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

Diagnosis: Dementia
Treatment: Personal Care Services 12 Hours a Day, 7 Days a 
Week For 84 Hours Total
The insurer denied: Personal Care Services 12 Hours a Day, 7 Days a Week For 84 Hours Total
The denial is overturned.

The patient is an elderly female with a history of general debility due to dementia. The request is for Personal Care Assistance through Home Health care (Level 2) to be increased from 35 hours per week (5 hours per day, 7 days per week) to 84 hours per week (12 hours per day, 7 days per week) based on UAS (Uniform Assessment System) evaluation of last month.
The health plan denied the request, because she can direct her care and has a supportive daughter helping with making decisions. The health plan does not provide assistance services based on a need for safety supervision alone, companionship, or when no tasks are being done. The additional hours requested are because of the patient's chronic medical conditions, and to help with her Activities of Daily Living (ADLs), as she has cognitive decline and requires extensive assistance with most of her ADLs (activities of daily living). A review of the records showed that the patient has multiple chronic medical conditions, including dementia, diabetes mellitus, hypertension, obesity, CAD (coronary artery disease), CHF (congestive heart failure), depression, generalized osteoarthritis, hypothyroidism, and frequent falls. The UAS (Uniform Assessment System) evaluation of last month showed that she required extensive assistance with mobility, walking, locomotion, transfer toilet, toilet use and eating, required maximum assistance with upper/lower body dressing, and bathing, while totally dependent for meal preparation, medication management, and housework. The patient lives alone in a two-bedroom apartment on a second floor.

The requested increase in Personal Care Services to 12 Hours a Day, 7 Days a Week For 84 Hours Total, is medically necessary.

The patient is minimally cognitively impaired, and in specific recurring situations, her decisions become poor or unsafe requiring cues. She requires limited assistance with eating, extensive assistance with managing medications, phone use, personal hygiene, upper/lower body dressing, walking, locomotion, toilet use/transfer, bed mobility, maximal assistance for meal preparation, managing finances, stairs, shopping, transportation, bathing, and totally dependent for housework. The reason for denial by the health plan as noted in the clinical information above, does not align with her disability features as stated in the UAS (Uniform Assessment System) of last month. Therefore, the 84 hours per week (12 hours per day, 7 days per week) requested should be approved.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left sided kidney stone with mild obstruction
Treatment:  Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female with a history of hypothyroidism, hyperlipidemia who present to the emergency room (ER) with complaints of left flank pain and vomiting. She denied any fevers or chills. She had stable vital signs and was noted to have left cerebrovascular accident (CVA) and left lower quadrant abdominal tenderness on exam. A computed tomography (CT) scan of the abdomen/pelvis showed a 1.4-5 millimeter (mm) proximal left ureteral calculus situated just beyond the ureteropelvic junction and resultant mild left pelvocaliectasis as well as mild to moderate constipation. She was treated for pain and nausea with Morphine and Zofran. She was subsequently admitted, started on intravenous (IV) fluids and Ceftriaxone, placed nothing by mouth (NPO) and urology consulted and her home medications were continued. She was seen by urology at which time the pain was improved and he recommended to continue pain medications, follow up kidney ureter bladder (KUB) and strain urine for calculi and in the event that the patient did not improve, then other measures would be considered. The patient, however, continued to improve and was discharged on Bactrim for 3 days as well as Zofran, Pepcid, Oxycodone with urology follow up outpatient in 1 week.
At issue is the medical necessity of an inpatient stay.

Based on a review of provided records, the patient presented to the emergency room (ER) with a day's history of nausea, vomiting and left flank pain. The patient was seen in the ER and diagnosed with a left sided kidney stone with mild obstruction. Pain and vomiting were controlled in the ER with intravenous (IV) Morphine and Zofran. She was hemodynamically stable, had no protracted vomiting and had no acute kidney injury (AKI). She was noted to have a mild urinary tract infection (UTI) and no pyelonephritis. By the time she was seen by urology, the pain was controlled and she had a stable exam. She was subsequently discharged without the need for inpatient care. A full hospital admission was not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pleuritic Chest Pain and Dyspnea
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a male with a history of bipolar disorder, depression, and post-traumatic stress disorder (PTSD). Presenting complaints were pleuritic chest pain and dyspnea. On arrival to the emergency department, the patient's vital signs were blood pressure 122/87, heart rate 135, respiratory rate 24, with oxygen saturation 95 percent (%). The physical exam was notable for decreased breath sounds. Lab results were notable for hyponatremia with sodium 131. Radiology was notable for computed tomography angiography (CTA) chest with bibasilar opacities and bilateral pulmonary emboli. Treatment was started for community acquired pneumonia and pulmonary emboli, and the patient was admitted to an inpatient level of care.
At issue is he medical necessity of an inpatient level of care.
The inpatient level of care was not medically necessary. The patient presented with dyspnea and chest pain and was found to have a Pneumonia Severity Index Risk Class II pneumonia in addition to a low risk pulmonary embolism severity index (PESI) pulmonary embolism. The patient did not demonstrate hypoxia, with a partial pressure of oxygen (PaO2) of 102, and did not have hemodynamic instability or dangerous comorbidities. He did have significant chest pain which was difficult to control initially. A lower level of care would have been appropriate to begin medical treatment and ensure appropriate pain control, followed by transition to outpatient status.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

