completed 8 months ago, but the more recent advocacy and physician letters indicate that the patient now requires assistance for numerous activities of daily living including toileting, ambulating, and incontinence care product changes. She has also had numerous falls while attempting personal care tasks which are evidence of unmet personal care needs. Therefore, the requested hours are medically necessary and appropriate for the patient. This will allow her to have her needs met during the majority of her waking hours, including any toileting or incontinence care needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Skeletal class II malocclusion and severe mandibular crowding
Treatment: Braces and monthly visits
The insurer denied the braces and monthly visits.
The health plan's determination is overturned.

The patient in question is an adolescent female with impacted teeth number (#) 20 and #29. These teeth are unable to erupt due to crowding. She presents with a skeletal Class II malocclusion and severe mandibular crowding. She is treatment planned for 30-36 months of orthodontics to address the crowding and to create space to bring the impacted teeth into the arch.

At issue is the medical necessity of braces and monthly visits.

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

The requested braces and monthly visits are medically necessary.

It is in the best interest of patients to be referred to an orthodontist and oral surgeon when an impacted tooth is discovered. [1] Approximately 10 percent (%) of all impacted teeth are premolars. Studies have shown almost 65% of untreated impacted teeth will cause some kind of pathology. [2] The two most common types of pathology causes are periodontal bone loss and root resorption of adjacent teeth. [2] Given the proximity of teeth 20 and 29 to the roots of the adjacent teeth there is already concern that the mandibular first molars may be damaged. If left untreated, the damage that can occur to the patient's teeth will be more time consuming and costly to correct than the patient's existing orthodontic problem. For this reason treatment is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD)
treatment: Inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld. 

The patient is a male with a history of morbid obesity, chronic obstructive pulmonary disease (COPD), hypertension, diabetes. Presenting complaints were wheezing, productive cough, and weakness. On arrival to the emergency department, the patient's vital signs were blood pressure 128/81, heart rate 114, respiratory rate 20, with oxygen saturation 93% (percent) on room air. Physical exam was notable for wheezing and rhonchi. Labs were unremarkable. Radiology was notable for chest x-ray with possible right lower lobe pneumonia and mild pulmonary vascular congestion. The patient was admitted to an inpatient level of care for treatment of pneumonia and a COPD exacerbation.

An inpatient admission is not medically necessary.

The patient presented with a low risk pneumonia and mild-moderate COPD exacerbation. The patient did not demonstrate hemodynamic instability, need for supplementary oxygen, severe hypoxia, serious comorbid conditions, or need for ventilatory support. A lower level of care would have been reasonable to allow for monitoring the patient's response to initial therapies for COPD exacerbation and pneumonia - that is, steroids and antibiotics.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Hidradenitis suppurativa
Treatment: Humira 80mg (milligrams)/0.8ml (milliliter) Pen Injector
The insurer denied: Humira 80mg (milligrams)/0.8ml (milliliter) Pen Injector
The denial is upheld.

The patient is an adult female with severe hidradenitis suppurativa that has failed topical therapies with clindamycin, benzoyl peroxide, oral doxycycline. She started treatment with Humira injections 80 mg (milligrams) every 2 weeks (duration of this regimen not documented) and did not get a good response so her physician is requesting approval to increase the dose to 80 mg (milligrams) weekly. This was denied coverage by the health plan as experimental/investigational. This denial is being appealed.

The health plan should not cover the requested health service.

Humira (adalimumab) is FDA (United States Food and Drug Administration) approved and used as first-line biologic agent for the treatment of moderate to severe hidradenitis suppurativa in adults. The recommended dosing schedule for adults with hidradenitis suppurativa is an initial 160 mg (milligrams) subcutaneous dose (given at one time or split into two 80 mg [milligrams] doses given over two consecutive days), then 80 mg (milligrams) on day 15, and then 40 mg (milligrams) once weekly starting on day 29. In 2020, FDA (United States Food and Drug Administration) labeling for adalimumab was updated to include 80 mg (milligrams) every other week as an alternative to 40 mg (milligrams) weekly. Given the larger body of evidence to support the 40 mg (milligrams) once-weekly regimen, most typically prescribe 40 mg (milligrams) once weekly. There is insufficient evidence in the published, peer-reviewed medical literature to support the use of 80 mg (milligrams) of adalimumab weekly in patients with hidradenitis suppurativa. There is only one publication where this dosing regimen was found to be effective, but it is a retrospective chart review that included only 8 patients who all had co-morbid obesity. They concluded that an increased adalimumab dose of 80 mg (milligrams) weekly by subcutaneous injection may be associated with improved outcomes for overweight and obese patients with moderate to severe. In the absence of additional published data, the increased dosing regimen cannot be accepted as medically appropriate.