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

Diagnosis: left ankle wound
Treatment: inpatient stay
The insurer denied an inpatient stay
The health plan's determination is overturned. 

This case involves a woman with hypertension and chronic kidney disease admitted to the hospital with a left ankle wound. She got caught in a barbed wire and developed purulent drainage from the puncture site. She was seen in the walk-in clinic and started on clindamycin. X-ray was fairly unremarkable. She took antibiotics for eight days, with improved drainage; however, she started to develop blisters on the posterior heel. 

Based on the provided documentation, the inpatient hospital admission is medically necessary. This presentation qualified for inpatient admission based on a failure of outpatient therapy. The patient was on an appropriate antibiotic regimen, with clindamycin, providing Staphylococcus and Streptococcus coverage. The patient had a puncture wound, which developed into an abscess that required incision and drainage. The foot, which is a tight compartment space, was involved, with a significant possibility of neurovascular compromise. Fortunately, there was no evidence of osteomyelitis. The patient received appropriate broad-spectrum antibiotic therapy while awaiting culture results. This treatment could not have been accomplished in a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is a school age male with epilepsy and obstructive hydrocephalus status post VP (Ventriculo-Peritoneal) shunt. He presented to the Emergency Department brought in by ambulance for emergency evaluation of seizure. The patient was found by EMG (electromyogram) to be actively seizing, duration 15 minutes. He was given Versed, which stopped the seizure. On arrival to the emergency department, he was determined to be no longer seizing and determined to be post ictal. His primary neurologist was called but could not be reached. The on-call neurologist was consulted and recommended increase lacosamide dose to 30 milligrams twice daily. The patient's seizure frequency is one every two to three months. His last seizure had been three months prior to presentation. No missed medication dose was noted. No sick symptoms were noted.
The request for coverage of hospital admission was denied coverage by the health plan as not medically necessary. The denial of coverage is being appealed based on the patient requiring acute inpatient care for management of seizure. The hospital states that the patient required very close inpatient monitoring and a timely work up. The appeal states that inpatient setting was necessary to formulate a more viable follow-up treatment plan and prevent mortality and morbidity.

The inpatient admission was not medically necessary.

On review of the clinical documentation, the patient presented to the emergency department seizing. The ED (emergency department) provider note states that the patient was found by EMS (emergency medical services) and was given Versed (midazolam), which halted the seizure. Since then, the patient was sleeping. His examination was notable for normal vital signs. He was found to be drowsy but responsive. The ED (emergency department) physician attempted to reach the patient's primary neurologist but was unsuccessful. The on-call neurologist recommended continue home medication Keppra 700 milligrams twice daily and increase lacosamide to 30 milligrams twice daily. The emergency department physician impression was that the patient was post ictal. There is no documentation that there was concern for ongoing seizures or unexplained alteration of mental status that would necessitate inpatient admission. Given the above, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: cervical radicular pain

Treatment: computed tomography (CT) of the cervical spine without contrast

The insurer denied coverage for computed tomography (CT) of the cervical spine without contrast

The denial is overturned
 

This adult female has lumbar radicular pain that is controlled by bilateral Dorsal Root Ganglion stimulators (DRGS). The patient now has cervical radicular symptoms, and a cervical computed tomography (CT) scan has been requested.   The Health Plan wants her to get a Magnetic resonance imaging (MRI).

The patient CANNOT have an MRI because she has an implanted neurostimulation system.

Ghadimi and Sapra (1) noted this as an "Absolute contraindications:

.	Implantable neurostimulation systems

The Food and Drug Administration (FDA) (2) has published a notice of risks involving MRI:
.	"The radiofrequency energy and magnetic fields that change with time may cause heating of the implanted medical device and the surrounding tissue, which could lead to burns.
.	The magnetic fields and radiofrequency energy produced by an MRI scanner may also cause electrically active medical devices to malfunction, which can result in a failure of the device to deliver the intended therapy.
.	The presence of the medical device will degrade the quality of the MR image, which may make the MRI scan uninformative or may lead to an inaccurate clinical diagnosis, potentially resulting in inappropriate medical treatment."

