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

Diagnosis: Osteoporosis/decreased mobility
Treatment: Personal Care Services (PCS): 24 hours/day split-shift (two 12-hour shifts per day), 7 days/week, total of 168 hours/week
The insurer denied PCS): 24 hours/day split-shift, 7 days/week, total of 168 hours/week.
The health plan's determination is upheld. 

The patient is a female with past medical history of urinary incontinence, hypothyroidism, hypertension, gastroesophageal reflux disease (GERD), coronary artery disease, anxiety, depression, osteoporosis, and osteoarthritis who had been assigned PCA (personal care assistant) services following assessment performed via video assessing the patient at maximum assistance with tasks of meal preparation, ordinary housework, shopping, and transportation while extensive assistance with tasks of managing finances, managing medication, stairs, bathing, and dressing lower body. With tasks of phone use, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and eating the patient was assessed at limited assistance while supervision only with task of bed mobility. 

Personal Care Services (PCS): 24 hours/day split-shift (two 12-hour shifts per day), 7 days/week, total of 168 hours/week is not medically necessary for this patient.

There was a request for 24-hour, split shift services, 7 days/week and there is no documentation of overnight needs that would not allow a live-in aide to obtain at least 5 hours of uninterrupted sleep. There is no documentation of medical necessity of turning and repositioning at least every 2 hours overnight. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split shift, 7 days/week, to total 168 hours/week are not medically necessary for this patient. The hours approved by the health plan are appropriate to meet this patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: constipation

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is overturned

The patient presented with constipation secondary to gastroparesis requiring disimpaction. A syncopal episode was reported. The patient was hypotensive and had significant leukocytosis which trended upward from his visit in the emergency department 1-day prior to this encounter. Sodium Chloride 0.9% 1L (liter) intravenous (IV) Bolus STAT (immediately) and Lactulose 30 ml (milliliter) by mouth (PO) STAT was given. The patient was admitted for further evaluation and management of findings.

The patient could not have been safely and effectively managed at an observational level of care or been directly discharged from the ED (emergency department) or ambulatory surgery unit based on the advanced age, comorbidity, and presenting complaints.

Camilleri, M., Parkman, H. P., Shafi, M. A., Abell, T. L., Gerson, L., & American College of Gastroenterology (2013), "Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES), (approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms.

including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control."
The inpatient admission is considered medically necessary for this patient. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The insurer's denial of coverage for an inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: shortness of breath, heart failure.
Treatment: Inpatient admission.
The insurer denied: Inpatient Admission.
The denial is: Overturned.

The patient is a male who presented to the emergency department (ED) complaining of dyspnea, lower extremity edema, three pillow orthopnea and paroxysmal nocturnal dyspnea. His medical history was remarkable for hypertension, diabetes and recently diagnosed heart failure with reduced ejection fraction (13%). Initially, in the ED, he was diaphoretic and having difficulty speaking in full sentences. His blood pressure was 95/61 millimeters of mercury (mmHg) with a heart rate of 88 beats/minute. His respiratory rate was 21 beats/minute with a room air oxygen saturation of 98%. His physical exam was remarkable for pulmonary rales and lower extremity edema to the knees. Chest x-ray showed mild pulmonary vascular congestion and a small right pleural effusion. An electrocardiogram showed sinus rhythm with nonspecific repolarization changes. His serum troponin I level was .13 nanograms per milliliter (ng/ml) and was .14 ng/ml when remeasured. His brain natriuretic peptide (BNP) level was 582 pg/ml.

The patient was admitted to the hospital for management of decompensated heart failure and was treated with furosemide 40 milligrams (mg) twice daily. His troponin level remained stable. He had persistent rales and lower extremity edema. An echocardiogram showed a left ventricular ejection fraction of 15-20%. Cardiac catheterization was planned for when his volume status was sufficiently improved. Furosemide was continued; the dose was increased to 60 mg twice daily. It was further increased to 80 mg twice daily. The procedure was performed and showed no obstructive disease. There was low flow in the coronary vessels. The patient's left ventricular end diastolic pressure was markedly elevated at 32 mmHg. The patient then insisted upon being discharged due to a family emergency. Medical necessity for an inpatient admission is at issue.

