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

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

The patient is a female who presented to the emergency department (ED) with worsening buttock pain of several days duration. Past medical history included sickle cell trait. She was without fever and the heart rate was 101/minute. The patient's white blood cell (WBC) count was elevated at 12.5 thousand (K). Examination in the ED showed erythema, tenderness and fluctuance of the perineal area. Surgery consultation was completed. The patient was treated with intravenous (IV) fluid, pain medications, perioperative IV antibiotics. Computed tomography (CT) scan showed a 2.3 x 3.2 x 2-centimeter (cm) right gluteal fold abscess. Surgical incision and drainage of the abscess was performed. The patient was monitored following surgery.  Following surgery, the progress note states that the patient was medically cleared for discharge. Vital signs were normal. She was discharged from the hospital with instructions for outpatient follow up. The subject under review is the medical necessity for the inpatient hospital admission.

The health plan's determination is upheld.

The inpatient hospital admission is not medically necessary in this case. This patient presented with perianal pain. She underwent an uncomplicated surgical incision and drainage procedure. This type of care is reasonably provided with a lower level of care status.
This patient could have appropriately been treated with a lower level of care during this period of time. She was clinically stable at the time of presentation and remained so during the period of care. Provision of surgical incision and drainage, perioperative antibiotics and parenteral analgesia, including overnight monitoring could have been provided at a lower level of care status. Inpatient level of care was not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient admission 
The insurer denied coverage for an inpatient admission.
The denial is overturned.

The patient was reportedly transferred from the alcohol rehabilitation facility to this medical hospital setting due to acute medical issues including severe and persistent abdominal pain, black stools, and dizziness. He reportedly had anemia and elevated LFT's (liver function tests). He had diagnostic testing including esophagogastroduodenoscopy (EGD) and colonoscopy. He reportedly required IV (intravenous) hydration. He was discharged when medically stable.
  
The insurer denied coverage for inpatient hospital treatment as not medically necessary. They stated that he did not have hemodynamic, pulmonary, metabolic, or neurological reasons for acute inpatient hospital treatment. They recommended a less restrictive level of care.

The medical records provided enough specific evidence to support that the patient required hospital treatment. The APA (American Psychiatric Association) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that patients with comorbid medical condition that complicate the management of withdrawal are also candidates for inpatient detoxification and patients with acute medical conditions related to alcohol or substance use are candidates for inpatient hospital treatment. This patient reportedly had acute medical conditions related to heavy alcohol use including severe and persistent abdominal pain, black stools, dizziness, anemia, LFT's, esophagitis and gastritis with portal hypertensive gastropathy with areas of diffuse erythema in the gastric body and required inpatient medical treatment. 

He reportedly had intravenous (IV) hydration and medications and underwent diagnostic testing including esophagogastroduodenoscopy (EGD) and colonoscopy which revealed esophagitis and gastritis with portal hypertensive gastropathy with areas of diffuse erythema in the gastric body typical of AVM (arteriovenous malformation) which requires argon plasma coagulation to complete hemostasis. He also recently was in the hospital previously for similar symptoms and acute gastro-intestinal (GI) bleed requiring hospital inpatient treatment for anemia due to blood loss, which put him at risk medically. 
He was referred from an inpatient alcohol rehabilitation treatment to this hospital due to his acute medical issues in the setting of heavy alcohol use.

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 the inpatient admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hip fracture
Treatment: Wheelchair ramp
The insurer denied the Wheelchair ramp.
The determination is overturned.

The patient has coronary artery disease (CAD), hypertension (HTN), diabetes mellitus (DM) and a recent hip fracture who has been denied a ramp outside of her home for a wheelchair. At issue is the medical necessity for a wheelchair ramp.

A wheelchair ramp outside the front entrance of the patient's home is medically necessary for this patient. She requires assistance with all mobility and activities of daily living (ADLs). She cannot walk outside of the home and uses a wheelchair for mobility. She requires two people to carry her down the 3 outside steps and this is unsafe. She cannot exit the home in the event of an emergency and this is unsafe. A wheelchair ramp would allow for safe and efficient transport outside of the home for physician visits, shopping, and emergencies.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's disease, heart disease, hypothyroidism, arthritis, and chronic pain
Treatment: Increase Personal Care Aide (PCA) Services for a Total of 56 Hours/Week
The insurer denied an increase in PCA services for a total of 56 hours/week.
The denial is overturned.

