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

Diagnosis:  Diabetes, hypertension, dementia, and coronary artery disease.
Treatment:  Increase Personal Care Aide (PCA) Services for a Total Amount of 84 Hours Per Week.

The insurer denied an Increase Personal Care Aide (PCA) Services for a Total Amount of 84 Hours Per Week.  The denial is overturned.

The patient is an elderly female. Her medical conditions include diabetes, hypertension, dementia, and coronary artery disease. Denial of increase personal care aide (PCA) services for a total amount of 84 hours per week is being appealed. The health plan approved PCA (personal care aide) 6 hours per day, 7 days per week for a total of 42 hours per week. The patient's Uniform Assessment System evaluation completed recently shows modified independent condition and functional status: total dependence with housework and shopping; maximal assistance with meal preparation, managing finances and medications, bathing, lower body dressing, walking, locomotion, and toilet transfer; extensive assistance with phone use, personal hygiene, upper body dressing, toilet use, and bed mobility; and independent with eating. Compared to UAS (Uniform Assessment System) evaluation completed last year, there has been no decline. She has bowel and bladder incontinence.

A letter from the patient's grandchild notes the patient is deteriorating, and she has progressive dementia. She has fluctuating blood pressure and blood sugar. She is a fall risk. She cannot perform ADLs (activities of daily living) without assistance. A statement from the patient's provider notes the patient has chronic medical conditions and progressive dementia. Her condition has deteriorated, and she needs supervision and care for the full day.

The requested Increase Personal Care Aide (PCA) Services for a Total Amount of 84 Hours Per 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 personal care aide (PCA) services for a total amount of 84 hours per week is being appealed. The health plan approved PCA (personal care aide) 6 hours per day, 7 days per week for a total of 42 hours per week.
The patient has multiple chronic conditions. Uniform Assessment System evaluation completed recently shows the patient requires assistance with all ADLs (activities of daily living), except eating. She has bowel and bladder incontinence. Appeal statements indicate that the patient's functional status has deteriorated, and her dementia has progressed. The information provided shows that this patient has significant limitations in functioning. The approved PCA (personal care aide) 42 hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living). The requested increase PCA (personal care aide) 84 hours week is medically necessary to meet the patient's needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes, breast cancer, major depressive disorder, chronic kidney disease, obesity, and obsessive-compulsive disorder.
Treatment: Personal Care Aide (PCA): 5 Days for 7 Hours for a Total of 35 Hours/Week
The insurer denied the PCA: 5 days for 7 hours for a total of 35 hours/week.
The denial is upheld.

This elderly female patient has medical conditions including diabetes, breast cancer, major depressive disorder, chronic kidney disease, obesity, and obsessive-compulsive disorder. She lives with her husband. She is appealing denial of increase in personal care aide (PCA) to 5 days for 7 hours for a total of 35 hours/week. The health plan approved PCA 4 days for 6 hours and 1 day for 5 hours for a total of 29 hours/week. The request was denied due to lack of changes that affect function of medical needs. Health plan evaluation performed earlier this year showed functional needs of total dependence with housework and stairs, maximal assistance with meals, shopping, transportation, and bathing; extensive assistance dressing; limited assistance with hygiene, walking, toileting, and locomotion; and independent with finances, medication, phone use, bed mobility and eating. The patient has limited mobility due to obesity. She has infrequent bladder incontinence.

The proposed treatment is not medically necessary.

Personal Care 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 medical conditions. She is appealing denial of increase in PCA to 5 days for 7 hours for a total of 35 hours/week. The 
health plan approved PCA 4 days for 6 hours and 1 day for 5 hours for a total of 29 hours/week. Health plan evaluation performed earlier this year showed the patient is independent with finances, medication, phone use, bed mobility, and eating. Otherwise, the patient requires assistance with ADLs. She has infrequent bladder incontinence. The documentation does not support a decline in the patient's functional status. The information provided does not support that the tasks needed cannot be completed with the approved PCA of 29 hours/week. The proposed increase in PCA to 35 hours/week is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Palpitations
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

