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

Diagnosis: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS).
Treatment: intravenous immunoglobulin (IVIG) .
The insurer denied intravenous immunoglobulin (IVIG). 
The health plan's determination is upheld. 

The patient is a female. According to reports, she has been diagnosed with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS), an Immune Mechanism Disorder, and Autoimmune Encephalitis. According to a visit note, her symptoms started shortly after she had started her menstrual periods. She began to stay in her room, not wanting to meet with friends or relatives. She developed obsessive compulsive tendencies, including sexual thoughts, and thoughts of self-harm, together with a facial tic in the form of eye blinking. She also had nightmares, anxiety, and separation anxiety. A rapid streptococcal test was negative. She had a past history of 6-10 streptococcal infections in the past. A Cunningham Panel was abnormal. She had lost 6lb (pounds), experiencing abdominal pain and vomiting. 

The Immune Globulin Injection is not medically necessary for this patient.
Records describe that the patient has Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS), an Immune Mechanism Disorder, and Autoimmune Encephalitis. The patient does not appear to have received a diagnostic workup for autoimmune encephalitis, including magnetic resonance imaging (MRI) brain, a lumbar puncture and autoimmune encephalitis panel. There is no documentation provided to indicate that this patient had the recommended diagnostic work up to include CSF(cerebrospinal fluid) and neuroimaging studies, and the medical records provided do not describe a clear history of the post-infectious onset of neuropsychiatric symptoms.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Home Health Care. 
The insurer denied Personal Care Assistance Services, total of 112 hours per week. 
The health plan's determination is upheld in whole.

The patient is a male a with a past medical history of diabetes type 2, obesity, coronary artery disease, pacemaker, osteoarthritis, and hypertension who had been assigned personal care services. The patient underwent an assessment for personal care assistance services. The patient lives at home alone. Regarding his functional status, he is minimally impaired with no memory problems, he is able to communicate and understand others. He has minimal vision and hearing difficulty. He requires assistance with Instrumental Activities of Daily Living (IADLs) as follows: maximal assistance with meal prep, maximal assistance with housework; limited assistance with managing medications and finances, extensive assistance with stairs, and maximal assistance for shopping and extensive assistance for transportation.
He requires assistance with Activities of Daily Living (ADLs) as follows: extensive assistance with bathing, limited assistance with personal hygiene, dressing upper body, extensive assistance needed for dressing the lower body, locomotion, and walking, limited assistance with toileting transfers, toilet use, and bed mobility and independent with eating. He uses a cane for mobility and a rollator has been ordered. He is occasionally incontinent with bladder and continent with bowel. ADL status in the last 90 days is unchanged. One fall in the last 30 days. He has diminished energy and is unable to complete day-to-day activities. He has no pressure ulcers. Per assessment, he required about 20 hours of personal assistance services. He has a cane, shower chair, and grab bars.
Prior assessment completed determined that patient required 29 hours of personal assistance services.
This review is for the medical necessity of request to increase personal care assistance services to 112 hours per week.

The health plan's determination is upheld.

The requested health service of personal care assistance services for 112 hours per week is not medically necessary for this patient. Per assessment, the patient requires extensive assistance with bathing, dressing lower body, locomotion and walking and, limited assistance with personal hygiene, dressing the upper body, toileting transfers, toilet use, and bed mobility. There is no documented acute decline in functional status or documentation that the patient needs additional assistance that would be medically necessary for the patient above and beyond those documented with the previous nursing assessments that would require up to 112 hours per week.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lack of coordination. 
Treatment: Occupational Therapy. 

The insurer denied the Occupational Therapy. 
The determination is upheld. 

The patient has a diagnosis of lack of coordination. The clinical records available include a letter from Integrated Children's Therapy, treatment note which details activities/exercises performed described as play activities and an obstacle course. Also available is an occupational therapy (OT) initial evaluation. The initial evaluation documents standardized instruments of Hawaii Early Learning Profile 2nd ed. (HELP-2) with decreased attention and minimal deficit in fine motor skills. 

At issue is the medical necessity of occupational therapy services. 

