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

Central Nervous System. 
Nursing Services (including Private Duty Nursing). 

Diagnosis: Cerebrovascular Accident (CVA). 
Treatment: Personal Care Services. 

The insurer denied an increase in personal care services. The health plan's determination is overturned. 

The patient is a female with past medical history of cerebrovascular accident (CVA) with right hemiparesis, bed bound status, sacral bed sores, history of falls, dementia, heart disease, urinary incontinence, bowel incontinence, hypothyroidism, osteoporosis, gastroesophageal reflux disease (GERD), and diabetes mellitus (DM) type 2 who had been assigned PCA (personal care assistant) services 9 hours/day, 7 days/week, to total 63 hour/week. There was a request to increase PCA hours to 24 hours/day, split shift, 7 days/week to total 168 hours/week. The patient had telephonic assessment tool performed assessing the patient at total assistance with tasks of meal preparation, ordinary housework, stairs, shopping, transportation, locomotion, and toilet use while maximal assistance with tasks of bathing, dressing upper/lower body, and bed mobility. The patient was assessed at extensive assistance with tasks of managing finances, managing medication, phone use, personal hygiene, and eating while activities of walking and transfer toilet did not occur. 

The increase in personal care services to 24 hours a day, 7 days a week (split-shift) for a total of 168 hours per week is medically necessary for this patient. 
The patient has diagnosis of prior CVA with right hemiparesis with documented worsening functional status and requires assistance with all ADLs/ Instrumental activities of daily living (IADL). The patient also has history of urinary and bowel incontinence with documented pressure sores and her PCP (primary care provider) documenting the need to be turned and repositioned every two hours. The plan's own assessment documented the patient's bedbound status with noted increase in pressure ulcers and documented recommendation to reposition patient every two hours to prevent pressure ulcers. The patient has unpredictable and unscheduled care needs over a continuum of time and the plan failed to develop a plan of care that can meet these unscheduled or recurring daytime and nighttime needs with personal hygiene, toilet use, incontinence cares, and bed mobility. Because of the patient's 24 hour care needs the assessment tool should not have been utilized in calculating the patient's PCA service hours, an increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. In reviewing the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, an increase in PCA hours for this patient is medically necessary. Personal care 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: Medical necessity
Decision: Upheld

Diagnosis: Anemia
Treatment: Inpatient Hospital
The health plan denied the inpatient hospital stay. 
The health plan's determination is upheld.

The patient is a woman with a history of iron deficiency anemia and Coombs positivity. She was sent to the emergency room by her primary care physician (or provider) after routine labs revealed a hemoglobin of 5.4. These labs had been drawn as part of presenting compliant of vaginal itching and discharge. She was otherwise asymptomatic. The vital signs were unremarkable, and she was in no distress and was non-toxic in appearance. Labs were notable for a hemoglobin of 6.2 g/dl, mean corpuscular volume (MCV) of 52.8, positive direct coombs, a minimally elevated lactate dehydrogenase (LDH), a low serum iron, a low serum ferritin, a low serum B12, and a total bilirubin of 2.3. The chest x-ray and electrocardiogram (EKG) were negative, and an abdominal ultrasound was non-contributory. A transfusion of packed red blood cells was administered. The patient was admitted for further treatment and evaluation.
Upon admission, the patient was treated with another blood transfusion, as well as treatment for vulvovaginal candidiasis. The following day, the hematologist evaluated the patient. It was noted that the hemoglobin rose to 8.9 g/dl after the two transfusion. Intravenous iron, along with oral iron and oral B12 supplementation, was recommended. The remainder of the stay was clinically uneventful, and the patient was discharged.
At issue is the medical necessity of the inpatient stay.

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

No, the requested health service/treatment of inpatient stay was not medically necessary for this patient.
Based on a thorough review of the information provided, the requested acute inpatient stay was not medically necessary. Upon presentation, there was no objective evidence on physical exam, labs, imaging, or EKG of an imminently life-threatening cause of the patient's complaints that required acute inpatient admission. The patient, who had a previous history of iron deficiency and Coombs positivity, was essentially asymptomatic with normal vital signs and no postural hypotension. There was no evidence of severe jaundice, sepsis, severe metabolic disarray, or major organ pathology. The services provided - blood transfusions, iron infusions, and hematology consultation - were not at the acute inpatient level of intensity and could have been safely and efficiently provided at a lesser level of care. [1]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Trauma/injuries-Gunshot wound
Treatment: Inpatient stay
The health plan denied the inpatient stay as not medically necessary. 
The reviewer has upheld in whole the health plan determination.