This is a patient who presented to the emergency department (ED) complaining of palpitations, near syncope, and epigastric discomfort that occurred while walking. At the time of her presentation, she was wearing an ambulatory electrocardiographic monitor (AEM) as she had had similar symptoms before. Her medical history was remarkable for hypertension and anxiety. By report, she had an echocardiogram that was normal. In the ED, her blood pressure was 159/92 millimeters of mercury (mmHg) with a heart rate of 104 beats/minute. Her room air oxygen saturation was 98 percent (%). An electrocardiogram showed sinus rhythm with premature ventricular beats and a prolonged QT interval (the start of the Q wave to the end of the T wave). The ED physician was able to obtain tracings from the patient's AEM; these showed recurrent, self-terminating runs of ventricular tachycardia with rates from 150-170 beats/minute that lasted longer than 30 seconds. The patient was treated with intravenous amiodarone and admitted to the hospital with plans for transfer to another institution the following day for an electrophysiologic study and catheter ablation. Metoprolol was prescribed and she had no further ventricular tachycardia. She was transferred to the other hospital. The medical necessity for an inpatient hospital admission is at issue.

Yes, the inpatient hospital stay was medically necessary.

This patient presented to the hospital with near syncope due to recurrent runs of rapid sustained monomorphic ventricular tachycardia. The near syncope was an indication that the arrhythmia was associated with hemodynamic compromise. She required careful and continuous monitoring with the ability to intervene emergently, if needed. This warranted an inpatient hospital admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic urticaria
Treatment: Xolair
The insurer denied Xolair. 
The health plan's determination is upheld. 

The patient is a male with chronic urticaria. He has tried and failed fexofenadine tablets, roflumilast cream, and tacrolimus ointment. He has also failed prednisone and intermittent Benadryl. The medication under review is Omalizumab (Xolair).

Omalizumab (Xolair) is not medically necessary for this patient. The preferred agents are appropriate agents for the treatment of the patient's urticaria. These medications should be tried and failed prior to initiating Xolair.
It is noted that the patient has tried and failed fexofenadine. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Xolair prior to the alternatives such as a leukotriene receptor antagonist such as montelukast or zafirulakst.
Khan et al write in "Efficacy of Montelukast as Added Therapy in Patients with Chronic Idiopathic Urticaria" that "Almost half of our patients with chronic urticaria responded to montelukast and combined anti-H1 and anti-H2 therapy". Maurer et al writes "For the treatment of chronic urticaria, the new algorithm recommends a three-step process starting with a standard dose of a non-sedating H1 antihistamine. If there is an insufficient treatment response, the dosage should be increased up to four times. In, therapy refractory patients, ...montelukast are advised in the third step". Montelukast and other leukotriene receptor antagonists are effective for urticaria. They should be trialed prior to Xolair. Therefore, Xolair is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines. 
Treatment: Nurtec ODT. 

The insurer denied Nurtec ODT. 
The determination is upheld. 

This is a patient with migraines who was prescribed Nurtec oral dissolving tablet (ODT) for migraine prevention. The drug was denied because there was not documentation of migraine frequency. In a letter of appeal, her provider indicates that the patient has chronic migraine and experiences 15 days per month with "escalation to headache frequencies." At issue is the medical necessity of Nurtec ODT. 

Nurtec ODT is not medically necessary for migraine prevention. Nurtec ODT is only Food and Drug Administration (FDA) approved and literature supported for prevention of episodic migraine. 

The patient's provider indicated that the patient has chronic migraines. Episodic migraine is characterized by those with migraines who have 0 to 14 headache days per month, while chronic migraine is characterized by 15 or more headache days per month. The patient's provider indicated that the patient had 15 headache days per month, further confirming the diagnosis of chronic migraine. 

As such, Nurtec ODT is not supported as a migraine preventative agent for this patient based on available literature and the Food and Drug Administration (FDA) labeling and manufacturer's prescribing information.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Plaque psoriasis
Treatment: Sotyktu
The insurer denied Sotyktu.
The health plan's determination is upheld. 

The patient is a male with psoriasis. He has tried and failed Otezla, methotrexate, betmaethasone, and calcipotriene. The medication under review is Sotyktu.

A formulary exception is not indicated.

The formulary drug will not be and has not been ineffective. The formulary drugs would be as effective as the non-formulary drug, and would not have adverse effects.

According to the American Academy of Dermatology Psoriasis Guidelines and medical literature, the preferred medicines such as Skyrizi covered by the patient's insurance plan are effective treatments for the management of psoriasis.