The patient is an elderly female. Her medical conditions include Alzheimer's disease, heart disease, hypothyroidism, arthritis, and chronic pain. Denial of increase personal care aide (PCA) services for a total of 56 hours/week is being appealed. The health plan approved 22.5 hours/week.

It is noted that the patient has advanced dementia, weakness, loss of balance and poor vision in one eye. She is afraid of being alone and concerned with falling and not having help. Uniform Assessment System (UAS) evaluation completed earlier this year shows minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation; extensive assistance with managing medications, bathing, lower body dressing, toilet use, and bed mobility; limited assistance with managing finances, personal hygiene, upper body dressing, walking, locomotion and toilet transfer; and independent with eating. She has bladder incontinence. Compared to UAS evaluation from last year, there has been a decline with toilet use and bed mobility.

A statement from the patient's provider recommends increase in home care because of "patient's severe" condition. A letter from another provider notes the patient's dementia and memory issues have progressed. She can no longer effectively and safely care for herself. They are recommending 24-hour home care due to her dementia and paranoia.

The requested increase in PCA services for a total of 56 hours/week 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. Denial of increase in PCA services for a total of 56 hours/week is being appealed. The health plan approved 22.5 hours/week.

This patient has multiple medical conditions including progressive dementia. She is concerned with being left alone. UAS evaluation completed earlier this year shows the patient needs assistance with all ADLs, except eating. She has bladder incontinence. Compared to UAS evaluation completed last year, there has been a decline with toilet use and bed mobility. Appeal letters note the patient's condition has deteriorated and recommend increased home care. The records and appeal statements support that the patient's physical status has declined between UAS evaluations. This patient's physical functioning is significantly impaired and she has no informal support. The approved PCA services of 22.5 hours/week is insufficient to meet this patient's needs for assistance with ADLs. The requested increase in PCA services to 56 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Varicose Veins
Treatment: Endoluminal ablation of varicose veins (heat treatment of leg veins)
The insurer denied coverage for endoluminal ablation of varicose veins (heat treatment of leg veins).
The determination is upheld.

The patient is a male with a history of Factor V Leyden, coronary artery disease and renovascular hypertension. The patient also has a history of peripheral artery disease of lower extremity, carotid artery disease, status/post (s/p) left lower extremity saphenous vein ablation and lower extremity venous thrombosis. 

There has been no documentation that attests to the fact that the patient's activities of daily living (ADL's) have been affected by varicose veins. There is no history that the patient has severe problems in his daily life or work that have not improved with six weeks of consistent conservative medical therapeutics. This is standard medical care.

The requested Endoluminal ablation of the Right Greater Saphenous Vein is not medically necessary since the information submitted does not meet the criteria necessary to establish necessity. There is no history of bleeding episodes from varicosities nor cutaneous ulceration from any superficial venous insufficiency.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Saxenda
The insurer denied: Saxenda
The denial is: Overturned.

The patient is a female being treated for obesity with Saxenda (liraglutide). Per notes from the plan, the medication was denied because it did not meet their established criteria. A letter of support for this appeal was provided by the treating physician. The physician asserts that the patient qualifies for ongoing treatment under a different set of criteria: the patient has completed at least 16 weeks of therapy, the drug is being used in conjunction with a low-calorie diet and exercise plan that will continue for at least 6 months, the patient has a body mass index (BMI) greater than (>) 30, and the patient has comorbid hyperlipidemia. The subject under review is the medical necessity for Saxenda for this patient.

The health plan's determination is overturned.

The requested treatment with Saxenda is medically necessary for this patient. The treating physician provided sufficient attestation to the patient meeting the criteria for ongoing treatment with the medication. There is no proof of a 4% (percent) weight loss, however the patient is receiving a comprehensive weight management plan to include low calorie intake and increase in physical activity, behavioral modification, and continuing follow up for at least six months, in addition to having a BMI over 30. Based on this she qualifies for ongoing treatment consistent with best practices as recommended by current clinical practice guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Developmental delays, seizure disorder, mild cerebral atrophy, cortical visual impairments, gastrointestinal tube (GT) dependent with dysphagia, scoliosis, movement disorder, and Perthe disease.
Treatment:  Durable Medical Equipment (Special Bed).
The insurer denied the Durable Medical Equipment (Special Bed).  
The denial is overturned.