Therefore, patients with implanted medical devices should not receive an MRI exam unless the implanted medical device has been positively identified as MRI Safe or MRI Conditional.

A CT scan is medically reasonable and 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 computed tomography (CT) of the cervical spine without contrast is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: substance abuse
Treatment: inpatient stay
the insurer denied the inpatient stay
The health plan's determination is overturned. 

The patient is an adult male who presented for detoxification and substance-related services. The patient has a history of severe substance use disorders with alcohol, opioid (heroin), stimulants (cocaine), and cannabis (marijuana) class substances of abuse, as well as misuse of Klonopin in the context of an anxiety disorder. He has a history of multiple detoxification treatment episodes with recent relapse. He was using one six-pack of beer on a continuous daily basis together with up to one bundle of heroin, one blunt of marijuana, and $80 worth of cocaine daily.

Inpatient Substance Use Detoxification (3 Days) was medically necessary for this patient.
The Inpatient detoxification treatment and withdrawal management and monitoring and other medical services could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using large quantities of alcohol and heroin on a daily continuous basis together with use of cocaine and cannabis that did warrant the admission and the continued inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode could not have been safely or effectively provided at a lower level of care following the comprehensive assessment that was provided at the time of admission. Moreover, the patient's social environment was not conducive to an effective detoxification, and the patient had struggled with withdrawal symptoms which were being effectively addressed with Librium and methadone protocols and supportive measures. The patient had associated clinical features that included lack of sober supports and limited insight, impaired judgment, and poor control of impulses. Thus, the continued structure of an inpatient level setting with withdrawal management and psychosocial supports, and 24-hour monitoring was medically necessary. The patient's history of substance abuse (frequency and quantity) together with the severe psychosocial stressors and functional impairments do reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management as the patient was at high risk for treatment failure or general medical complications such as seizures if detoxification and withdrawal management were to be attempted at a lower level of care. Therefore, medical necessity is met in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: speech hesitancy and hallucinations
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This is a case of a male admitted for diagnosis of speech hesitancy and hallucinations. The patient had a history of depression, anxiety and stress induced hallucinations. Symptoms have been present for a week prior to admission. Vital signs demonstrated blood pressure 118/87, temperature 37.3C, pulse 104, respiratory rate 16 and O2 (oxygen) saturation 98%. Physical exam showed no acute distress. There was no altered mental status. There was no dysarthria. Cranial nerves were intact. Bicarb was 21 and creatinine was 0.87. Calcium was 9.0. A computed tomography (CT) of the head showed no acute infarct, hemorrhage or mass. He was thought to have a psychiatric disorder such as mania or psychosis. 

The inpatient admission was not medically necessary. 
According to the documentation submitted, the patient had hallucinations and difficulty with word finding but did not have abnormal behavior or severe altered mental status from a life-threatening cause such as intracerebral hemorrhage, mass lesion, poisoning, infection, seizure or a metabolic/endocrine abnormality requiring treatment with dextrose, thiamine or hormone replacement. He was thought to have bipolar disorder or schizoaffective disorder after evaluation by psychiatry. He was treated with mood stabilizers and gabapentin. There was no hemodynamic instability or hypoxia.
Although the patient required services in the hospital setting the monitoring, diagnostics testing and therapeutic interventions prescribed could have been rendered at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stroke

Treatment: Initiation of personal care assistance (PCA) services

The insurer denied coverage for initiation of personal care assistance (PCA) services

The denial is upheld 

This is a patient with chronic medical problems including stroke, hypertension and depression.  The patient lives with their son in a private residence.  The insurer denied coverage for initiation of personal care assistance (PCA) services, as not medically necessary leading to an external review.  

