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

Diagnosis:  Diabetes, congestive heart failure and dementia.
Treatment:  Personal care assistance (PCA) services 24 hours per day split shift for 7 days per week.
The insurer denied coverage for personal care assistance (PCA) services 24 hours per day split shift for 7 days per week.
The denial is overturned.

This is an elderly female with chronic medical problems including diabetes, congestive heart failure and dementia. She lives alone in a 1-bedroom apartment. The insurer approved PCA services 27 hours/week. Under review is the requested increase in personal care assistance (PCA) services 24 hours per day, split shift for 7 days per week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "modified independent- some difficulty in new situations only." She was also able to identify an emergency plan. The patient requires maximal assistance for bathing, lower body dressing and toilet use. Extensive assistance is needed for personal hygiene, upper body dressing, and toilet transfers. She is infrequently incontinent of bowel and bladder. Extensive assistance is also reported for bed mobility and locomotion. Eating is independent. 

The treating physician's assertion of the patient's "severe dementia" is inconsistent with the UAS report of "modified independent" cognition. However, the patient's functional impairments support the medical necessity of increasing PCA services. Her cognitive status and functional needs are not at a level or unpredictable as to require the requested services 24 hours per day split shift for 7 days per week. This physician would agree the patient may require 24-hour monitoring. However, safety monitoring under personal care services does not include monitoring an individual (e.g., dementia) when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by her supportive family and increasing PCA services to 12 hours/day, 7 days/week for a total of 84 hours. 

From a physical medicine and rehabilitation perspective, the requested increase in personal care assistance (PCA) services 24 hours per day split shift for 7 days per week is not medically necessary. 

From a physical medicine and rehabilitation perspective, personal care assistance (PCA) services 12 hours/day, 7 days/week, totaling 84 hours is medically necessary.

Based on the above, the insurer's denial must be modified. 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 personal care assistance (PCA) services 24 hours per day split shift for 7 days per week services is not substantiated. PCA services 12 hours/day, 7 days/week, totaling 84 hours is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis (OA). 
Treatment: Supartz FX 25/2.5 milliliter (ml) syringe. 

The insurer denied coverage for Supartz FX 25/2.5 milliliter (ml) syringe.  The denial is upheld. 

This is an adult with a history of osteoarthritis, coronary artery disease (CAD), hypertension, gastroesophageal reflux disease (GERD), COVID 19, hyperlipidemia, obesity, and obstructive sleep apnea (OSA). The patient presented to the Orthopedic Surgeon's office with complaints of pain in both knees. The patient had a cortisone injection without relief. The patient underwent surgery on the left knee in the past. The physician recommended a course of viscosupplementation with Supartz to treat osteoarthritis. 

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. The recommendations for use of viscosupplementation have changed. 

A review of the Clinical Practice Guideline by American Academy of Orthopedic Surgery (AAOS) cites: 

"The 2013 OA knee treatment CPG contains one significant recommendation change from the 2008 CPG (Clinical Practice Guideline's), and this is with regard to the issue of viscosupplementation. The 2008 OA knee CPG included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the CPG.  The second edition CPG recommendation reads "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from 3 high-quality and 11 moderate-quality research studies that met the inclusion criteria." 

The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the Clinical Practice Guideline's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight hyaluronic preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.) 

A meta-analysis was completed of multiple references. This is a high-level evidence based criteria which does not support use. 

There are other factors which should be taken into consideration as well. The listed diagnosis has changed. The patient has been treated for Rheumatoid arthritis and Polymyalgia rheumatica. He has a chronic inflammatory process affecting his joints. His treatments have been directed to managing the above condition. It is unclear whether a diagnosis of osteoarthritis is applicable. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage Supartz FX 25/2.5 milliliter (ml) syringe is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary Tract Infection (UTI). 
Treatment: Inpatient Hospital Admission. 

The insurer denied the inpatient Hospital Admission.  The denial is overturned. 

The patient in this case is an adult female with a history of endometrial cancer, for which she previously underwent total hysterectomy.  She presented to the emergency department with complaints of bilateral lower leg pain and increased urinary frequency associated with burning.  The lower leg pain had been present since her hysterectomy last year but had worsened in the two weeks before presentation. 

