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

Diagnosis: Right thumb laceration infection.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male. This patient sustained a laceration to his right thumb. The laceration was repaired but subsequently became infected. The patient presented to the hospital with a right thumb infection. Surgical incision and drainage were performed under local anesthesia. Incision and drainage of complex finger abscess and debridement of necrotic soft tissue were performed successfully. Cultures were obtained that showed GPC (gram-positive coccus) pairs, GNB (gram-negative bacilli), and gram-positive bacilli. Infectious diseases recommended broad coverage antibiotics. As per the Plastic Surgery consultation, the patient was to receive IV (intravenous) antibiotics, with soaking of thumb in peroxide/saline/betadine solution. The neurovascular function was closely monitored. The patient received Zosyn 3.375 mg (milligrams) IV (intravenous) every 8 hours and Vancomycin 1G (gram) IV (intravenous) every 12 hours. The pain was managed with acetaminophen 975mg (milligrams) PO (by mouth) every 6 hours as needed for mild pain, and acetaminophen/oxycodone 325mg (milligram)-5mg (milligram) PO (by mouth) every 6 hours for moderate pain. Further lab studies showed normalization of WBC (white blood count) and low Vancomycin levels. Vancomycin dose was increased to 1250mg (milligrams) IV (intravenous) from 1000mg (milligrams) IV (intravenous). The patient reported improvement in pain, swelling, and mobility of fingers. Antibiotics were transitioned to Augmentin 875mg (milligrams) PO (by mouth) twice daily and Doxycycline 100mg (milligrams) twice daily for a total of 10 days.

As per Hand Surgery, the patient's wound was healthy, with subcutaneous tissue showing healthy granulation tissue at the base. The patient will eventually need wound coverage surgery with an FDMA (first dorsal metatarsal artery) flap and skin grafting from the forearm to the donor site of the flap on the index finger. Skin grafting was to be performed as an outpatient. Following medical optimization, the patient was deemed medically stable for discharge to home.

The inpatient admission was not medically necessary.
According to MCG (Milliman Care Guidelines) General Admission Criteria: "General Criteria: Observation Care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically it is 48 hours or less, but can be up to 72 hours in certain situations."

This patient was medically stable and needed only additional analgesic medication. He could have been safely managed at a lower level of care. This patient received surgical drainage, pain medication, and IV (intravenous) antibiotics. He responded to the treatment and was discharged home within 72 hours. He could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: including hypertension, coronary artery disease, arthritis and Alzheimer's disease.

Treatment: PCA (personal care aide) level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week.

The insurer denied coverage for PCA level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week.

The denial is modified.

This is a patient with chronic medical problems including hypertension, coronary artery disease, arthritis, and Alzheimer's disease.  She was recently hospitalized on 2 occasions due to falls; one episode resulted in a femur fracture.  The patient is currently in a skilled nursing facility for short-term rehabilitation services.  According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "severely impaired."  She requires maximal assistance for bathing, dressing, locomotion, eating, and toilet transfers/use.  She is occasionally incontinent of bowel and bladder.  Extensive assistance is needed for bed mobility and ambulation.  The patient's functional ability has declined since the UAS report, essentially for every aspect of her activities of daily living. However, the enclosed physical and occupational therapy notes from the skilled nursing facility demonstrate modest functional improvement.    

The patient's severe cognitive deficits and functional impairments support the medical necessity for increasing the PCA services to 12 hours/day, 7 days/week totaling 84 hours.  Her condition and functional needs are not at a level or unpredictable as to require the requested PCA level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week.  This physician would agree the patient may require 24-hour monitoring.  However, safety monitoring (e.g., for dementia) under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by increasing the PCA services to 12 hours/day, 7 days/week totaling 84 hours.  

From a physical medicine and rehabilitation perspective, the requested PCA level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week, is not medically necessary.  However, increasing the PCA services to 12 hours/day, 7 days/week totaling 84 hours is medically necessary.

Based on the above, the insurer's denial must be modified.   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 aide (PCA) Level 2: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week services are not substantiated. However, increasing the PCA services to 12 hours/day, 7 days/week totaling 84 hours is medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Coronary heart disease, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia.