This patient is a male child with history of developmental delays, seizure disorder, mild cerebral atrophy, cortical visual impairments, gastrointestinal tube (GT) dependent with dysphagia, scoliosis, movement disorder, and Perthe disease. The patent has been referred for SleepSafe bed options due to the fact that this patient's previous bed has been broken, the patient requires a special bed for rest and there is evidence of safety concerns taking into consideration this patient's lack of awareness and impulsivity. A prescription for a safety bed has been endorsed by the child pediatric physiatrist.

The proposed durable medical equipment (special bed) is medically necessary.

In this case, the patient is a male child with multiple comorbid conditions including but not limited to seizure disorder, movement disorder, developmental delays and most importantly, well documented evidence of impulsivity and safety concerns while in the specialty bed that this child outgrew due to linear growth. The patient has been evaluated by the skilled providers where alternative bed options have been discussed. The clinical records state that this child should be safe during sleep and/or rest time; the specific choice of durable medical equipment has been made by the multidisciplinary team to ensure safety of this child with special needs during sleep/rest in bed hours. The durable medical equipment (DME) that has been requested for this child with special needs is not a convenience or comfort item. This durable medical equipment has been prescribed based on standards of care and medical needs of this child.  The use of this safety bed is within acceptable standards of care for this patient with seizure disorder, movement disorder, and impulsivity.  The safety bed, which includes full length rails and padding, provides a controlled environment for the patient to sleep/rest; it also provides a controlled environment in the case of a seizure during sleep/rest periods.  Without such a bed, the patient's caregivers would not be able to leave the child unsupervised for any period of time, day or night.  The safety bed is medically necessary for this patient; without the safety bed, this child is at risk of bodily harm due to movement disorder, seizure, and impulsivity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld.

This is a female with a history of chronic low back and left leg pain. She has had physical therapy, injections and medications without relief. She apparently was set up to have surgery. She presented to the emergency room (ER) and threatened suicide if she were discharged. The neurologic exam showed alternating weakness and normal strength of the left leg with an inconsistent exam. The lumbar magnetic resonance imaging (MRI) shows mild narrowing L (lumbar) 5-S (sacral) 1 left due to disc osteophyte complex. The provider recommended a lumbar discectomy L5-S1 left that was performed. 

The inpatient admission was not medically necessary from the standpoint of her lumbar radiculopathy and subsequent lumbar laminectomy and discectomy. The procedure performed is an outpatient procedure, and therefore an inpatient admission is not medically necessary. It appears that the patient was having psychological issues and was also admitted for these reasons. Also, it appears that the patient had previously been denied surgery and was trying to have the procedure performed. Regardless, the procedure performed is an outpatient procedure and does not require an inpatient stay. A lower level of care would have been appropriate to address the patient's issues.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Abdominal Pain
Treatment: Inpatient Stay
The insurer denied: Inpatient Stay
The denial is: Overturned

The patient is a male who presented with abdominal pain of 1-day duration. Vital signs identified normal pulse and blood pressure. He was tender in the epigastrium and right upper quadrant. The white blood cell (WBC) count was elevated at 15 thousand (K). Serum transaminase, alkaline phosphatase and bilirubin were normal. Lipase was elevated (793). Ultrasound showed findings of gallstones and a distended thickened gallbladder. Surgical and gastroenterology consultations were requested. The patient was further evaluated with magnetic resonance cholangiopancreatography (MRCP) that was negative for common duct stones.

He was admitted to the hospital with the diagnosis of gallstone pancreatitis. He was treated with intravenous (IV) fluid, nothing by mouth (NPO) status, pain medications, and serial examination. MRCP showed no evidence for common bile duct stone or obstruction. The patient had less abdominal pain and underwent laparoscopic cholecystectomy. The post-surgical course was uncomplicated, and he was able to be discharged from the hospital.
The subject under review is the medical necessity for the inpatient stay.