The requested occupational therapy health service is not medically necessary for this patient. 
The patient's therapy progress notes do not support medical necessity for the standards of practice for occupational therapy. OT is medically necessary when there is documentation that it is improving a patient's current condition, or preventing or slowing further deterioration of the patient's condition, or to help a person keep, learn or improve skills and functioning for daily living to maintain the patients current condition and all of the following elements of the plan are documented in the health care record: the services are considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition; the level of complexity or sophistication or the condition of the patient is such that the services required can be safely and effectively performed only by a qualified health care provider; and the services including amount, frequency and duration are reasonable under accepted standards of practice. 

No indication of interventions which can only be provided by a skilled therapist, no indication of progress towards goals, and no medically necessary goals are documented in the clinical information submitted nor is there any notation of activities which cannot be performed within the home exercise program environment. Transition to a home exercise program is appropriate when patients have reached a plateau or when the activities performed in therapy can be performed by non-skilled caregivers/parents who have received training by therapists which is the case for this patient. Skilled occupational therapy is not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Type 1 Diabetes Mellitus.

Treatment:  Durable medical equipment for a continuous glucose monitor (CGM) for type 1 diabetes mellitus.

The insurer denied coverage for durable medical equipment for a continuous glucose monitor for type 1 diabetes mellitus.  The denial is overturned.

The patient has a history of type 1 diabetes mellitus.

The coverage request is for continuous glucose monitor (CGM). The coverage was previously denied; this is an appeal initiated by the treating provider. The coverage was previously denied because the patient did not meet medical necessity criteria under health plan.

Per treating provider's appeal letter, the patient has type 1 diabetes with high autoantibodies and negative C-peptide with fasting glucoses. He is using blood sugar measurements to adjust prandial insulin 4 times daily. The Dexcom CGM will also be used to integrate with the pump. Per office note, the patient is on multiple daily insulin and is now using carbohydrate and correction boluses with his 4 times daily insulin. He is checking blood sugars 4-6 times daily. His A1c (glycated hemoglobin) is 8.7. His C peptide was <0.1.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. Continuous glucose monitor is medically necessary for this patient with type 1 diabetes. This patient has failed 4 times daily glucose monitoring. The patient has multiple daily insulin injections with adjustments with uncontrolled blood sugars. He would benefit from CGM use. The national guidelines generally recommend CGM use in type 1 diabetes and consider its use as clinically effective and safe. Therefore, the request for continuous glucose monitor is medically necessary for this patient with type 1 diabetes.

AACE [American Association of Clinical Endocrinologists] in its comprehensive diabetes care guideline (Handelsman et al.) states that CGM may be considered for patients with type 1 diabetes and type 2 diabetes on basal-bolus therapy to improve A1c levels and reduce hypoglycemia. The Endocrine society in their statement paper (Peters et al.) stated that CGM has in multiple trials shown to result in improved glycemic control and decreased hypoglycemia in type 1 diabetic patients, however does note that the greatest benefits are seen in those who wear the devices more frequently to maximize benefit. Similarly, the ADA [American Diabetic Association] standards of care notes that when used properly, CGM with intensive insulin regimens is a useful tool to lower A1C in adults with type 1 diabetes who are not meeting glycemic targets, those diabetes patients with hypoglycemia unawareness and/or frequent hypoglycemic episodes. 

The insurer's denial of coverage for the durable medical equipment for a continuous glucose monitor for type 1 diabetes mellitus is overturned.  Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: osteoid osteoma of the left tibia
Treatment: Radiofrequency Ablation

The insurer denied radiofrequency ablation. 
The health plan's determination is overturned. 

The patient is a male with a history of chronic recurrent multifocal osteomyelitis (CRMO) and osteoid osteoma of the left tibia. He has pain and a limb length discrepancy due to this lesion that has affected his ability to walk. He has had prior surgical treatments to include curettage and packing and epiphysiodesis hardware. His most recent imaging showed a calcified nidus in the mid tibia with diffuse periosteal reaction and bowing of the tibia. He has issues with left tibia values and procurvatum deformity that is worsening. 