The health plan's determination is overturned.
Based on the documentation provided an inpatient admission was medically necessary. This patient presented with acute decompensated heart failure with a markedly depressed left ventricular ejection fraction. Despite several days of high dose furosemide, he remained markedly volume overloaded. Five days after admission his left ventricular end diastolic pressure was still severely elevated at 32 mmHg. Given his failure to respond promptly to treatment with intravenous diuretics he required continued diuresis and hospitalization. This warranted an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hydronephrosis

Treatment is an inpatient admission 

The insurer denied coverage for an inpatient admission 
 
The denial is upheld

This is an adult female with a past medical history of renal stones, abnormal uterine bleeding (AUB), ovarian cyst, and asthma. The patient presented to the hospital with complaints of sharp left sided abdominal pain radiating to her bilateral groin for 4 days with nausea. Imaging revealed a 7mm (millimeter) stone in her left mid ureter with moderate left hydronephrosis. The patient was admitted to urology for cystoscopy and left stent placement. The patient tolerated the procedure well without complications. Postop her pain was well controlled, and she voided freely without pain. She was stable for discharge with an outpatient urology follow-up. 

Per MCG (Milliman Care Guidelines) Health (25th): Renal Colic & Kidney Stones, RRG, the patient failed to meet guidelines for an acute inpatient admission, the urinalysis was not consistent with a possible urinary tract infection (UTI), and there was no positive urine culture. 

Per MCG Health (25th): Urologic Surgery or Procedure GRG, the patient meets the GRC discharge parameter within 24 hours post procedure. 

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

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epidermolysis bullosa (EB)
Treatment: Cyclosporine 0.05% (Restasis) OP EMUL (Ophthalmic Emulsion)
The insurer denied coverage for cyclosporine 0.05% (Restasis) OP EMUL.
 The denial is upheld.

The patient's visual acuities were 20/70 to the right eye (OD) and 20/200 to the left eye (OS). Examination showed scan in visual axis OU (both eyes), inferior-temporal neovascularization into the paracentral visual axis OS. A diagnosis of epidermolysis bullosa (EB) was noted. It was noted that patient has current keratopathy in the setting of EB. The patient was to continue polysporin ointment and artificial tears.

In the appeal letter, the doctor stated that the patient would benefit from the medication, providing studies on the safety of Restasis for children under age 16. Restasis is not considered medically necessary for this patient. The patient does not have a diagnosis of dry eye disease and there is insufficient evidence in the medical literature for the use of Restasis in patients under 18 for the patient's specific diagnosis (epidermolysis bullosa, blepharitis and keratitis).

The health plan acted reasonably with sound medical judgment in the best interest of the patient. The insurer's denial of coverage for the cyclosporine 0.05% (Restasis) OP EMUL is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Constipation
Treatment: Motegrity
The insurer denied Motegrity.
The determination is upheld.

The patient has chronic idiopathic constipation, Ehlers-Danlos syndrome, small fiber neuropathy, autonomic dysfunction, and pelvic floor weakness. She has had hard bowel movements, bloating, and a feeling that food does not pass from the stomach (slow gastric emptying on the early part of a gastric emptying study many years ago). She has failed MiraLAX, magnesium hydroxide, bisacodyl, and Linzess. Motegrity for the treatment of chronic idiopathic constipation is requested. The request was not approved because the patient has not attempted lubiprostone.
At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Motegrity (prucalopride) or would have adverse effects.

The request for Motegrity is not supported over the formulary alternative lubiprostone. The American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as lubiprostone (Amitiza) should be used if non-pharmaceutical laxatives fail [1]. Lubiprostone has shown safety and efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain [2-7]. Motegrity has not demonstrated higher safety or efficacy than lubiprostone in a direct controlled comparison. For these reasons, the request for Motegrity is not supported over the use of lubiprostone in this case.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Non-small cell lung cancer (NSCLC) with EGFR (epidermal growth factor receptor) mutation

Treatment: Tagrisso

The insurer denied coverage for Tagrisso

The denial is overturned.

This is an adult with a diagnosis of non-small cell lung cancer (NSCLC) with EGFR mutation. The treating provider has requested therapy with Tagrisso.