Treatment: personal care aide (PCA) level 2: 6 hours per day - 7 days per week - for a total of 42 hours per week.

The insurer denied coverage for personal care aide (PCA) level 2: 6 hours per day - 7 days per week - for a total of 42 hours per week.

The denial is modified.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "modified independent."  She requires extensive assistance for bathing, lower body dressing, bed mobility, and toilet transfers.  Limited assistance is needed for toilet use.  She is frequently incontinent in her bladder and continent of the bowel.  She is independent with personal hygiene, upper body dressing, and eating.  She requires supervision for ambulation.  According to her treating nurse practitioner's note, she has normal lower extremity strength, and her gait was documented as normal.  

The combination of the patient's medical condition and functional impairments support the medical necessity of the Personal Care Aide Services of 5 hours/day, 7 days/week for a total of 35 hours/week; allowing the ability to continue living safely and independently at home.  The requested personal care aide (PCA) Level 2: 6 hours/day - 7 days/week - for a total of 42 hours/week is not medically necessary.  

From a physical medicine and rehabilitation perspective, PCA level 2: 6 hours/day - 7 days/week - for a total of 42 hours/week is not medically necessary.  However, PCA level 2: 5 hours/day - 7 days/week - for a total of 35 hours/week is medically necessary.  

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 personal care aide (PCA) Level 2: 6 hours per day - 7 days per week - for a total of 42 hours per week is modified. Medical Necessity for Personal Care Aide Services of 5 hours/day, 7 days/week for a total of 35 hours/week is substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Genetic Testing. 
The insurer denied molecular profiling testing. 
The health plan's determination is overturned. 

The patient is a woman diagnosed with low risk myelodysplastic syndrome (MDS). The bone marrow showed single lineage dysplasia with ring sideroblasts. The Panel Test of Genes: Molecular Profiling Testing was ordered and is under review. 

The molecular profiling testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The use of molecular profiling in cases of MDS assists in the proper diagnosis of the particular subset of MDS categories. Such molecular markers assign prognostic value for overall survival and risk of transformation to AML (Acute myeloid leukemia). Such information may also aid clinicians in the selection of various treatment modalities depending on specific markers. The use of this testing in this case was indicated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Genetic testing. 
The insurer denied molecular profiling testing. 
The health plan's determination is overturned. 

The case involves a female, previously diagnosed with left breast cancer, treated with lumpectomy followed by adjuvant chemotherapy and radiation. Recently, the patient was noted to exhibit leukopenia and anemia. The patient underwent a bone marrow biopsy and aspiration which revealed myelodysplastic syndrome with ring sideroblasts with single lineage dysplasia. As part of the patient's evaluation, molecular profiling was performed. 

The proposed molecular profiling testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 
The testing was performed to risk stratify and offer prognostic insight into the patient's myelodysplastic syndrome (MDS) and is generally considered part of a standard of care evaluation. The National Cancer Care Network (NCCN) endorses such testing to assist in distinguishing MDS from other marrow disorders such as chronic myelomonocytic leukemia or MDS/MPN (myelodysplastic/myeloproliferative neoplasms) overlap syndromes which may have therapeutic implications. In addition, the detection of the SF3B1 mutation, as was noted here, would potentially offer a patient a treatment option with luspatercept, which is Food and Drug Administration (FDA) approved for patients with MDS with ringed sideroblasts and a SF3B1 mutation. In addition, the presence of particular mutations may potentially influence a decision for allogeneic stem cell transplant in a patient with high risk mutations.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Cancer. 
Treatment: Genetic testing. 
The insurer denied molecular profiling testing. 
The health plan's determination is upheld. 

This is a female with myelodysplasia with ring sideroblasts with single lineage dysplasia. The patient has low risk disease. Next generation sequencing (NGS) was sent on the diagnostic bone marrow examination with reported SF3B1 (Splicing Factor 3b Subunit 1) and PDGFRA (platelet-derived growth factor receptor A) mutations. Erythropoietin stimulating agent therapy was recommended followed by luspatercept at prorgression or lack of response. 

The requested testing is not likely to be more beneficial than standard treatment for this patient. 

