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

Diagnosis: Weakness, Fatigue and Low Blood Pressure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male with a history of diabetes, asthma, pancreatic insufficiency, and vitamin D deficiency who presented to the emergency room with complaints of weakness, fatigue, and hypotension. He was sent to the emergency room after a podiatry visit. On presentation, the patient was afebrile and hemodynamically stable. Exam showed cloudy urine in the Foley catheter. Urinalysis was suggestive of infection; chest x-ray was normal. The patient was admitted to the inpatient service and managed with intravenous fluids and antibiotics. He had an uneventful hospital stay and was discharged home on day #6. Medical necessity for inpatient stay is under review.

The requested health service was not medically necessary.

The majority of patients who present with urinary tract infection (UTI)/pyelonephritis can be discharged within 24-48 hours of the presentation. This patient did not present with hemodynamic instability, renal failure, severe obstruction, sepsis, or unstable medical problems requiring inpatient management. The hospital course was essentially normal without any significant complications or major issues with pain control. There was no procedure performed. The information provided and the patient's clinical status do not suggest the need for acute inpatient care. Observation status for this patient's clinical presentation and hospital course was the safe, effective, generally accepted standard and the most appropriate treatment option. Admission status may be changed anytime during observation if the patient requires continuing services and monitoring, and if the patient's condition is severe enough to require inpatient treatment. Therefore, the requested health service was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: elevated creatinine and hyperkalemia
Treatment: inpatient stay
the insurer denied the inpatient stay
The health plan's determination is upheld. 

The patient is male who was admitted for worsening pain in the right foot. He had a history of a diabetic foot ulcer and was treated with antibiotics prior to admission. He was evaluated by the podiatry service and underwent debridement but had no signs of infection and did not require additional antibiotic course. He was noted to have elevated creatinine and hyperkalemia. Kidney function improved with intravenous (IV) fluid. He was discharged in stable condition. Under review is the inpatient stay.

The inpatient hospital admission was not medically necessary. The gold standard for the distinction between prerenal disease secondary to volume depletion and post-ischemic and nephrotoxic acute tubular necrosis (ATN) is the response to fluid repletion per Kidney Disease Improving Global Outcomes (KDIGO) and National Kidney Foundation guidelines. If sufficient fluid is given to reverse any signs of volume depletion (e.g., hypotension, cool extremities, low urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent a correction of prerenal disease, whereas persistent acute kidney injury (AKI) is considered to represent ATN. This patient's kidney function improved back to baseline in 48 hours, which is not consistent with serious, irreversible acute tubular necrosis which may benefit from inpatient admission to monitor kidney function and the need for renal replacement therapy.
In addition, he was hemodynamically stable and had no signs of recurrent foot infection and was discharged in stable condition in 48 hours. His condition could have been treated safely under a lower level of care.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: coronary artery disease (CAD)
Treatment: Nexletol 180 ml (milligram) 
The insurer denied Nexletol 180 ml (milligram) 
The health plan's determination is upheld. 

This case involves a female with a past medical history significant for coronary artery disease (CAD) and hyperlipidemia. According to records provided for this case review, the patient has reported intolerance to formulary statin, atorvastatin 40 milligrams (mg), causing an allergic reaction (not specified) and joint pains. For treatment of hyperlipidemia and the patient's established cardiovascular (CV) disease, the non-formulary medication, Nexletol 180 milligrams (mg), has been prescribed by the treating provider. 

A formulary exception is not indicated. The patient has previously experienced adverse effects to the formulary statin, atorvastatin, causing allergic reaction (not specified) and joint pains. However, there is no documentation provided that the patient has tried and failed or experienced adverse effects to the other statin medications (rosuvastatin, simvastatin) on the patient's prescription formulary. For this reason, the patient has not met coverage criteria for the non-formulary medication, Nexletol. For this patient with established CV (Cardiovascular) disease, the formulary, high-intensity statin medication, rosuvastatin, should be considered in this case as recommended by the 2018 American Heart Association (AHA) / American College of Cardiology (ACC) guideline on the management of blood cholesterol.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alcohol Intoxification
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is overturned.

The patient is an adult female who received inpatient level of care for alcohol-related problems. The patient reportedly had been in an argument and was aggressive with her roommate. There was no suicidal or homicidal ideation on admission. The patient had an alcohol of 333. At one point during evaluation, the patient stated, "I wish I was more drunk." The patient's clinical history indicated respiratory asthma, anxiety, anemia, diabetes mellitus type II, and bipolar disorder. The patient reportedly had lactic acidosis despite fluids. The patient was reported to be sweaty and diaphoretic but not otherwise showing signs of withdrawal. The lactic acidosis was said to be of unknown etiology even as it could possibly be due to alcohol intoxication. There was concern that it had not yet cleared. She reported that she was drinking a liter of vodka per day with last drink prior to the emergency department admission. Patient had a history of pancreatitis and cavitary pneumonia.

the Inpatient admission was medically necessary.

The patient's admission was evaluated only with regard to alcohol withdrawal management criteria. However, clinical records make clear that a primary concern was lactic acidosis that had not cleared after intravenous fluids and time passing from initial intoxication. Clinical records establish medical necessity for admission with regard to lactic acidosis. Therefore, the requested health service was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 1 Diabetes
Treatment: Ozempic
The insurer denied: Ozempic
The denial is upheld.