Tagrisso would be more effective than the formulary drug in the treatment of NSCL with EGFR mutations.

"Third-generation EGFR-TKIs (epidermal growth factor receptor tyrosine kinase inhibitor) are specifically designed to selectively inhibit the T790M mutation by covalent binding to the C797 residue and possess the ability to also inhibit EGFR activating mutations while sparing wild-type EGFR and therefore expected to have less adverse effects from wild-type EGFR blockade in the skin and gastrointestinal tract. Osimertinib, a third- generation central nervous system (CNS)-active EGFR-TKI, selectively and potently inhibits EGFR sensitizing mutations as well as EGFR T790M mutations (4)." (Liam, 2019).

"Osimertinib is an oral, third-generation, irreversible epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) that selectively inhibits both EGFR-TKI-sensitizing and EGFR T790M resistance mutations. We compared osimertinib with standard EGFR-TKIs in patients with previously untreated, EGFR mutation-positive advanced non-small-cell lung cancer (NSCLC)." (Soria, et al., 2018).

The formulary drug is not likely to cause the patient an adverse reaction. However, Tagrisso has a favorable safety profile and has improved adverse event profile over Tarceva (erlotinib).

The formulary drug has not been ineffective, based on the patient's clinical history. The patient has not tried and failed Tarceva.

The formulary drugs are not expected to cause adverse effects. The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is not expected to be ineffective.

The formulary drug is expected to be more effective that the formulary alternatives. The carrier's denial of Request for Formulary Exception for Tagrisso is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vertigo, Depression and Dementia. 
Treatment: Personal Care Worker (PCW) services 7 days per week, 12 hours per day: 84 hours per week. 

The insurer denied coverage for Personal Care Worker (PCW) services 7 days per week, 12 hours per day: 84 hours per week. 

The denial is overturned. 

This is an elderly patient with multiple medical problems including vertigo, depression and dementia. She was recently hospitalized, transferred to a nursing facility and discharged. The patient is approved for PCW services 7 hours/day, 7 days/week for a total of 49 hours/week and is requesting an increase to 7 days/week, 12 hours/day: 84 hours/week. 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times."   She requires extensive assistance for bathing, personal hygiene, dressing, ambulation and toilet transfer/use. Limited assistance is needed for bed mobility and eating. She is frequently bladder incontinent and infrequently bowel incontinent. There has been a functional decline compared to UAS report, particularly for locomotion, ambulation and toilet use. Her activities of daily living (ADL) status and overall self-sufficiency over the past 90 days have declined and deteriorated, respectively. The combination of the patient's cognition and functional decline support an increase in PCW. Her condition and functional needs are at a level and unpredictable as to require the requested 84 hours/week. Based on the enclosed documents reviewed, the patient's health and safety is more appropriately provided and maintained by increasing the PCW to 84 hours/week. 

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested Personal Care Worker (PCW) services 7 days/week, 12 hours/day; 84 hours/week is medically necessary. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for Personal Care Worker (PCW) services 7 days per week, 12 hours per day; 84 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Impacted teeth
Treatment: D7230 extraction of impacted tooth with some bone, Tooth #17; D7240 extraction of impacted tooth covered by bone, Tooth #1; D9243 intravenous sedation (each 15 minutes)
The insurer denied: D7230 extraction of impacted tooth with some bone, Tooth #17; D7240 extraction of impacted tooth covered by bone, Tooth #1; D9243 intravenous sedation (each 15 minutes)
The denial is upheld.

The patient is an adult female. The appeal is regarding the medical necessity of wisdom tooth surgery with IV (intravenous) anesthesia services.

The requested health service is not medically necessary.