Gu, et al writes "Risankizumab is a humanized immunoglobulin G (IgG) monoclonal antibody that binds to the p19 subunit of IL-23 (Interleukin-23) and inhibits its interaction with the IL-23 receptor. Clinical trials showed that risankizumab was significantly more effective than ustekinumab. Risankizumab was well tolerated." [2]

Reddy, et al writes "As the number of biologic agents used to treat psoriasis expands, newer medications provide promise of enhanced efficacy. In phase III trials conducted thus far, risankizumab has proven to be both efficacious and safe in the treatment of plaque psoriasis. By specifically targeting the IL-23 p19 subunit and thereby blocking the pathway, Risankizumab, when compared to other more non-specific agents, may have a lesser impact on normal immune function. The head-to-head phase III clinical trials discussed in this review have demonstrated that risankizumab is superior to ustekinumab and adalimumab in efficacy, including time to visible clinical improvement, and comparable in its safety profile." [3]

The evidence-based literature is consistent. The preferred agents are appropriate agents for the treatment of the patient's psoriasis. The formulary medications should be tried and failed prior to approving Sotyktu.

There is no documentation provided that would justify the patient requiring treatment with Sotyktu prior to the formulary alternatives such as Skyrizi.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vomiting/Diarrhea/Weakness.
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 with vomiting, diarrhea, and generalized weakness. Pertinent history included chronic diarrhea, outpatient twice weekly potassium and magnesium infusions, hypertension, lupus, fibromyalgia, and prior cerebrovascular accident (CVA).

Initial vital signs revealed a temperature of 37 Celsius (C), heart rate (HR) 109, blood pressure (BP) 151/93, respiratory rate (RR) 18. Initial examination documented the patient as alert and oriented. Initial laboratory testing revealed a white blood cell (WBC) 9.1, hemoglobin (Hgb) 9.7, platelets (Plt) 124, sodium (Na) 138, potassium (K) 2.5, magnesium (Mg) 1.1, creatinine (Cr) 0.65, glucose (Glu) 134. Electrocardiogram (EKG) did not reveal ischemic changes or other significant abnormalities. Potassium and magnesium were administered. The patient was admitted with an impression of intractable vomiting, hypokalemia, hypomagnesemia, and chronic diarrhea. Treatment plan included anti-emetics, intravenous fluids, and electrolyte replacement. Hemodynamics were stable. Emesis resolved and oral liquids were tolerated. Serum potassium increased to 3.3 and magnesium to 1.7. Computed tomography (CT) of the abdomen/pelvis was unremarkable for acute pathology. There was no significant change in treatment plan. Continued clinical improvement was noted. Hemodynamics were stable. Potassium was 3.8 and Mg was 1.6. Gastroenterology consulted and recommended alcohol abstinence and rifaximin for possible small intestine bacterial overgrowth. The patient was discharged. The subject under review is the medical necessity for the inpatient hospital admission.

The inpatient hospital admission was not medically necessary.
Based on the clinical documentation provided, evidence based literature and standards of care, acute inpatient level of care was not indicated as medically necessary for the entire admission. Evaluation and management could have been performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Ozempic
The insurer denied: Ozempic
The denial is: Overturned

The patient is a male who sought medical treatment for obesity. The request is for the prescription medication Ozempic 0.25-0.5 milligram (MG)/dose pen-injectors. The patient has comorbid health conditions of hypertension and supraventricular tachycardia. He is 74.5 inches tall and weighs 406 lbs. (body mass index [BMI] 51.4 kilograms per square meter [kg/m2]). The glycated hemoglobin (HbA1c) was 5.8% (normal 4-5.6).
The subject under review is the medical necessity for treatment with Ozempic.

Ozempic is medically necessary for this patient.
Semaglutide (Ozempic, Wegovy) is approved by the Food and Drug Administration (FDA) for the requested indication/diagnosis of obesity. In treatment trials, Ozempic was associated with weight loss.
Some glucagon-like peptide-1 (GLP-1) agonist medications (Ozempic, Wegovy, Saxenda) are proven effective medications that can be used as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adults with an initial BMI of 30 kg/m2 or greater or a BMI of 27 kg/m2 or greater in the presence of at least one weight related comorbid condition (hypertension, type 2 diabetes mellitus [DM], dyslipidemia, etc.). In this case the patient is morbidly obese with a BMI in excess of 50 kg/m2. There is documentation that he is actively participating with a reduced calorie diet and exercise program as described in the consultation. He is requesting health plan coverage for Ozempic which is FDA approved as primary treatment for weight loss. This treatment is medically necessary for this patient at this time. Semaglutide would be expected to be health beneficial for this patient in conjunction with a reduced calorie diet and exercise program based on evidence-based literature.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Open surgical wound site
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is overturned.

