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

Diagnosis: Decreased mobility
Treatment: Personal Care Aide (PCA) level 2: 6 hours/day, 5 days/week + (plus) 5 hours/day, 2 days/week - total amount of 40 hours/week
The insurer denied PCA level 2: 6 hours/day, 5 days/week + 5 hours/day, 2 days/week - total amount of 40 hours/week.
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for mobility issues, osteoarthritis, and tremor. The patient and her care team requested Personal Care Aide (PCA) level 2: 6 hours/day, 5 days/week + (plus) 5 hours/day, 2 days/week - total amount of 40 hours/week.

The patient's husband provided a letter of support for this appeal. The letter states that following an accident, the patient has chronic low back pain. She needs assistance with stairs, transportation, bathing, dressing, and other activities that require motion due to pain. The letter writer states that he is also disabled and is not strong enough to provide assistance to his wife. Their child is not available to provide informal support.

The requested PCA level 2: 6 hours/day, 5 days/week + 5 hours/day, 2 days/week - total amount of 40 hours/week is medically necessary for this patient.

There is a discordance in the documentation provided regarding the amount of assistance that the patient requires with activities of daily living (ADLs). The Uniform Assessment System (UAS) states that the patient requires supervision only or is independent for ADLs. However, the attestation from the patient's treating physician as well as description of her needs from family members describe a patient that requires hands-on personal care assistance for completing mobility related ADLs such as transfers and bathing. Therefore, it is reasonable to expect that she will require a modest increase in personal care hours beyond what was recommended in the task tool. The requested increase is therefore medically necessary and reasonable for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease and celiac disease
Treatment: Rinvoq
The insurer denied Rinvoq
The health plan's determination is overturned. 

The patient is a female with Crohn's disease and celiac disease. She has failed 6-mercaptopurine, Remicade, Entyvio, and Stelara (started in 2018) every 4 weeks. While on Stelara every 4 weeks, she had improvement, but persistent rectal disease. She had improvement in rectal disease with the addition of Rinvoq.

Rinvoq is medically necessary for this patient.
The current medical literature supports the request for Rinvoq for the treatment of Crohn's disease. The patient's disease is severe and diagnosed at a young age, with history of multiple medication failures, including all primary therapeutic medication classes recommended by guidelines for the treatment of Crohn's disease. Several studies have assessed the use of multiple therapies concurrently, including biologic therapy (such as Stelara) with small molecule therapy (such as Rinvoq). In aggregate, no significant safety issues were attributed to combination therapy, and the therapy was broadly successful in improving response in patients who had failed biologic therapy. Rinvoq is Food and Drug Administration (FDA) -approved for the treatment of Crohn's disease, and has demonstrated safety and efficacy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebrovascular Accident.
Treatment: Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week.

The insurer denied CDPAS (7 days per week, 12 hours per day - 84 hours per week).  The health plan's determination is overturned. 

The patient is a female with a past medical history of cerebrovascular accident (CVA) with hemiparesis, hypertension, coronary artery disease (CAD), congestive heart failure (CHF), diabetes mellitus (DM) Type 2, gastroesophageal reflux disease (GERD), urinary incontinence, atrial fibrillation on chronic anticoagulation, anemia, and a foot drop. The patient had been assigned Consumer Directed Personal Assistance Services (CDPAS).

Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 12 Hours per Day - Total of 84 Hours per Week are medically necessary for this patient.

There is documentation from the patient's medical provider of the medical necessity of increased CDPAS services. There is documentation from the plan's own assessment of extensive assistance with walking, locomotion, transfer toilet, and toilet use. Therefore, the patient has unpredictable and unscheduled care needs that span a continuum of time. The insurer failed to document a plan to meet these unpredictable and unscheduled care needs. The requested increase in CDPAS services is not solely for safety and supervision but to assist the patient with safely completing activities of daily living (ADL) and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan had suggested that the patient discuss further evaluation and/or medication with her medical provider and did have an up-to-date office visit with no other recommendations. Considering 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 for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support functions is essential to maintaining the patient's health and safety in her home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease.
Treatment: Inpatient Hospital Stay.

The insurer denied the Inpatient Hospital Stay.  The determination is upheld.