The patient presented to the Hospital emergency department (ED) on as a trauma activation with a gunshot wound to the right arm. Comorbid health conditions included hypertension. He was awake and alert at the time of presentation. A computed tomography (CT) scan and x-ray of the right arm showed a comminuted humerus fracture. The patient was admitted to the hospital. Initial treatment included pain management, intravenous (IV) fluid and orthopedic consultation. He was treated with closed reduction and splinting of the right arm. He remained neurovascularly intact and was considered to be stable for discharge home the following day.

Inpatient admission was not medically necessary for this patient based on the submitted clinical documentation. The records support that a lower level of care would have appropriately satisfied the clinical needs of this patient. This patient presented as a trauma patient with a gunshot wound to the right arm and an associated right humerus fracture. He was clinically stable at the time of presentation. Orthopedic evaluation yielded the recommendation for non-operative therapy for the right arm fracture with splinting. This patient did not require emergent surgery or other acute intervention that required inpatient care. The medical and nursing progress notes document clinical stability during the course of treatment care.
A lower level of care would have been clinically appropriate and would have been consistent with the accepted standard of care. In this case there is no documentation of compartment syndrome, major injury that required inpatient stabilization or major injury that required inpatient treatment. There was no limb-threatening injury and no documentation of severe pain that required an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient presented to the emergency department complaining of chest and back pain. Her medical history was remarkable for coronary artery disease, coronary artery bypass graft surgery, percutaneous coronary interventions, diabetes, hypertension, peripheral vascular disease and obesity. Her blood pressure was 139/84 millimeters of mercury (mmHg) with a heart rate of 92 beats/minute. Her room air oxygen saturation was 100%. Her physical exam was remarkable for obesity and lower extremity edema. An electrocardiogram showed ST segment depression in the lateral leads and T wave inversion in leads I [one] and aVL [augmented vector left]. Her serum troponin I level was .085 nanograms/milliliter (ng/ml) and was .069 ng/ml when rechecked. The patient was treated with aspirin and nitroglycerin and admitted to the hospital for treatment of acute coronary syndrome. She was treated with beta-blockers and nitrates. Her troponin level was .076 ng/ml. Myocardial perfusion imaging showed a large fixed inferior defect extending into the anterolateral, lateral, inferolateral and apical segments with mild stress induced ischemia in the proximal anterolateral/lateral region. The post-stress left ventricular ejection fraction (LVEF) was 26% and increased to 38% with rest. By echocardiogram, the LVEF was 55%. A cardiac catheterization showed severe multi-vessel disease. There were patent grafts to the left anterior descending, posterior descending and distal third obtuse marginal arteries. Treatment with Imdur was recommended. The patient was discharged. The medical necessity for an inpatient admission is at issue. An inpatient stay was medically necessary.
This patient, with known coronary artery disease, presented with chest pain, significant ST segment depression and an elevated troponin level. Based on her HEART (History, Electrocardiogram, Age, Risk factors, Troponin) score of 7, she was at high risk (50-65%) for major adverse cardiac outcomes, including death, shock and malignant arrhythmias. Given her electrocardiographic changes and elevated troponin level, current guidelines, including the 2014 American Heart Association (AHA) / American College of Cardiology (ACC) Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, recommend inpatient admission is this situation.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Breast Cancer.
Treatment: Radiation Therapy (Proton).
The health plan denied the requested treatment. 
The health plan's determination is upheld.

This patient is a woman with a stage Ia breast carcinoma post lumpectomy, radiation therapy to the breast and adjuvant hormonal therapy. She has done well until recently she was found to have neurologic changes that are due to brain and leptomeningeal metastases. She has no other sites of disease on restaging studies. Intrathecal chemotherapy and radiation therapy are recommended to the brain and craniospinal axis and proton beam approach is requested.
At issue is the medical necessity of the requested treatment.

I uphold in whole the health plan's determination of medical necessity.

No, the requested treatment of proton beam therapy is not medically necessary for this patient. The recommended proton beam radiation therapy to deliver radiation to the brain and spinal axis with craniospinal irradiation (CSI) for this patient is not considered medically appropriate nor necessary. There is lack of any significant studies published in peer reviewed literature supporting the treatment of CSI for this clinical scenario and also not for the use of proton beam radiation for CSI in this clinical scenario. This is not supported as a standard of care treatment option in the oncologic medical community as well as National Comprehensive Cancer Network (NCCN) Guidelines. This should be denied.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Psoriasis
Treatment: Prescription Drugs (Cosentyx)
The health plan denied the requested medication. 
The health plan's determination is upheld.