This patient had a bone marrow examination, which revealed the diagnosis of myelodysplasia. A NGS panel was obtained on the biopsy. This patient subsequently went for a second opinion (without a change in clinical or laboratory status) and a peripheral blood NGS panel was requested. Data demonstrating a benefit to peripheral blood testing in this clinical scenario is scant. Sequential testing is not recommended by the National Comprehensive Cancer Network (NCCN), the authors of UpToDate, nor by the peer-reviewed literature as this approach has not been demonstrated to improve outcomes. Given the lack of change in the patient's status, its not clear that any additional information could be gleaned from this test that would improve the patient's outcomes or alter treatment recommendations.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: General debility and weakness post sepsis. 
Treatment: Continued Stay in Skilled Nursing Facility. 

The insurer denied: Continued Stay in Skilled Nursing Facility. 
The denial is upheld. 

The patient is an adult male with general debility and weakness after he developed sepsis secondary to bilateral lower extremity cellulitis and chronic venous insufficiency. The patient's relevant past medical history includes Diabetes Mellitus, Asthma, COPD (chronic obstructive pulmonary disease), Hypertension, Hyperlipidemia, CHF (congestive heart failure), Depression, hyperthyroidism, lymphedema, OSA (obstructive sleep apnea), pressure ulcers, et cetera. 

Prior to admission, the patient lived with his partner in a 15th floor apartment building with elevator access and two to three steps to enter with right hand rail and a ramp at the back of the building. He was able to perform ADLs (activities of daily living) independently. He had a rolling walker, cane and shower chair and was only able to walk 200 feet. 
The plan is to discharge the patient to live with family members. 
The patient was admitted to SNF (skilled nursing facility) on as total dependence. He remained total dependence for most ADLs (activities of daily living). He has not shown tangible improvement in rehabilitation since admission. The goals set in rehabilitation is towards maximum assistance from total dependence. 

The continued stay in Skilled Nursing Facility was not medically necessary. 
The patient was admitted to SNF (skilled nursing facility) as total dependence. He remained total dependence for most ADLs (activities of daily living). He has not shown tangible improvement in rehabilitation since admission. The goals set in rehabilitation is towards maximum assistance from total dependence. 

Therefore, given the above, the continued stay in SNF (skilled nursing facility) was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Vomiting (gastroparesis). 
Treatment: Inpatient admission. 

The insurer denied: Inpatient admission. 
The denial is partially overturned. 

The patient is an adult female with gastroparesis. She presented an eight-day history of intractable nausea / vomiting and diarrhea. The patient was seen at an outside hospital three times before admission. Her husband had a viral gastroenteritis.
The patient was treated with IVF (intravenous fluids), antiemetics, and IV (intravenous) morphine for abdominal pain, but this was discontinued as she was also having constipation issues. GI (gastroenterology) was consulted and agreed with conservative management. 
The next day, the patient was sipping some clear liquids. She did not have any significant pain. She vomited the previous day. 
The following day, the patient was on clear liquids and the diet was advanced slowly to low fat as tolerated. She tolerated crackers and toast in the morning. 
On day three, the patient was restarted on IV (intravenous) morphine, Compazine IV (intravenous), Ativan IV (intravenous) with a very good response. 
On day four of the admission, the patient was able to tolerate her diet and requested to be discharged home. 

The inpatient admission was medically necessary, in part. 
An inpatient admission was medically necessary for the day of admission and the next day, with discharge on the day after. The inpatient admission was not medically necessary from that day and forward. 

The initial inpatient admission was medically necessary for slow advancement of diet, administration of IV (intravenous) fluids, and control of pain. The second day of admission, the patient was on clear liquids and the diet was advanced slowly to low fat as tolerated. She tolerated crackers and toast in the morning. 

The patient could have discharged at that time as the patient was tolerating a diet. The medical records do not support that the acute inpatient admission was medically necessary from that day and beyond. The patient did not require services of such intensity that could have been safely and effectively provided only on an inpatient level of service. The health, safety, and medical condition of the patient would not have been threatened by providing the care given in a lower level of care setting. 