The patient is an adult male. He has a past medical history of spinal stenosis, hypertension, dyslipidemia, and lumbar fusion last year. He presented to the hospital with complaints of bleeding and drainage from the back surgical site with a fever up to 101 at home. The patient had been referred to the emergency room by his neurosurgeon for a similar problem but was discharged without surgical intervention. The wound had been present for a month and was treated with wet-to-dry dressings.
The patient's examination in the emergency room was notable for a dime-sized back wound, which had reduced in size over the prior month. The patient's labs were notable for an elevated CRP (C-reactive protein) of 61. WBC (white blood count) and procalcitonin levels were normal. A CT (computed tomography) scan showed fluid and edema at the L5 level. Vitals were unremarkable. The patient was admitted with neurosurgery and plastic surgery consultations. Plastics deferred interventions to interventional radiology.  On day number one, the patient underwent an IR (interventional radiology)-guided aspiration of lumbar fluid. Wound cultures were negative. On day number two, the patient received local wounds care and Tylenol for pain. He was discharged on the following day with follow-up with a plastic surgeon.

The Inpatient Hospital Admission was medically necessary.

The patient had been seen a month prior for a surgically related back wound. The wound worsened, with complaints of bleeding and non-healing. There was notable mention of fever at home. The patient went to the emergency room at the advice of his neurosurgeon. Inflammatory marker (C-reactive protein) was elevated. Although his temperature was normal during the course of stay, imaging indicated fluid in his low back with possible infection. The patient required an interventional procedure to evaluate for an infectious etiology. This was performed on the day after admission. Patient monitoring and evaluation for fluid culture required admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Oligodontia

Treatment: Dental implants teeth number 3 and 30

The insurer denied coverage for dental implants teeth number 3 and 30

The denial is overturned
 

Upon review of the submitted documentation including copy of pretreatment panoramic radiograph, undated post implant radiographs, narrative letter from the patient, narrative letter of medical necessity from the dentist, and insurer correspondence, it appears that this patient presented for dental evaluation. Oligodontia and a gag reflex was documented and therefore, it was recommended the aforementioned endosteal implants in lieu of removal prostheses. The insurer has denied these services as not medically necessary as the services recommended do not meet their medical necessity criteria as there are other methods of tooth replacement. The patient is appealing. 

Based on review of the documentation it appears that this patient is exhibiting oligodontia. In this case, a standard of care in dental practice would be the aforementioned recommended treatment. Peer reviewed literature supports implants in this clinical circumstance to restore function. Further, implants are covered services and this patient's clinical circumstance fulfills their medical necessity criteria. In addition, the insurer already approved implant for site number (#) 30 and it appears arbitrary to deny implant at the #3 site as this is also a covered and similar service. As this is the case and these (endosteal implants) are covered services, the implants and associated services are deemed medically necessary. 

Reverse denial and approve coverage for surgical placement of endosteal implant (D6010) as medically necessary as peer reviewed literature supports this treatment as effective in restoring function and these are covered services as per the insurer.

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 surgical placement of endosteal implant (D6010) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, depression, hypertension, osteoarthritis, congestive heart failure

Treatment: increase in personal care services to 12 hours per day, 7 days per week

The insurer denied coverage for increase in personal care services to 12 hours per day, 7 days per week

The denial is overturned

This is a geriatric patient with a history of dementia, depression, hypertension, osteoarthritis, and congestive heart failure (CHF). According to the most recent Uniform Assessment System (UAS), the patient is alert with periods of forgetfulness and confusion. The patient requires total dependence for ordinary housework. Maximal assistance for meal preparation, managing medications, bathing, dressing lower body, and toilet use. Extensive assistance for personal hygiene, dressing upper body, walking and transfer to and from the toilet. The patient often forgets to use a walker and has to be prompted each time. The patient has infrequent incontinence of bowel and has daily incontinence of bladder with some control. The patient had a fall. 

The medical records show continued deterioration to this elderly person. There have been frequent hospital admissions for several different types of medical conditions such as urinary tract infection, CHF, high platelets, and falls. The records show progression to loss of independence and need for constant follow-up. The patient has poor mobility and mental status, is incontinent, requires assistance with most activities and medication monitoring, and is unlikely to maintain the current status based upon recent medical services. The proposed 12 hours per day for 7 days are 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 increase in personal care services to 12 hours per day, 7 days per week is substantiated.