The patient's physical exam was without significant abnormal findings.  Urine testing revealed evidence of infection.  She also had an ultrasound done which revealed a right popliteal vein deep vein thrombosis (DVT).  She was treated with intravenous fluids and intravenous Rocephin for her urinary tract infection and was admitted to the hospital.  Computed tomography of the abdomen and pelvis was done and revealed no acute process.   Laboratory studies were notable for elevated creatinine (2.4), elevated white cell count (92.1) and reduced platelet count (76).  Renal ultrasound was ordered at the time of admission and the patient was started on intravenous Heparin to treat her deep vein thrombosis. 

The next day the patient was seen by hematology/oncology given her abnormal blood counts.  She was noted to have abnormal circulating cells and circulating blasts.  She was felt to likely have acute leukemia. She was started on Hydrea to help lower her white cell count. She was continued on intravenous fluids and uric acid testing was done along with other labs.  The patient was to be transferred to an outside hospital. 

The patient was discharged for transfer to an outside hospital. 

The proposed treatment was medically necessary. 

This patient had urinary tract infection associated with impaired kidney function and also with severe leukocytosis.  She had findings consistent with a diagnosis of acute leukemia.  Also, the patient had an acute deep vein thrombosis and required anticoagulation with intravenous heparin. Given the combination of complicated urinary tract infection, deep vein thrombosis requiring intravenous heparin (she required this due to her impaired kidney function) and marked leukocytosis consistent with acute leukemia, the acute care inpatient admission in this case was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Opioid withdrawal
Treatment: Inpatient hospital stay
The insurer denied the inpatient hospital stay.
The health plan's determination is upheld. 

This is a case review for a male with a history of daily intravenous heroin use. He presented to the emergency department with generalized malaise, chills, and difficulty breathing with last use of heroin the day prior to presentation. The patient reported he felt like he was in withdrawal. He was admitted. The medical necessity of this inpatient hospital admission is under question. At the time of admission, the patient had a blood pressure (BP) of 120/44, heart rate of 130, and temperature of 38.1 degrees Celsius. Track marks were noted in the bilateral antecubital region without abscess, warmth, or ecchymosis noted.

The inpatient hospital admission is not medically necessary for this patient.

The patient presented with symptoms of acute withdrawal from opiates, which fit with the timeline given by the patient of last fentanyl administration the day prior to admission. His withdrawal was not severe on the basis of his clinical scoring criteria. His withdrawal symptoms resolved overnight with the administration of methadone for opioid agonist therapy.

He did present with systemic inflammatory response syndrome (SIRS) criteria, but this was likely due to acute withdrawal from opioids. He did not have an elevated white blood count or lactate. He did not ever develop sepsis. It was appropriate for him to undergo observation in the hospital given the concern for infection, but his clinical status stabilized overnight with opioid agonist therapy. He presented with a mild prerenal acute kidney injury that resolved overnight with intravenous fluids. These conditions are all appropriate for a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: atopic dermatitis
Treatment: Dupixent
The insurer denied Dupixent.
The health plan's determination is upheld. 

The patient is a male with moderate to severe atopic dermatitis of the face, groin, hands, arms, legs, and trunk. The patient has a sharp facial delineation consistent with either allergic contact dermatitis (possibly related to a continuous positive airway pressure (CPAP) machine) but possibly also atopic dermatitis. The patient has reportedly tried and failed topical fluticasone ointment, halobetasol ointment, and Tacrolimus ointment (he was transitioned from topical mometasone to tacrolimus for his facial rash). Elidel and Eucrisa have also been used topically in the past. Cetirizine has been used at a 10 milligrams (mg) dosage as needed at night for itch. 