There are no clinical notes outlining a history of problems, infection, pain, swelling, or other pathology. There are no periodontal charting depths, no history of pain, swelling, discharge, adenopathy, or history of treatment with antibiotics or rinses, or any other modalities. Radiographs do not give any clear indication of a reason for removal to correlate with any clinical findings. The request is elective and not medically necessary, based upon the information submitted. Currently published parameters of care as outlined by The American Association of Oral and Maxillofacial Surgeons are not satisfied or substantiated by the request.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: General debility, gastrectomy/resection with jejunostomy (J)-tube, chronic respiratory failure, acute chemical pneumonitis and malnutrition. 
Treatment: Continued Skilled Nursing Facility
The insurer denied: Continued Skilled Nursing Facility
The denial is upheld

The patient is an older adult male with a history of general debility status post open gastrectomy/resection with jejunostomy (J)-tube for all nutrition/hydration and is status post tracheostomy for chronic respiratory failure, acute chemical pneumonitis and malnutrition.  The patient requires percutaneous endoscopic jejunostomy-tube feed, Foley catheter care, and trach collar with oxygen at two liters per minute. The patient's relevant past medical history includes hypertension, gastroesophageal reflux disease (GERD), diabetes mellitus, benign prostatic hyperplasia (BPH), malnutrition, malignant neoplasm of the stomach, chronic respiratory failure, atrial fibrillation, tuberculosis, vitamin deficiency, etc.  Prior to admission, the patient was independently living with his wife on the second floor in a walk-up building with 14 steps to enter. 

The proposed continued stay in a skilled nursing facility (SNF) is not medically necessary.
The patient was re-admitted to skilled nursing facility requiring total dependence for all activities of daily living including wheelchair mobility and for Physical Therapy, Occupational Therapy and Speech Therapy.  As of the first date of this denial, the patient continued to require maximum-assistance to total dependence for most activities of daily living.  The patient has not shown tangible progress in rehabilitation and he is most appropriate for custodial care.  Therefore, continued stay in skilled nursing facility was not medically necessary and his needs will be better met in a custodial care long-term.

Standard custodial care by definition means basic dependent care for activities of daily living by another person. Custodial care is most appropriate in this case because the patient needs maximum assistance up to total dependence on most activities of daily living including transfer, bed mobility, feeding, grooming, et cetera for which the patient requires a health aid assistance and for which he is unable to continue to participate effectively in rehabilitation towards any of the rehabilitation goals.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronavirus disease 2019 (COVID-19) pneumonitis
Treatment: Inpatient emergency admission
The insurer denied coverage for inpatient emergency admission.
The denial is overturned.

This is a patient with past medical history significant for stage 4 lung cancer, hypertension, hyperlipidemia, obstructive sleep apnea (OSA), and obesity who presented to the emergency room with complaints of fever, a productive cough, shortness of breath, and pleuritic chest pain. 

Vitals on presentation included: Temperature 101.8 degrees Fahrenheit, blood pressure 119/83, heart rate 115, respiratory rate 18, oxygen saturation 95% (percent) on room air. Laboratory values were notable for the following: white blood cell (WBC) count 4.7, hemoglobin 13.7, hematocrit 40.3, creatinine 0.95, glucose 112, C-reactive protein (CRP) 16.

The patient was admitted to the hospital for Coronavirus disease 2019 (COVID-19) pneumonitis. Computed tomography (CT) angiogram showed bilateral lower lobe ground-glass opacification. The patient required supplemental oxygen and was started on intravenous (IV) Remdesivir. The patient remained afebrile and hemodynamically stable. He was discharged to continue outpatient management. 

Although COVID treatment and management guidelines continue to evolve, the decision to hospitalize patients with COVID infection is typically based on presence of severe dyspnea (dyspnea at rest and interfering with the ability to speak in complete sentences), oxygen saturation on room air less than or equal to 90% (regardless of severity of dyspnea), alternations in mentation (i.e. [that is], confusion, change in behavior), and other signs of hypoperfusion or hypoxia. Similarly, the National Institutes of Health (NIH) COVID-19 Treatment Guidelines Panel suggests hospitalization for patients with any of the following: an oxygen saturation of < (less than) 94 percent on room air, respiratory rate of > (greater than) 30 breaths/minute, partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) < 300 millimeters of mercury (mmHg), or lung infiltrates > 50 percent. According to medical records, the patient had fever, cough, shortness of breath, with tachycardia, and ground-glass findings on CT scan. Additionally, the patient had co-morbid conditions including stage 4 lung cancer. Based on above findings, the inpatient hospital admission was medically necessary.

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

The insurer's denial of coverage for inpatient emergency admission is overturned. Medical necessity is substantiated.