The patient is a female patient with anti-phospholipid syndrome and daily marijuana use who presented to the emergency room (ER) with dizziness and fatigue. She was evaluated, but left prior to return of lab testing. Her troponin level was elevated, at 124, and she was asked to return to the emergency room (ER). She complained of lightheadedness and urinary frequency. She had no chest pain or dyspnea. She reported heavy bleeding with her current menstrual period. The blood pressure was 95/55 millimeters of mercury (mmHg), pulse 62 beats per minute (bpm) and respiratory rate 16. She was afebrile. An electrocardiogram (EKG) showed sinus bradycardia at 47 beats per minute (bpm) and sinus arrhythmia. No ST segment or T wave changes were noted. She was anemic, with a hemoglobin (Hg) 10.4 and low ferritin of 6.2.
She was admitted to telemetry and given intravenous (IV) fluids. Repeat troponins were downtrending, at 114, then 102. The elevated troponin was felt due to demand ischemia. She remained stable, with no cardiac symptoms of chest pain, dyspnea or palpitations. She was discharged with outpatient follow-up with her primary physician and gynecologist. At issue is the medical necessity of an inpatient stay.

The patient was admitted with an elevated troponin level. However, this was not due to an acute coronary syndrome but due to demand ischemia in the setting of dehydration and anemia. She was hemodynamically stable, without angina, ischemic EKG changes or other evidence for myocardial injury.
Inpatient admission is not medically necessary for this patient. Per Milliman Guidelines, inpatient admission for acute myocardial infarction requires both an elevated troponin plus evidence for myocardial injury due to acute ischemia, as indicated by 1 or more of the following:
"symptoms consistent with myocardial ischemia (eg, chest pain, dyspnea), new or presumed new electrocardiogram (ECG) changes consistent with ischemia (eg, ST-segment change, left bundle branch block), ECG with new or presumed new pathologic Q waves, cardiac imaging with new or presumed new regional wall motion abnormality or loss of viable myocardium consistent with ischemia, or identification of a coronary thrombus (eg, by angiography, intracoronary imaging)." The patient did not have any of these conditions. Her troponin elevation was due to demand ischemia rather than myocardial injury.
For type 2 myocardial infarction (MI), per the current literature (3), conservative management is appropriate, which would include observation care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: mastitis, cellulitis in the breasts
treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is overturned.

The patient is a female with a past medical history of hidradenitis suppurative, who presented with bilateral breast pain and worsening erythema. She reported a history of hidradenitis suppurative affecting both armpits and breasts. Initially, a week before her presentation, she noticed mild redness on her left breast, but the erythema progressed, and tenderness developed. The patient was admitted to the hospital with a diagnosis of mastitis, cellulitis in the breasts bilaterally, and a history of hidradenitis. Intravenous antibiotics and fluids were initiated as part of the treatment plan.

The acute inpatient hospital stay was medically necessary. The patient presented to the hospital with worsening bilateral erythema, and tenderness in her breasts consistent with worsening cellulitis. The patient clearly failed outpatient treatment based on the fact that the symptoms progressed while being on an adequate regimen of antibiotics, which unfortunately the patient was unable to tolerate because of nausea. In order to establish an adequate regimen of intravenous antibiotics, ensure adequate response, and subsequently transition the patient to the regimen of oral antibiotics that she could tolerate, inpatient hospitalization was indicated, as was done in this clinical case.
Therefore, admission at the acute inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:	Abdominal Contusion	

Treatment: Radiologic Evaluation

The insurer denied inpatient stay

The denial is upheld

This infant has a history of atrial septal defect (ASD) being followed by Cardiology. 

This infant boy was brought to the emergency department (ED) in June 2023 for evaluation for abdominal wall ecchymosis. The provider indicated the patient was found to have a small bruise measuring 3.5 cm x 3cm above umbilicus, otherwise, no other external signs of trauma over chest, abdomen, or extremities noted. According to the parents they believe that the patient's car seat harness might have been tight which could have potentially been the cause of the bruise. The parents denied any trauma and any episodes of agitation. The ED physician stated that the patient was observed playful, does not appear agitated, Based on the clinical finding presented in the medical records, inpatient stay is not medically necessary for this patient. The patient was noted to be medically stable, there are no signs of respiratory distress, or clinical indication to warrant inpatient stay. This patient's presentation and imaging finding concerning for trauma and possible splenic injury warranted that he should be brought in, however, this could have been done as observation given his clinical stable condition and rather benign exam.