The patient is a male with moderate to severe psoriasis (40% body surface area involvement) affecting the hands, feet, legs, arms, chest, abdomen, buttocks, face, and back. The patient has tried and failed topical Hydrocortisone and Betamethasone, as well as sunlight. The patient drinks alcohol weekly (social drinking).
Cosentyx is under review for medical necessity.

The health plan's denial of Cosentyx coverage is recommended to be upheld, in whole.

No. Cosentyx is being requested based on convenience rather than true medical necessity, and either oral Methotrexate or Acitretin (and/or phototherapy) are appropriate first-line systemic treatments for a patient who has only used topical therapies to date.
The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line systemic therapies such as either Methotrexate, Acitretin, and/or phototherapy. The patient does not consume enough alcohol to preclude use of Methotrexate or Acitretin with respect to safety or liver issues. Therefore, consistent with current medical literature [1-4], the requested Cosentyx is not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disease; Generalized Anxiety Disorder. 
Treatment: Vyvanse 30mg. 

The insurer is denied coverage of a formulary exception for Vyvanse 30mg. 

The denial is overturned. 

This female patient has a diagnosis of Attention Deficit Hyperactivity Disease (ADHD) and Generalized Anxiety Disorder (GAD).  She was taking Vyvanse 30 mg per day to target ADHD symptoms it was controlling the symptoms. There were no reports of adverse side effects. She was also taking Zoloft and Clonazepam for anxiety. 
	
The insurer denied coverage for Vyvanse 30 mg per day for the treatment of ADHD. They stated that the patient did not try and fail preferred medications such as generic Adderall XR, Methylphenidate ER, Desmethylphenidate ER, or Atomotextine or have adverse effects from these formulary medications. 

The medical records provided support that the patient requires Vyvanse 30 mg per day to treat ADHD and has benefitted from it. It was reported she had efficacy so it was controlling the symptoms without adverse side effects. 

The American Academy of Child & Adolescent Psychiatry (AACAP) Practice Parameters for the Assessment and Treatment of Children, Adolescents, and Adults with Attention Deficit Hyperactivity Disorder reports that pharmacotherapy with psychostimulants are considered first line treatment for ADHD. This patient had a diagnosis of ADHD and had improvement with Vyvanse which is considered a Food and Drug Administration (FDA) approved medication for ADHD.  Vyvanse is a brand name medication and is called Lisdexamfetamine dimesylate (generic). It is an inactive prodrug in which d-amphetamine is pharmacologically activated after oral ingestion. This has a different mechanism than the other mentioned psychostimulants as it is a prodrug needing to be activated after ingestion. This medication gets activated after ingestion so abuse potential is considered less than other psychostimulants. Even though the patient did not try and fail or have adverse reactions to a formulary psychostimulant such as generic Adderall XR, Methylphenidate ER, Desmethylphenidate ER, or Atomoxetine, these psychostimulants do not have the same mechanism of action as Vyvanse.  Since she had efficacy from Vyvanse, which has a unique mechanism of action and also is an FDA approved psychostimulant, it is in the patient's best interest to continue with this medication. 

Vyvanse is considered an FDA approved medication for ADHD and this patient had a diagnosis of ADHD. The requested drug is likely to produce a more clinically beneficial outcome. 

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

The medical necessity is substantiated. The carrier's denial of coverage for Vyvanse 30mg is overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertrophy of uterus
Treatment: Panniculectomy
The insurer denied a panniculectomy. The health plan's determination is overturned.

This patient is a female with morbid obesity, body mass index 47; hypertrophy of uterus, excess panniculus of abdomen, menorrhagia, and acute post-hemorrhagic anemia. She requires a hysterectomy. Her body mass index (BMI) is 47. Her surgeons recommend simultaneous panniculectomy and hysterectomy to allow the hysterectomy to be safely performed.

The inpatient surgery (panniculectomy) is medically necessary.

An extensive literature search confirms the safety of this procedure in conjunction with pelvic surgery as well as its importance in improving operative exposure and enhancing the safety of pelvic surgery. Surgical access to the pelvis is compromised in the presence of a massive pannus, and a panniculectomy will improve operative exposure and operative safety. This has been clearly demonstrated in the medical literature. This patient has an elevated BMI, and her large pannus will compromise access to the pelvis. The standard of care as defined by the medical literature is to perform a panniculectomy at the time of pelvic surgery to improve access. The patient's gynecologist appropriately requested that the plastic surgeon perform a panniculectomy to improve access and eliminate her infections.