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as independent.  The patient's ability to perform Instrumental Activities of Daily Living (IADL) tasks ranges from independent (meal preparation) to maximal assistance (ordinary housework).  However, most of the patient's IADL tasks are independent.  The patient is also independent with activities of daily living(ADLs) including bathing, personal hygiene, dressing, eating, bed mobility, toilet transfer/use, locomotion and ambulation (uses a walker outdoors), with no reported falls over the prior 90 days.  The patient is also continent of bladder and bowel.  

Based on the case notes, the patient does not have functional needs at a level or unpredictable as to require PCA services.  The letter from the patient's treating physician describing the patient's clinical condition and "would benefit tremendously from a home health aide" was reviewed.  However, the provider does not include the associated treatment notes to support their claim of the patient's reported limited functional capacity, particularly given the patient's independence with ADLs.  There are also shared household responsibilities with the other adult living in the home.  

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 initiation of personal care assistance (PCA) services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hidradenitis Suppurativa

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld 

The patient has a past medical history significant for hidradenitis suppurativa related infections to the axilla, inguinal, and gluteal regions who presented to the emergency room with complaints of pain and swelling over the sacral area with drainage.

Vitals on presentation included: temperature (T) 97.9 Fahrenheit (F), blood pressure (BP) 132/82, pulse (P) 107, respiratory rate (RR) 18, oxygen (O2) saturation 99% on room air (RA). Laboratory results included the following: white blood cell (WBC) 6.9, hemoglobin (HGB) 10.1, hematocrit (Hct) 32.8, creatinine 0.74, and glucose 88.

The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn) for chronic abscesses related hidradenitis. A computed tomography (CT) scan of the abdomen/pelvis showed multiple collections in the sacral region and right gluteal muscle. Surgery was consulted and recommended no surgical intervention since there was "no signs of overlying skin infection with erythema or induration and collections communicated with sinus tracts." Infectious Diseases recommended a prolonged course of oral antibiotics. The patient remained afebrile, clinically, and hemodynamically stable. The patient was discharged to continue outpatient management.   

According to documentation, the patient presented with a chronic hidradenitis to their sacral area. Otherwise, the patient was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. The patient had no evidence of a disseminated infection and no surgical intervention was required. Based on the above, the patient met criteria for observation level of management.      
  
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 hospital inpatient services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week 
The health plan's determination is overturned. 

This is a female patient with a history of dementia, back pain due to spinal stenosis, urinary incontinence, hypertension, gastroesophageal reflux disease, hypothyroidism, hyperlipidemia, vitamin B12 deficiency, anemia, depression, stage 3 chronic kidney disease, and secondary hypoparathyroidism. She currently resides at a nursing home and wishes to return home. 

Personal Care Services (PCS): 12 Hours per Day, 7 Days per Week - Total of 84 Hours per Week are medically necessary for this patient.
There is documentation in the Uniform Assessment System (UAS) of the patient requiring at least extensive assistance with the task of toilet use. More recent documentation from her nursing indicates she requires extensive assistance with walking, locomotion, transferring, and toilet use. Therefore, the patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. A tasking tool should not have been used to calculate hours given the patient's assistance with unscheduled and unpredictable care needs. There is documentation from the patient's PCP (primary care provider) of medical necessity of increased PCS. The patient does not have informal support for the entire time outside of the previously assigned PCS hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The requested increase in PCS is not solely for safety and supervision but to assist the patient with activities of daily living (ADL).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Thyroiditis
Treatment: Wig
The insurer denied the wig.
The determination is overturned. 

The patient is a female with a thyroid problem (thyroiditis). The patient has alopecia secondary to her thyroiditis. Her hair line has been receding due to the thyroiditis. She is requesting a wig.
At issue is the medical necessity of the wig.