Milliman Care Guidelines indicates Pediatric General Admission is indicated for 1 or more of the following: Hemodynamic instability; cardiac arrhythmias of immediate concern; severe heart failure in child as indicated by pulmonary edema/respiratory distress, hypoxemia, anasarca; severe respiratory findings; neurologic abnormalities; altered mental status that is severe or persistent; severe electrolyte abnormalities requiring inpatient care; severe anemia; high risk low platelet count; severe pain requiring acute inpatient management; encopresis or severe fecal impaction; inpatient monitoring needed; treatment requiring inpatient care, patient requires high concentration oxygen, frequent respiratory therapy, epidural analgesia, IV [intravenous] anticoagulation/vasoactive/antiarrhythmic medication, acute thrombolytics, other treatment needed; OR emergency procedures needed.

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 inpatient hospitalization is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Low back pain.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female. The patient had treatment with a lumbar microdiskectomy and had an inpatient hospital admission. The patient has no significant past medical history. The patient presented with chronic low back pain radiating into the right lower extremity. The symptoms began almost 14 years ago and have been intermittent. The patient had pain in the right leg and back pain. This was in an S1 distribution. The pain was exacerbated by activity, bending, standing, and walking. The patient had previous treatment with exercise, medications, and physical therapy as well as chiropractic care. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated disc degeneration of L5-S1 with a cranially migrated right paracentral disc extrusion. There was moderate to severe right subarticular recess stenosis and posterior displacement impingement of the right S1 nerve root. The patient had surgery for a right L5-S1 microdiskectomy. The patient had routine postoperative treatment and physical therapy for ambulation. On post-operative day number (#) 1, the patient ambulated 40 feet with rolling walker and later ambulated 20 feet with a rolling walker. The patient continued treatment with oxycodone and Toradol. The patient had a hemoglobin of 11.4 and hematocrit of 33.7. The patient continued with physical therapy on post-operative day #2. The patient 
had complaints of severe back pain on post-operative day #3 and then was discharged on post-operative day #4 after 
ambulating 150 feet with a rolling walker. This is a review for the inpatient hospital stay.

The requested health service was not medically necessary.

The patient was prescribed an inpatient level of care after the microdiskectomy surgery. The microdiskectomy surgery is an outpatient procedure and does not require inpatient level of care. The patient had no associated medical conditions that would require an inpatient level of care and did not have any complications after surgery that would require a higher level of hospital care. The patient had postoperative pain symptoms. This required analgesics and physical therapy, which can be provided to the patient at a lower level of hospital care. Thus, the inpatient care would not be approved. The requested health service is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld



Diagnosis: attention deficit hyperactivity disorder (ADHD).
Treatment: Vyvanse.
The insurer denied Vyvanse.
The health plan's determination is upheld. 

This case involves an adult female diagnosed with attention deficit hyperactivity disorder (ADHD) since childhood. No other comorbid psychiatric disorders are reported and there is no co-occurring substance use disorder or a general medical condition that is known to be a focus of treatment, nor is there a reported diagnosis of narcolepsy or binge eating disorder.
The patient has been prescribed Vyvanse 10 milligrams (mg) caps. The patient failed treatment with generic formulations of Strattera, Ritalin, Concerta or Metadate, Adzenys, and Focalin XR (extended-release), as well as off-label use of Wellbutrin.

A formulary exception is not indicated. In this case, the remaining formulary drugs would likely be as effective as the non-formulary drug, and the remaining formulary drugs and the requested non-formulary drug would pose a risk for adverse effects.
The formulary contains two additional agents that have proven to be effective in treating ADHD including generic formulations of Dexedrine and Adderall XR. These formulary alternatives could be reasonably prescribed to address the patient's ADHD.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Diamond Blackfan anemia
Treatment: Deferasirox
The insurer denied Deferasirox.
The determination is upheld.

This is a female patient with Diamond Blackfan anemia. The patient has a history of transfusions - 300-400 units over her lifetime. She has previously received chelation and Exjade, and, most recently, Jadenu, which she continues. The patient had a ferritin of 5110. The patient's iron saturation was 68 percent (%). Ongoing deferasirox (Jadenu) has been recommended and is under review.

There is a paucity of data indicating that the formulary option, defriprone//Ferriprox, is inferior to deferasirox (Jadenu) with regard to efficacy. Amongst the options in this space, the authors of UpToDate state "...There is no current consensus on which agent to choose...". This agent has been demonstrated to be effective in this clinical scenario. Multiple studies including those by Cohen, et al, have confirmed the safety of deferiprone. Safety deficits relative to Jadenu have not been demonstrated in direct comparison trials.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Idiopathic Urticaria
Treatment: Xolair
The insurer denied: Xolair
The denial is overturned.