The radiofrequency ablation is medically necessary for this patient. This recommended Radiofrequency Ablation treatment is considered standard of care in the field. There are no other reasonable treatment options for this young child at this time that would be expected to result in relief in pain, improvement in growth concerns, and limited long-term toxicity. Therefore, based on the clinical information provided for review, the current peer-reviewed medical literature and standards of care in the field, the Radiofrequency Ablation is medically necessary at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Radiation Therapy. 

The insurer has denied Proton Beam Therapy -Radiation Therapy for Head/Neck Cancer. 
The denial is overturned. 

This is a female patient, with a history of pT2N0M0 invasive ameloblastic carcinoma of her right maxillary sinus status/post (s/p) resection with a positive medial soft tissue margin. She has been recommended to proceed with a course of postoperative external beam radiotherapy with a curative intent.
At issue is the medical necessity of Proton Beam Therapy -Radiation Therapy for Head/Neck Cancer.

The health plan's determination of medical necessity is overturned in whole.

The requested health service/treatment of Proton Beam Therapy-Radiation Therapy for Head/Neck Cancer is medically necessary for this patient.
The requested proton radiation therapy is medically necessary in this patient's setting. The treating provider supplied a proton/photon plan comparison which shows that the photon-based intensity modulated radiation therapy (IMRT) plan is unable to adequately protect the patient's oral cavity and right parotid gland. If delivered, the photon based IMRT plan would lead to an unacceptable and unnecessary risk for xerostomia and swallowing dysfunction creating a risk for life-threatening aspiration. The proton radiation plan is able to significantly reduce the exposure to these surrounding critical normal tissues, thereby minimizing the patient's risk for serious toxicity. There are numerous high quality prospective clinical outcomes published in the medical literature that support the safety/efficacy of proton beam radiotherapy for management of the patient's head and neck malignancy. The American Society for Radiation Oncology (ASTRO) Model Policy for proton radiation supports its use in this patient's setting since she will be treated on a prospective registry trial and photon radiation cannot provide adequate safety and precision.
Therefore, the requested health service/treatment of Proton Beam Therapy-Radiation Therapy for Head/Neck Cancer is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar spinal stenosis with radiculopathy, osteoarthritis of knee, osteoporosis, and anxiety/depression.
Treatment: Increase Personal Care Services, Total of 84 Hours (12 Hours a Day, Seven Days a Week).

The insurer denied the Increase Personal Care Services.
The denial is overturned.

This female patient has conditions including lumbar spinal stenosis with radiculopathy, osteoarthritis of knee, osteoporosis, and anxiety/depression.  She is appealing denial of increase personal care services (PCS), total of 84 hours.  The health plan approved 42 hours.  

An appeal letter from Advocacy reports the patient has limitations that require 24 hours assistance.  The patient had multiple falls over the past six months, including a trip over her walker and fell.  Her family is ensuring 12 hours of personal care daily.  Her provider wrote a letter of medical necessity due to the patient's functional needs and falls occurring at night.  Her provider notes the patient has frequent falls when left alone.  A daily schedule shows the patient receives care 24 hours.  

A letter from the physician notes the patient lives in assisted living and needs 24 hour care due to functional limitations.  The letter notes the patient has many falls during the night.  

A Daily Schedule Log provided shows the patient receiving assistance approximately every one hour with transfers and activities of daily living (ADLs).

Yes, the proposed treatment, increase in Personal Care Services, Total of 84 Hours (12 Hours a Day, Seven Days a 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.  This patient has multiple chronic conditions.  She is appealing denial of increase in personal care services, total of 84 hours.  The health plan approved 42 hours.  Uniform assessment system (UAS) evaluation completed, shows the patient requires assistance with all activities of daily living, except personal hygiene, bed mobility, and eating.  She has bowel and bladder incontinence.  Appeal statements note the patient requires 24 hours assistance due to functional limitations.  There is a daily schedule that supports the patient receiving care during the day and nighttime to include assistance approximately hourly.  The approved personal care services 42 hours per week is inadequate to meet the patient's needs for assistance with activities of daily living (ADLs) and personal care.  The proposed increase in personal care services to total 84 hours per week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders 
Treatment: Pharmacy/Prescription Drugs - Siliq
The insurer denied Siliq. 
The denial is upheld in whole. 