The patient did not require any procedural or surgical intervention, did not require to be nothing by mouth, did not have acute kidney injury, did not have electrolyte derangement needing intravenous replacement, did not have fevers, did not have an elevated white count, and did not have any complications such as intra-abdominal abscess or a surgical abdomen.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malignant neoplasm of bone and articular cartilage, unspecified
Treatment: Increase Personal Care Aide (PCA) Services for A Total of 168 Hours/Week (Split Shift)
The insurer denied an increase in PCA services for a total of 168 hours/week (split shift).
The denial is overturned.

The patient is an elderly female. The request is for additional personal care aid (PCA) hours, as the patient's daughter reports that the patient is often found soiled in the morning and that the patient needs more assistance with toileting during the evening.

Per the Uniform Assessment System (UAS), the patient lives alone in a two bedroom apartment on the second floor of an elevator-accessible apartment building.

The patient's cognitive skills for daily decision making are minimally impaired. The patient has age-related cognitive decline. The patient had blurred vision due to cataract and wears reading glasses when needed. The patient is maximal assistance for meal preparation. She is total dependence for ordinary homework. She is maximal assistance in shopping and activities of daily living (ADLs). She is total dependence in toilet use and excessive assistance in bed mobility. The patient needs significant weight bearing assistance with dressing lower body. The patient needs a caregiver to hold her armpits when getting on and off from toilet use. The patient is frequently incontinent of bladder and bowel. She cannot make it to the toilet in time. There has been significant change in status reassessment, and she has decline in the last 90 days.

The increase in PCA services for a total of 168 hours/week (split shift) is medically necessary.

The patient is frequently incontinent of bladder and bowel. She cannot make it to the toilet in time. There is significant change in status on reassessment, and she has declined in the last 90 days.

The patient has been having diarrhea and cannot make it to the bathroom. She is having bladder and bowel incontinence. The patient lives alone and is maximum dependence with ADLs and mobility. The request for 24/7 assistance is appropriate for this patient.

The patient has bladder and bowel incontinence. She will need help to be cleaned or use the bathroom. She cannot change independently, and if help is not available, the patient will not be able to be cleaned, which would result in increased risk of infection. The health plan's currently approved regimen of 84 hours/week is inadequate to meet this patient's needs for her ADLs and IADLs (instrumental activities of daily living).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Peripheral vascular disease
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult female with a history of peripheral vascular disease (PVD). She had left subclavian steal syndrome with a subclavian stent in 2006. The patient had multiple strokes. There was bilateral upper arm claudication and subclavian steal. Ultrasound demonstrated a short occlusion of the left subclavian artery and reversal of vertebral flow. The patient was admitted electively for, and underwent, a percutaneous intervention.

The proposed treatment was not medically necessary.
This patient had subclavian steal syndrome. There was no acute coronary syndrome, acute neurologic syndrome, severe procedure related complication, need for emergent repeat surgery, need for ongoing/prolonged and-hospital medications, or administration of prolonged medications requiring ongoing and-hospital monitoring. This setting - inpatient, compared to outpatient, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heavy irregular bleeding. 
Treatment: Oriahnn 300-1-0.5 and 300 mg (milligrams) OR (oral route). 

The insurer denied coverage for Oriahnn 300-1-0.5 and 300 mg OR (oral route).

The denial is overturned. 

The patient is a female with complaint of heavy irregular bleeding. She has tried oral contraceptives and Depo-Provera for months with no control of her bleeding. She had an endometrial biopsy that showed proliferative changes. Ultrasound showed multiple myomas both intramural and submucosal as well as thickened endometrial lining. 

The provider recommended Oriahnn and tranexamic acid. 

This patient is having heavy abnormal bleeding probably due to fibroids. There are multiple treatment options for this patient. The patient can be treated with surgery, a gonadotropin releasing hormone (GnRH) agonist like Depot Lupron Tranexamic acid, endometrial ablation or a GnRH agonist like Oriahnn. 

Oriahnn is a combination of elagolix, a GnRH receptor antagonist, estradiol, an estrogen, and norethindrone acetate, a progestin, indicated for the management of heavy menstrual bleeding associated with uterine leiomyomas (fibroids) in premenopausal women. 

This patient is premenopausal, and has heavy vaginal bleeding associated with her fibroids. Oriahnn is indicated and approved for her condition. 

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 the Oriahnn 300-1-0.5 and 300 mg OR is overturned. Medical Necessity is substantiated.