The patient is an adult female with a diagnosis of chronic idiopathic urticaria (CIU). The request is for Xolair. The health plan denied coverage of the request, noting that the patient has not tried leukotriene receptor antagonists. The reason the physician is appealing the determination is to provide further documentation.

The requested Xolair is medically necessary.

Xolair is FDA (United States Food and Drug Administration) approved for the treatment of chronic idiopathic urticaria in adults and adolescents 12 years of age and older who remain symptomatic despite H1 antihistamine treatment. This is based on clinical trials showing efficacy of Xolair in treating chronic idiopathic urticaria in patients who remain symptomatic despite H1 (histamine H1 receptor) antihistamine treatment. The patient has had persistent hives despite using cetirizine, loratadine, diphenhydramine, steroids. The patient tried up to Zyrtec 20 milligrams twice daily for a few weeks but continued to have hives. The patient has a diagnosis of chronic idiopathic urticaria and remains symptomatic despite maximal H1 (histamine H1 receptor) antihistamine treatment. Therefore, the patient meets the FDA (United States Food and Drug Administration)-approved indication for the use of Xolair. Medical literature does not suggest that the use of a leukotriene antagonist is required prior to using Xolair.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative Colitis
Treatment: Entyvio
The insurer denied Entyvio.
The determination is upheld.

This is a male patient with a history of ulcerative colitis. The requested service is Entyvio. At issue is the medical necessity of the Entyvio.

Entyvio is not medically necessary based on the current medical literature and treatment guidelines.
Entyvio is Food and Drug Administration (FDA) approved for the use in the treatment of inflammatory bowel disease (IBD) in adults. There are many peer reviewed literature reports supporting the use of Entyvio in pediatric patients with refractory IBD.
Per Ledder O et al, "Vedolizumab was safe and effective in this cohort of paediatric refractory IBD".
However, the current standard of care is to utilize the FDA approved treatments for pediatric ulcerative colitis (such as infliximab and adalimumab) before the off-label use of Entyvio. There is no evidence that Entyvio is superior to infliximab or adalimumab in pediatric ulcerative colitis. The clinical practice guidelines support using infliximab and adalimumab as first line biologics. There is not adequate literature support for using Entyvio as a first line biologic in children.
This patient has not tried and failed the FDA approved treatments (infliximab or adalimumab). There are no documented contraindications to infliximab or adalimumab. Therefore, his ulcerative colitis is not considered refractory to tumor necrosis factor alpha inhibitors and the off label use of Entyvio is not considered medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary incontinence, ataxia, generalized weakness, hyperlipidemia, corticobasal degeneration, essential tremor, and 
hypertension
Treatment: Increase Personal Worker (PCW) Service, 7 Days Per Week 24 Hours Per day Continuous Care by More Than One Person. 168 Hours Per Week
The insurer denied: Increase Personal Worker (PCW) Service, 7 Days Per Week 24 Hours Per day Continuous Care by More Than One Person. 168 Hours Per Week
The denial is overturned.

The patient is an elderly male. He is noted to have functional urinary incontinence, ataxia, generalized weakness, hyperlipidemia, corticobasal degeneration, essential tremor, and hypertension. The request is for increasing personal care worker hours to 168 hours per week. The patient's functional status is as follows: Requires maximum assistance with meal preparation, total dependence with ordinary housework in both performance and capacity, total dependence in finance management in both performance and capacity, extensive assistance with medication management in both capacity and performance, extensive assistance with phone utilization in both performance and capacity, maximum assistance with stair negotiation, total dependence with shopping in both performance and capacity maximum assistance with transportation, maximum assistance with equipment management, extensive assistance with bathing, limited assistance with personal hygiene, extensive assistance with upper body dressing and lower body dressing, extensive assistance with walking, locomotion, toilet transfer, toilet use, supervision with bed mobility; his activity of daily living performance had declined when compared to an assessment done a few months prior to this one.

The requested Increase Personal Worker (PCW) Service, 7 Days Per Week 24 Hours Per day Continuous Care by More Than One Person 168 Hours Per Week is medically necessary.

In this instance, this patient was previously approved for 12 hours a day, 7 days a week. However, it was noted during the latest evaluation that the patient had deteriorated significantly functional wise and had actually suffered multiple falls after the 12 hours shift had ended. In this instance, the patient requires extensive assistance with at least three activities of daily living. 
Given the multiple comorbidities, including advanced age, given the functional deterioration when compared to previous assessments, and given the multiple falls suffered outside the allotted hours, the current regimen is insufficient to adequately meet the patient's needs. The medical necessity is therefore established.