An inpatient stay was appropriate and medically necessary for this patient. A lower level of care would not have been consistent with the standard of care for this patient with acute biliary pancreatitis. It was reasonably expected that this patient's clinical needs for IV fluid, pain medications, antiemetics, and appropriate imaging diagnostics would span a period of greater than 48 hours. This diagnosis (based on clinical exam, labs and imaging results) and the potential for rapid clinical deterioration warranted an inpatient level of care for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Social Day Care (SDC) in-home meals services
The insurer denied: Social Day Care (SDC) in-home meals services
The denial is overturned.

The patient is an elderly female with mild dementia. The patient has mild dementia, poor balances and arthritis. She lives with her mildly demented husband.  Uniform Assessment System showed no change in status reassessment. The patient was alert and oriented times 2 (two), forgetful. She has Alzheimer's. She leaves the stove on and forgets to turn it off. She is total dependence in preparing meals, maximum assistant in managing medication, maximal dependence for transportation. The patient is noted to be maximum assistance with bathing, hygiene, dressing, walking, transfers to toilet, eating. The patient has a decline in ADL (activities of daily living) function. She is bladder incontinent. As per the documents, the patient's condition deteriorated as computed in the prior assessment. The request is for SDC (social day care) in-home meal services.

The requested Social Day Care (SDC) in-home meal services are medically necessary.
The patient has mild dementia and lives with her husband, who has dementia as well. They need maximum assistance with ADL (activities of daily living). The patient has urinary incontinence.

As the patient needs help with dressing, walking, cleaning the apartment, bathing and feeding, with several doctor appointments a week, the home care would not have enough time to prepare meals for the patient.

Therefore, given the above, the requested Social Day Care (SDC) in-home meal services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Steroid Refractory Severe Ulcerative Colitis
Treatment: Stelara
The insurer denied the Stelara
The denial is overturned

The patient is a female. She has been diagnosed with severe ulcerative colitis. She failed steroids and Remicade (infliximab). She was hospitalized recently requiring blood transfusions. She was started on Xeljanz (tofacitinib) and then Stelara (ustekinumab) as a dual biological therapy. Her doctor requested to continue dual therapy with Stelara 90 mg (milligrams).

The health plan's reason for prior denial is that the requested Stelara is used with another biological agent. The denial is being appealed.

Yes, the requested Stelara 90 mg (milligrams), at a frequency of every 8 weeks, is medically necessary.
Current medical evidence shows that ustekinumab (Stelara) is reasonably safe and effective in children with moderate to severe ulcerative colitis that failed anti-TNF (tumor necrosis factor) drugs and other biological agents (1-2). This patient has had severe refractory ulcerative colitis and failed conventional therapy, and biologics including anti-TNF (tumor necrosis factor) drug Remicade.  Thus, Stelara may be the next treatment option. The standard maintenance dose is 90 mg (milligrams) every 8 weeks. For patients who responded to Stelara initially and then lost response due to low drug concentration and/or antibody formation, shortening the interval to every 4 weeks is recommended (1-3).

Dual therapy with Stelara and other biological agents were reported in children with refractory inflammatory bowel disease including ulcerative colitis (3-6).

For this patient with severe ulcerative colitis, the patient failed steroids and one anti-TNF (tumor necrosis factor) drug Remicade. The patient has not tried and failed other biological agents such as Stelara and Entyvio. Thus, a dual therapy with Stelara and Xeljanz is not indicated, as supported by current medical literature. A treatment with Stelara alone would be indicated per current medical literature. While Stelara every 4 weeks is not indicated, since the patient has not tried and failed standard dosing, Stelara maintenance dosing should be 90 mg (milligrams) every 8 weeks.

The appeal letter stated that their goal is to wean the patient off tofacitinib (Xeljanz) in the next 6 to 12 months. For Stelara, the letter stated that "Please review the literature provided and request for an expedited prior-authorization approval for Ustekinumab 90mg [milligrams] SC [subcutaneous] every 4 weeks at this time with intention for proactive drug monitoring to optimize therapy, or at minimum approval for Ustekinumab administration every 8 weeks." Since the patient has failed steroids and anti-TNF (tumor necrosis factor) drug Remicade, Stelara at standard dosing of 90 mg (milligrams) every 8 weeks would be medically necessary while weaning off Xeljanz over the next 6-12 months.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.