Dupixent is not medically necessary.
The patient has no documented treatment failure with, or true medical contraindication to, either his current regimen of topical steroids and topical calcineurin inhibitors, and/or the addition of standard, first-line oral medications used for moderate to severe atopic dermatitis (such as Azathioprine or Cyclosporine). These treatments are all as medically appropriate for this patient's particular clinical scenario at this time. Dupixent is not proven to be superior to all other formulary alternatives as per comparative, controlled studies. Therefore, consistent with current medical literature, Dupixent is not medically necessary.
The diagnosis of the patient's facial rash is possibly either allergic contact dermatitis or atopic dermatitis, so that an allergic reaction or component of the rash may have to be considered. However, if any allergic contact dermatitis is only an aggravating factor for this patient's overall condition, then the diagnosis of atopic dermatitis must be concluded. However, the clinic notes discuss overall control of this patient's condition on topical medications. Furthermore, first-line oral/systemic traditional therapies such as azathioprine or cyclosporine have not yet been tried and are both appropriate for this patient. Dupixent also can worsen facial or periocular dermatitis in atopic patients, which also must be considered.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath
Treatment: Inpatient Admission
The health plan denied: Inpatient Admission
The denial is: Upheld

The patient is a female with a past medical history significant for rheumatoid arthritis, asthma, and tobacco use who had never been intubated or hospitalized and presented to the emergency department because of chest tightness and shortness of breath for one day. The patient woke up on the day of admission with these symptoms and used Albuterol treatment without significant improvement. The patient denied any fever, chills, palpitations, dizziness, headache, runny nose, nausea, vomiting, diarrhea, or any other symptoms.

The patient was admitted to the hospital with acute asthma exacerbation and received treatment with bronchodilators and corticosteroids.
As a result of the treatment, the patient sustained significant improvement in her symptoms. The patient was discharged home with a recommendation to take prednisone for 5 days, and start using a Dulera inhaler, and an albuterol inhaler. The patient was instructed to follow up with a primary care physician after discharge.
The subject under review is the medical necessity of the inpatient admission.

The health plan's determination is upheld.

The inpatient admission is not medically necessary. The patient presented to the hospital with shortness of breath that started on the day of admission. It was suggested that the patient most likely had acute asthma exacerbation, which was relatively mild. It was clearly indicated that the patient's vital signs were normal including normal respiratory rate and oxygen saturation. The patient definitely did not need any kind of ventilatory support. Although her peak flow was diminished, the baseline was unknown. The patient had an oxygen saturation of 94% and no signs of cyanosis. There was no significant carbon dioxide (CO2) retention based on the results of the arterial blood gas (ABG). There was no evidence of bradyarrhythmia. The patient remained awake, alert, and oriented during the entire hospitalization without any evidence of altered mental status. The chest x-ray did not demonstrate any complications including pneumonia or pneumothorax. The patient had a slightly prolonged QT interval on the electrocardiogram (EKG) that was not associated with any symptoms, but no other evidence of arrhythmias of immediate concern. The patient could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Shortness of breath
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is overturned.

The patient is a male with anxiety and alcohol abuse (recently in rehab), and tobacco abuse, who presents to the emergency room (ER) after being referred by his primary care physician (PCP) with shortness of breath, coughing up black phlegm and low oxygen saturations. Reports he was Coronavirus 2019 (COVID-19) positive. The patient reports coughing, chest discomfort, night sweats. Saturations intermittently dropping to the 80's. Vitals showed a temperature of 99.4 degrees Fahrenheit, heart rate 108, respiratory rate 20, blood pressure (BP) 110/68, sating 91% (percent) on room air. Labs remarkable for D-dimer of 1.17 and C-reactive protein (CRP) 74. Computed tomography (CT) pulmonary embolism (PE) study shows bilateral infiltrates and negative for PE. The patient was placed on 4 liters (L) nasal cannula (NC) with saturations of 96% and given fluids and Decadron. Heart rate improved with fluid resuscitation. The patient was admitted for supportive care. The patient was given steroids and weaned off of oxygen. He was discharged. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is overturned.

The inpatient hospital admission is medically necessary. Predicting trajectories for patients with COVID-19 has been deemed difficult (Kilaru, et al, 2020). Some clinical criteria have been found to be predictive of poor outcomes. The patient presented to the hospital with COVID-19 with pulse oximetry with saturations of 90% with notes documenting intermittent desaturations to the 80's. Based on recommended guidelines, patients with a peripheral capillary oxygen saturation (SpO2) less than (<) 92% should be admitted to the inpatient level of care and not to the observation level of care (Tian, et al, 2021). Hypoxia has been determined to be a factor that is associated with predicting severe COVID-19 and poor outcomes (Myrstad, et al, 2020). Based on these findings, the patient would be expected to stay longer than 48 hours and require a complex level of care (Centers for Medicare and Medicaid Services [CMS] guidelines) and therefore qualifies for the inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Suicidal Ideation. 
Treatment: Inpatient Mental Health. 