The requested health service/treatment of wig is medically necessary for this patient.
The patient has hair loss due to thyroiditis, which is considered a natural cause (1-3) of hair loss. Therefore, the wig is considered a covered benefit and medically necessary. According to the policy, coverage for a wig is provided for "members who have hair loss due to natural causes or because of therapy with certain types of cytotoxic agents in cancer treatments." This criterion is met, as the patient has hair loss due to natural causes (thyroiditis). Therefore, the wig should be covered under the terms of the plan and is considered medically necessary as the patient's hair loss is from a natural cause.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: Inpatient Hospital Stay.
The insurer denied Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a past medical history significant for hypertension, hyperlipidemia, active smoking, coronary artery disease, prior myocardial infarction (MI), heart failure with recovered left ventricular ejection fraction, prior percutaneous coronary intervention (PCI), heart block status post permanent pacemaker implantation, who underwent elective percutaneous coronary intervention (PCI) via radial approach of right coronary artery (RCA)in-stent restenosis (ISR) chronic total occlusion (CTO). Percutaneous coronary intervention (PCI) was successful and 1 drug-eluting stent was placed to distal RCA. The patient tolerated the procedure well and there were no procedural complications. The patient was admitted to telemetry service for overnight monitoring. He was treated with dual antiplatelet therapy (DAPT) and received intravenous (IV) fluids per hydration protocol. He remained hemodynamically stable and was discharged home the following day. At issue is the medical necessity of an inpatient stay.
Inpatient admission for elective PCI in this case was not medically necessary. The patient presented for elective PCI of ISR RCA CTO. The procedure was successful and there were no complications. The patient remained hemodynamically stable and asymptomatic. The patient was admitted for overnight monitoring then discharged home the following day. For these reasons, inpatient level of care was not medically necessary. Rather, the patient could have been monitored overnight post PCI under outpatient status supported by the length of stay guidelines following percutaneous coronary intervention from the society for cardiovascular angiography and interventions (1).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia
Treatment: home health care
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 56 Hours per Week
The health plan's determination is overturned.

The patient is a female with past medical history of dementia, hypertension, anxiety, depression, diabetes mellitus type 2, hyperlipidemia, gastroesophageal reflux disease (GERD), vitamin D deficiency, hallucinations, bladder incontinence, and bowel incontinence who had been assigned PCA (personal care assistant) services based on a video assessment that assessed the patient at total assistance with tasks of meal preparation, managing finances, and shopping while maximum assistance with tasks of ordinary housework and managing medication. With tasks of stairs and dressing lower body the patient was assessed at extensive assistance while limited assistance with tasks of phone use and dressing upper body. The patient was assessed at supervision with tasks of bathing, personal hygiene, and transfer toilet while independent with tasks of walking, locomotion, toilet use, bed mobility, and eating. 

Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 56 Hours per Week is medically necessary for this patient.
There is documentation from the patient's medical providers of medical necessity of increased services. The patient's family is unable to provide support outside of the currently assigned hours of 35 hours/week. The patient's recent assessment documented an increase in assistance needs with tasks of ordinary housework, managing medication, phone use, bathing, personal hygiene, walking, locomotion, transfer toilet, and toilet use. The patient requires at least extensive assistance with walking, locomotion, transfer toilet, and toilet use. The patient therefore has unpredictable and unscheduled care needs that span a continuum of time and the insurer failed to document a plan to meet these unpredictable and unscheduled care needs when the patient does not have informal support. The plan incorrectly noted the patient had no bowel incontinence. Daytime care logs documented assistance needs at least every hour and a half. The requested increase in services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). The requested increase in services cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Pain.
Treatment: Hysingla ER (extended release).

The insurer denied: Hysingla ER.  The denial is upheld.

The patient is an adult male with chronic pain who was prescribed extended-release hydrocodone (Hysingla). This was denied, as the patient has not failed 3 formulary alternatives, which include hydrocodone extended release.

The health plan should not cover the proposed formulary exception.

The health plan should not cover the proposed treatment. While this is a continuation of therapy, the same medication in non-brand name (hydrocodone extended release) is a formulary alternative. There is no documentation to support superiority of the brand name version over the formulary allowed medication and is not likely to be superior or more beneficial or have more adverse effects. Given the above, the requested medication is not medically necessary.