The patient is a male for whom an inpatient hospitalization is under review. The patient had a history of hypertension, hyperlipidemia, coronary artery disease (CAD), and percutaneous interventions. He presented with chest pain and dyspnea. There was an abnormal myocardial perfusion imaging (MPI) stress test. His ejection fraction (EF) was normal. He presented electively for cardiac catheterization. His vital signs and the oxygen saturation were essentially normal. The electrocardiogram (ECG) was not acute. The creatinine was normal. He underwent a successful and uncomplicated percutaneous intervention of a left anterior descending (LAD) stenosis, remain stable, and was discharged. At issue is the medical necessity of an inpatient stay.

This patient underwent successful elective and non-emergent stenting without complications and was monitored for an adequate post procedure period. There were no vascular complications, acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, cerebrovascular accident (CVA), severe bleeding, renal failure, need for urgent revascularization, need for prolonged intravenous medications or oxygen support, or introduction of high-risk medications requiring prolonged in-hospital monitoring. In this setting, an inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care towards percutaneous catheterization or overall cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: fall/head injury
Treatment: Air Ambulance
The insurer denied the Air Ambulance.
The health plan's determination is overturned. 

The patient is a young child with medical history significant for seizure disorder and genetic calcium channelopathy, non-verbal and developmental delay. He was involved in a stroller accident. He was unrestrained in his stroller, and as his nanny was attempting to descend stairs, he fell out of the stroller down two steps to concrete hitting his head. He developed a hematoma to the left side of his forehead with abrasions to his face. He cried immediately.
The nanny contacted Emergency Medical Services (EMS) immediately. EMS personnel described him as extremely lethargic. His Glasgow Coma Scale (GCS) was reported as 11. EMS activated air transport and he was taken via air ambulance from his location to the closest appropriate facility.

The air ambulance transport was medically necessary for this patient. In this circumstance, the child fell from his stroller to concrete striking his head. There was no loss of consciousness. However, the child was non-verbal at baseline due to his genetic condition and developmental delay. He was unable to communicate with his caregiver or Emergency Medical Services (EMS). The EMS personnel determined that immediate evaluation was medically necessary and appropriate. Because the closest appropriate ED was 37 miles away, they determined that ground transportation would take too long placing the child at risk should he have suffered an intracranial injury. Air ambulance transportation was activated for safe passage to the ED.
Air ambulance was medically necessary in this case because of the child's developmental status and the nature of the trauma. He was noted to be extremely lethargic when EMS arrived, and the most prudent decision was to get him to the closest ED as quickly as possible for evaluation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Thyroidectomy

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

According to the patient's medical record, this is a patient with a past medical history of aortic stenosis (AS), hyperlipidemia (HLD), and hypertension (HTN) who presented for a thyroidectomy with possible sternotomy. The patient underwent an uneventful right hemi thyroidectomy, substernal using cervical approach. Surgery was uneventful. 

Post operative check indicated no acute events since the operation. The patient was doing well. The incision was clean and dry. Calcium was 7.4 and hemoglobin (Hgb) was 10.9. 

The insurer has denied coverage for the full hospital admission as not medically necessary. In their Final Adverse Determination letter they state they are keeping the previous decision. They noted that the hospital is requesting a full hospital admission for the patient after the thyroid gland surgery. The plan clinical criteria consider a full hospital admission medically necessary if there are problems during or after the surgery. The might include nerve injury, neck swelling or low calcium level in the blood. The information provided does not show that the patient had these or other severe problems. For this reason, the request for full admission is denied as not medically necessary. The denial was based on Milliman Care Guidelines 27th Edition using guideline S-1090 Thyroidectomy. 

Based upon the information provided, the inpatient admission was not medically necessary as the patient could have been managed with a 23-hour observation which would have included appropriate postop monitoring and care. According to MCG health Inpatient and Surgical Care 27th Edition Thyroidectomy ORG: S-1090 (ISC) the operative status goal is ambulatory.  Extended Stay as defined by Minimal (a few hours to 1 day), Brief (1 to 3 days), Moderate (4 to 7 days), and Prolonged (more than 7 days) is indicated for select situations.  Inpatient stay may be needed for selected patient factors, which include: 1) extensive thyroid carcinoma requiring lymph node dissection; Large substernal extension of goiter; Graves' disease with large goiter and marked elevation of thyroid hormone; Severe co morbidities (e.g., heart failure, chronic obstructive pulmonary disease [COPD], diabetes mellitus); or 2) Complications of procedure including: Postoperative hematoma or neck swelling requiring close observation; Recurrent laryngeal nerve injury or edema sufficient to cause respiratory compromise or bilateral vocal cord palsy; Postoperative hypocalcemia not easily stabilized with oral calcium supplementation; or Thyroid storm; or 3) Failure to achieve discharge status criteria. The patient did not meet any of these criteria and therefore should have been safely monitored in a 23-hour setting and discharged without having an acute inpatient admission.  