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

The patient is a male with history of anxiety, depression, attention deficit and hyperactivity disorder who was admitted for worsening suicidal ideation with plan. The patient has a history of co-morbid substance abuse and felt suicidal thinking was becoming more intrusive. The patient was with worsening depressed mood, isolation and anhedonia. The health plan has denied inpatient level of care as not being medically necessary. 

The inpatient hospitalization is medically necessary. The patient was acutely suicidal and required 1:1 monitoring. The patient failed outpatient levels of care and disclosed worsening suicidal thinking to his mental health provider necessitating emergency room (ER) visit and subsequent admission for monitoring and starting of antidepressants. As no psychiatric beds were available, the patient was admitted for monitoring and treatment to the pediatric floor. The patient is an acute danger to himself and treatment at the inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Progressive dysphagia
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult female who has a history of osteoporosis. The patient had progressive dysphagia to both solids and liquids over the previous two months with a 20-to-25-pound weight loss. The patient underwent an esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) for a noted stricture on radiologic imaging. The patient was noted to have a mediastinal/esophageal mass. A scope could not be passed beyond this mass. Surgery was consulted for gastrostomy (G)-tube placement. The patient declined tube placement at the facility filing the appeal and the patient wanted to leave against medical advice (AMA). She was evaluated and felt not to have capacity to sign out against medical advice. The patient was subsequently discharged with a visiting nurse service arranged.

The proposed inpatient admission was not medically necessary.

The patient underwent an esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) which determined a near complete obstruction by a mass in her mediastinum/esophagus. The patient had no safe way to obtain nutrition and hydration. Surgery was proposed while an evaluation of the mass was undertaken. The patient declined further care and was eventually sent home with a visiting nurse service.

The patient received no care that required a full acute level of service. The patient underwent an outpatient procedure and then declined a feeding tube placement. The patient requested to sign out against medical advice (AMA) and additional time was spent obtaining a psychiatric evaluation to see if she could sign out.  When it was determined that she could not, she was discharged home with a visiting nurse service. None of the care provided required an acute level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status, cytomegaloviral disease, dizziness, leukemia, shortness of breath, and depression
Treatment: Personal care worker (PCW) services: 7 days per week, 12 hours per day, 84 hours per week
The insurer denied coverage for PCW services: 7 days per week, 12 hours per day, 84 hours per week.
The denial is overturned.

The patient is a female with chronic medical problems including cytomegalovirus disease, dizziness, and depression. The insurer approved PCW services 5 hours/day, 7 days/week for a total of 35 hours/week. 

The most recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive status is described as "minimally impaired." She requires extensive assistance for bathing and lower body dressing. Limited assistance is needed for personal hygiene, upper body dressing, bed mobility and toilet transfer/use. She is continent of bowel and bladder. The patient uses a rollator for ambulation. Her treating physician submitted a letter and indicated the patient has functional deficits and progressive encephalitis that "has resulted in the patient being completely demented." The physician also noted that this was also partially related to coronavirus disease (COVID) and recommended a "full time aide and anything less than that would be insufficient." She must be prompted to do everything including eating, toileting, brushing her teeth et cetera." She cannot get to the bathroom alone. Her husband is elderly and does not live with her. 

The Request for Service (RFS) clinical review psychiatric evaluation notes "member has no memory, asks same thing every 5 minutes, confabulates and needs prompting for all activities of daily living (ADLs)." Also noted that Mini-Mental State Examination (MMSE) was 14 (consistent with moderate dementia).  

There is a progress note from the time she was in inpatient setting, confirming the marked deterioration and discussion regarding need for nursing home. 

There has been marked deterioration in her mental status since the last UAS which is well documented from different sources. This affects both instrumental activities of daily living (IADLs) and ADLs. Based on the enclosed documents reviewed, the patient's health and safety cannot be appropriately provided and maintained by the currently authorized PCW services 5 hours/day, 7 days/week for a total of 35 hours/week. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care worker (PCW) services: 7 days per week, 12 hours per day, 84 hours per week is overturned. Medical Necessity is substantiated.