According to Hardy, et al, "Our findings reveal that panniculectomy combined with pelvic surgery in the morbidly obese is a safe procedure that can decrease the incidence of intraoperative complications and postoperative wound complications without significantly increasing operative time or blood loss." The medical literature strongly supports the concept that a panniculectomy is medically necessary for this patient to ensure the safety of her gynecologic surgery. A one day hospitalization is appropriate given the magnitude of this procedure on this obese patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lymphoma
Treatment: Radiation Therapy
The health plan denied the requested radiation therapy. 
The health plan's determination is upheld.

This patient is a woman with a nasal extranodal T cell lymphoma, post partial resection. Chemotherapy and radiation therapy are recommended as definitive treatment and proton beam approach is requested.
At issue is the medical necessity of the requested radiation treatment.

I uphold, in whole, the health plans determination of medical necessity.

No, the requested treatment of radiation therapy is not medically necessary for this patient. The recommended radiation therapy for this patient can be safely delivered with photon beam intensity modulated radiation therapy (IMRT) approach with the lower doses that are needed for this type of cancer. Proton beam radiation therapy is not medically necessary. There is a lack of any significant studies published in peer reviewed journals showing a benefit of proton radiation over photon radiation in patients with this diagnosis. Additional studies are needed to determine the benefits and safety of proton beam radiation for T cell lymphomas of the head and neck. This treatment should be denied.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied increase in personal care assistance to 84 hours per week. 
The denial is overturned.

The patient is a female with past medical history of osteoporosis, dementia, osteoarthritis, urinary incontinence, constipation, peripheral edema, peripheral vascular disease, hypertension, gastroesophageal reflux disease (GERD), hyperlipidemia, generalized anxiety disorder, depression, and hypothyroidism who had been assigned personal care assistance (PCA) services 8 hours/day, 7 days/week, to total 56 hours/week. There was a request to increase PCA services and the patient underwent a telephonic assessment tool assessing the patient at extensive assistance with meal preparation, ordinary housework, stairs, shopping, transportation, bathing, personal hygiene, and dressing upper/lower body while limited assistance with tasks of managing finances, managing medication, equipment management, walking, locomotion, transfer toilet, toilet use, and bed mobility. Notes from this assessment stated the patient lived alone, had no informal helper, had a fall with fractured right shoulder, had unsteady gait, was unable to stand for long periods of time, was unable to bend over, was unable to carry heavy objects, was unable to raise hands overhead, was unable to navigate stairs, had a decline in function since fall due to fractured right shoulder, and required assistance to reheat meals. The subject under review is the medical necessity for the increase in hours.

The health plan's determination is overturned. 

The requested service of personal care assistance 84 hours per week is medically necessary for this patient. The patient has progressive medical conditions of osteoarthritis and dementia. The patient had a decline in her physical functioning following a fall with right shoulder fracture and documented decline in cognitive function by her psychiatrist. The patient is incontinent of urine. The patient requires at least supervision with all ADL/ Instrumental activities of daily living (IADL) tasks except phone use. The patient has no informal helper. The patient has unscheduled and unpredictable care needs that span a continuum of time. The patient needs assistance with meal preparation (not able to reheat her own meals), medication administration, walking, locomotion, transfer toilet, toilet use, incontinence cares, and personal hygiene outside of the currently assigned PCA hours. An increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Taking into account the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours/day, 7days/week, to total 84 hours/week are medically necessary for this patient. Personal care 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: Medical necessity
Decision: Overturned

Diagnosis: ALS (Amyotrophic Lateral Sclerosis). 
Treatment: Radicava. 

The insurer denied the Radicava. 
The determination is overturned. 

This is a patient with amyotrophic lateral sclerosis (ALS). She has a score of 2 or higher in each category of the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R). However, the patient had a forced vital capacity (FVC) of 64%. The provider notes that this is because the patient was unable to form a good seal with the apparatus due to abnormal movements of the face and bulbar weakness. As such, the provider notes that this is not a good reflection of her respiratory function. Treatment with Radicava is under review for medical necessity. 

The requested Radicava is medically necessary. Radicava has been shown to slow the progression of ALS. There are no cures for ALS, and there are only 2 Food and Drug Administration (FDA) approved medications. Radicava is one of these medications. The patient meets most criteria for treatment with ALS except for the forced vital capacity (FVC) which is 64%. Guidelines generally recommend an FVC of 80%; however, some patients with ALS have bulbar (facial and mouth weakness) which prevent the formation of a good seal with the pulmonary function testing. This results in a lower than expected forced vital capacity and this test becomes not a true reflection of their respiratory capability. The provider estimates that the corrected FVC is 92%. Furthermore, some experts argue that there is no reason to believe that all patients with ALS do not benefit from Radicava throughout the spectrum of the disease. 

Therefore, the Radicava is medically necessary for this patient.