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 the full hospital is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypoglycemia

Treatment: inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

The patient is an adult who was admitted for altered mental status. The patient was found to have hypoglycemia and was treated with intravenous (IV) dextrose. The patient was also evaluated by Nephrology and received routine dialysis therapy for clearance and volume removal. The patient's blood sugar improved, and mentation stabilized. The patient was discharged in stable condition.

It was noted that the patient was treated with dialysis for history of end stage renal failure (ESRD). However, the patient did not have persistent severe hyperkalemia. There were no signs of severe volume overload or hypoxia. There was no documentation of severe uremia such as encephalopathy or uremic bleeding. There was established dialysis access that did not require emergent vascular intervention. 

The patient's condition could have been treated safely under lower level of care such as observation or outpatient follow up. There were no complications, and the patient was discharged in stable condition in 48 hours. A review of the medical literature showed the following:

Analysis of 1039 adult patients with diabetes (33% [percent] type 1, 67% [percent] type 2) who presented to an emergency department due to hypoglycemia (median home or EMS glucose level of 43 mg/dL (2.39 mmol/L)) found that 74% (percent) of patients did not require inpatient admission. [1]

 A database analysis of 12,666 emergency department visits among older adults (61% [percent] of patients 75 years or older) due to adverse drug events found that among patients presenting with symptomatic hypoglycemia due to insulin or an oral hypoglycemic agent, 53% [percent] did not require hospital admission. [2]

Database analysis of 5995 patients seen in an emergency department for an adverse drug reaction to a hypoglycemic medication (81% [percent] due to insulin) found that 61% (percent) of patients did not require inpatient hospital care. [3]

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 inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: knee injury
Treatment: Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies (current procedural terminology (CPT) 27331)
The insurer denied Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies (CPT) 27331.
The health plan's determination is overturned. 

The patient is a female who sustained an injury to her left knee while playing kickball. Plain radiographs and subsequent computed tomography (CT) and magnetic resonance imaging (MRI) scans of the left knee revealed a bi-condylar tibial plateau fracture. She underwent surgical open reduction and internal fixation of this fracture. The surgeon opted to perform a sub-meniscal arthrotomy during the procedure to better visualize the joint surface and the fracture reduction. 

The requested arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies (CPT 27331) was medically necessary for this patient. The operative report clearly states that a sub-meniscal arthrotomy of the left knee was completed to provide exposure of the joint surface. In their peer-reviewed article published in 2019 on tibial plateau fractures, Buckley and colleagues concluded that "open reduction internal fixation (ORIF) with a sub-meniscal arthrotomy provides better quality reductions and better medium-term results as compared to CRIF (closed reduction internal fixation) for tibial plateau fractures. This may provide more long-term benefit from osteoarthritic symptoms in this patient group." Based upon this peer-reviews research, the requested procedure was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obesity
Treatment: Wegovy
The insurer denied Wegovy.
The determination is overturned.


This is a female patient being prescribed Wegovy for the treatment of obesity. Coverage for this medication was denied by the health plan. They state that the patient did not meet their criteria. The plan requires that continued use be approved only when certain criteria are met. These include at least a 5 percent (%) reduction in weight loss while using the requested drug, an ongoing calorie deficit of 30% calories per day and 150 minutes of exercise per week, no use of additional weight loss medications, and the ability to tolerate the 1.7 milligrams (mg) or 2.4 mg weekly maintenance dosage. They state that the patient did not have any evidence of a 5% weight loss and the required calorie deficit and weekly exercise program.
An office visit note states that the patient switched from Saxenda to Wegovy. She achieved a weight loss of 12% since the initial starting of the medication. The letter states that she is tolerating the 1.7 milligram (mg) weekly dose. She is exercising at least 30 minutes per day. She is maintaining a caloric deficit. The prescriber certifies that all of the required criteria for ongoing use are met at this time. At issue is the medical necessity of the Wegovy.