The patient is a male with psoriasis. He has tried and failed acitretin, phototherapy, Humira, Enbrel, Taltz, Cosentyx, Skyrizi, Tremfya, and Otezla. He has also failed topical steroids including clobetasol ointment, clobetasol solution, and clobetasol cream. The medication recommended by his provider is Siliq.

At issue is the medical necessity of Siliq.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of Siliq is not medically necessary for this patient.

According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, a formulary medication such as ustekinumab (Stelara) is an effective treatment for the management of psoriasis. (1, 2) Within the peer-reviewed literature, Langley, et al writes "Treatment with ustekinumab for up to 5 years was safe and effective." (3) Stelara has been approved for the treatment of psoriasis for over a decade and has shown strong efficacy and a favorable safety profile. The evidence-based literature is consistent. The preferred agents, such as Stelara, are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to initiating Siliq. It is noted that the patient has tried and failed many therapies. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Siliq. Therefore, the requested health service/treatment of Siliq is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fever.
Treatment inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.

The patient has a past medical history significant for nephrolithiasis who presented to the emergency room with complaints of fevers and chills following a prostate biopsy.
Vitals on presentation included the following: Temperature 98.9, Blood Pressure 123/92, Pulse 96, Respiratory Rate 18, and oxygen (O2) was 97% (percent) on room air. Laboratory results showed: white blood cell count (WBC) 7 .7, hemoglobin (Hgb) 13.1, hematocrit (Hct) 40.2, creatinine-1.02, glucose 93. 

The patient was admitted for evaluation of fever. He was empirically started on intravenous antibiotics (initially meropenem then de-escalated to ceftriaxone). Urology was consulted and no surgical intervention was deemed necessary. Renal ultrasound showed no acute findings. Cultures remained negative. The patient remained afebrile, hemodynamically, and clinically stable. He was discharged to continue oral antibiotics as an outpatient management.   

According to medical records, the patient was admitted for fever following a recent diagnostic prostate biopsy for an elevated prostate specific antigen (PSA) level. Otherwise, on presentation, he was afebrile, hemodynamically stable and laboratory results were unremarkable including a normal WBC. Urology evaluated patient and deemed no surgical intervention was required. Based on above findings, patient met criteria for observation level of care. The patient did not meet criteria for acute inpatient hospitalization.    

Prior determination of denial of hospital admission is upheld. 

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

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

Diagnosis: Fever
Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.
The denial is overturned.

The patient is a male with benign past medical history who presented to the emergency room with complaints of a fever, myalgias, and headaches.  Vitals on presentation included: Temperature - 103.4 Fahrenheit, blood pressure (BP) - 115/72, Pulse - 96, respiratory rate (RR) - 18, Oxygen saturation (O2 sat) - 96% (percent) on room air (RA). Laboratory values were notable for the following: white blood count (WBC) - 3.2, hemoglobin (Hgb) - 14.7, hematocrit (Hct) - 41.4, sodium-131, creatinine-1.42, glucose - 208. Chest x-ray (CXR) - was negative for infiltrates.

The patient was empirically started on broad-spectrum intravenous antibiotics (Zosyn->ceftriaxone). He tested negative for COVID (coronavirus) and other respiratory viral panel. Computed tomography (CT) scan of abdomen/pelvis was negative. Head CT scan was also unremarkable. Neurology and Infectious Diseases consulted. Stool ova and parasite was positive for Blastocystis hominus. Otherwise, evaluation was negative. The patient remained afebrile and hemodynamically stable. He was discharged to continue outpatient management. 
     
According to medical records, the patient presented with fever of unclear etiology. Initial laboratory results showed multiple abnormalities including leukopenia (WBC-3.2), elevated creatinine (1.42), hyperglycemia, and low sodium (131). Based on above findings, there was sufficient concern for an acute infection. According to Centers for Medicare and Medicaid Services (CMS) definitions, sepsis is an infection or suspected infection with two or more Systemic inflammatory response syndrome (SIRS) criteria. The patient met SIRS criteria based on fever and leukopenia. Based on above findings, hospital admission was medically warranted. 

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

Based on the above, the medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.