The requested health service of Wegovy is medically necessary for this patient.
Office visit notes provided by the patient's prescriber outline that the patient is meeting all criteria for ongoing usage of the medication. The medication is being used in accordance with nationally recognized guidelines and prescribing practices for the requested medication. The medication is appropriate to treat the patient's condition and could reasonably be considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis. 
Treatment: Dupixent Soln (solution) Pref (pre-filled) Syr (syringe) 200mg/1.14ml (milligrams/milliliter). 
The insurer denied Dupixent Soln Pref Syr 200mg/1.14ml.
The determination is upheld.

This is a female patient with atopic dermatitis. She has tried clobetasol. The prescriber is a dermatologist. The medication under review for medical necessity is Dupixent.
The requested health service/treatment of Dupixent is not medically necessary for this patient.
According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications covered by the patient's insurance plan, such as tacrolimus ointment, are effective treatments for the management of atopic dermatitis (1, 2). 
A Cochrane Database of Systematic Reviews for Topical tacrolimus (which is a preferred, formulary drug) for atopic dermatitis concluded that "In summary, tacrolimus ointment seems to be safe and effective for moderate to severe atopic dermatitis in children and adults" (3). 
It is noted that the patient has tried and failed topical steroids. However, the patient has no true contraindications to the other preferred, formulary medications which have been shown to be effective for the treatment of atopic dermatitis. The evidence-based literature is consistent and in line with the patient's medical policy. The preferred agents, such as tacrolimus ointment, are appropriate agents for the treatment of the patient's atopic dermatitis. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Erectile dysfunction. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a male with history of erectile dysfunction, hyperlipidemia, and diabetes mellitus (DM) who went to the operating room (OR) for inflatable penile prosthesis insertion. The following day, his Foley catheter and Jackson-Pratt (JP) were removed and the patient was discharged home. The preop (preoperative) history and physical (H&P) does not describe why the patient needed inpatient status. The operative report does not list any reason why the patient would need to be admitted. The anesthesia record does not list any specific comorbidities that would be of concern requiring inpatient status.

The inpatient hospital admission is not medically necessary. There was no documentation in the medical record as to the indication for impatient admission. Furthermore, the patient only spent one midnight in the hospital. There is no reason why the patient could not have been cared for at a lower level of care and then transition to inpatient care on post op date number one if he was not fit for discharge on that day. Most patients are discharged on postoperative day number one. A lower level of care was appropriate in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Seizure. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The health plan's determination is upheld. 

The patient is a young female with medical history significant for absence seizures treated with Keppra who presented to the emergency department (ED) after having breakthrough seizures in the morning. She reportedly had three seizures, returning to baseline twice. She also had increased seizure frequency for the week prior and two- to three-week history of nocturnal enuresis. 
Vital signs included temperature 36.9, heart rate 91, respiratory rate 30, blood pressure 100/50, and oxygen saturation 98% in room air. Examination was significant for no acute distress, non-toxic appearance, reactive pupils, regular heart rate and rhythm, clear lungs, benign abdomen, and non-focal neurologic exam. She had no witnessed seizure activity in the ED and was reportedly at baseline. Neurology consultation was requested with recommendations to admit for video electroencephalogram (EEG). 

The Inpatient hospital admission was not medically necessary for this patient. 
Electrical status epilepticus during slow-wave sleep (ESES) was first described fifty years ago as an age-dependent and self-limited syndrome with onset in childhood and associated with cognitive and/or behavioral disturbances. It may last months or years, may be associated with other childhood epilepsy syndromes, and may or may not be associated with clinical seizures. It is reported to be difficult to treat, with no specific recommendations for anticonvulsants. Corticosteroids and benzodiazepines are the current mainstay of treatment, although there is ongoing investigation into the utility of clobazam (Onfi) as a treatment modality. 
This child presented to the ED with increased seizure activity and new-onset nocturnal enuresis. Video EEG revealed abundant epileptogenic discharges and ESES without obvious developmental regression. Her Keppra dose was increased with plans to increase again in a week. Vitamin B6 was added, with consideration for addition of Onfi if necessary. While it was reasonable and medically necessary to monitor this child with known seizures and breakthrough seizure activity for progression of disease, she was overall hemodynamically stable with no clinical evidence of status epilepticus. She did not need acute inpatient admission and could have been safely managed at a lower level of care.