This patient is an adult female diagnosed with type I diabetes mellitus (T1DM) with hyperglycemia. This request is for Ozempic. As per visit note some months ago, the patient was diagnosed with diabetes at early age. She is on Medtronic 770 G; Dexcom g6; Humalog and insulin Lispro. The patient's glycated hemoglobin (A1C) some years ago was 8.6 percent.

The requested health service is not medically necessary. 

Ozempic is a glucagon like peptide-1 receptor (GLP1R) agonist (1) that is Food and Drug Administration (FDA) approved in the treatment of type II diabetes (2-4). There are no studies showing safety or efficacy of Ozempic in patients with type I diabetes. This patient has type I diabetes. The Food and Drug Administration label specifically prohibits use of Ozempic and type I diabetes. The request is not consistent with generally accepted standards of medical practice and is therefore not medically necessary. In addition, the policy criteria require the submission of medical records indicating a diagnosis of type II diabetes which is the approved indication of Ozempic. The patient does not have type II diabetes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Skyrizi
The insurer denied: Skyrizi
The denial is overturned.

The patient is an adult male with newly diagnosed moderate to severe colonic and small bowel Crohn's. He has an extensive family history of cancer, including colon cancer on both sides. He has been treated with budesonide (steroids) for 1 month with lack of response. The physician (MD) is requesting treatment with Skyrzi.

The requested Skyrzi is medically necessary.

The patient has newly diagnosed severe small bowel and colonic Crohn's and has had no response to budesonide. The provided guidelines require that patients fail at least one conventional therapy for Crohn's for 3 months. As the patient has not failed at least one conventional therapy for the treatment of Crohn's disease, the request for Humira does not meet the coverage policy requirements outlined in the attached guidelines. However, Ungaro et al showed that early biologic treatment is associated with improved clinical outcomes in adult Crohn's patients, not only in prospective clinical trials but also in real-world settings. Berg et al. showed that recent studies suggest that the use of biologic agents, earlier in the treatment course improves patient outcomes and can prevent progression to irreversible bowel damage. Mesalamines are not effective in patients with Crohn's. Steroids have not been shown to be effective long term in the treatment of Crohn's, and the patient has not had a complete response after 1 month of budesonide. While immunosuppressive agents have been shown to have efficacy, they have a slow onset of action and do not have a good safety profile. Skyrzi has been found to be safe and effective as a first line biologic in moderate to severe Crohn's. Therefore, as medical literature supports early biologics as being safe and effective for the treatment of small bowel Crohn's, the requested Skyrizi is clinically appropriate, accepted standard of care and is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Colon cancer status post resection and chemotherapy, hepatitis C, Parkinson's disease. 
Treatment: Personal care services (PCS) - 12 hours a day x 7 days a week, for a total of 84 hours per week. 
The insurer denied coverage for personal care services (PCS) - 12 hours a day x 7 days a week, for a total of 84 hours per week. 
The denial is overturned. 
 
This case involves an adult with a history of colon cancer status post resection and chemotherapy, hepatitis C, Parkinson's disease, depression, generalized muscle weakness, neuralgia neuritis, primary generalized arthritis, restless syndrome and urinary incontinence. The patient was found to have mild leukocytosis. The patient reported that he was started on new medications (Donepezil). 

This case involves an adult with a significant history of Parkinson disease, generalized muscle weakness, restless leg syndrome and generalized arthritis. During the daytime hours, the patient is mostly bound to a chair/wheelchair when not left in bed. The patient has a PCA (personal care assistant) who comes to the home for 46 hours/week, typically from 9 AM-3 PM. The PCA helps the patient with his activities of daily living (ADLs) such as getting in/out of bed, dressing, transferring to use of bathroom, bathing, personal hygiene, and eating, and with instrumental activities of daily living (IADLs). The patient has very poor balance and motor control, and uses an assistive device when walking. The patient is occasionally incontinent with bladder and continent with bowel, and uses incontinence supplies overnight. The patient recently received a hospital bed with side rails to prevent frequent falling out of the bed at night but does not have the mobility to raise or lower the siderails to get into and out of bed independently. The patient has durable medical equipment (DME): a commode, side rails, and incontinence supplies. The patient has personal emergency response system (PERS) from Connect America at the bedside. 

The initial request was for 12 hours/day, and the doctor recommended 24-hour care to address the patient's declining ability to care for themselves. The records noted that the patient does not have the accommodation for a live-in aide as required by Managed long-term care (MLTC) 15.09. With the currently approved hours, the patient receives approximately 7 hours/day of services and is left alone for approximately 17 hours/day. The nurse assessors stated the patient meets the nursing facility level of care. Based on the clinical documentation presented and considering the nature of the patient's condition, 12 hours/day x7 days/week is medically necessary. These hours can be used flexibly to meet the patient's needs, reduce the time that the patient will be left alone, and help to ensure safety. 

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 personal care services (PCS) - 12 hours a day x 7 days a week is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment: Nurtec
The insurer denied Nurtec. 
The health plan's determination is upheld. 

The patient is a man with acute migraines, who is prescribed treatment with Nurtec ODT (oral disintegrating tablet). The drug was denied because the patient has not tried and failed Ubrelvy. This is under review.

A formulary exception is not indicated in this case. There is no documentation that the patient has tried and failed the formulary alternative of Ubrelvy. Additionally, there is no reason to believe that this drug would be ineffective, or would not be as effective as the non-formulary medication. Ubrelvy is Food and Drug Administration (FDA) approved for treatment of acute migraine. The drug has the same mechanism of action as the non-formulary drug. There is no medical reason that the patient cannot try this drug for treatment of severe headaches.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vulvar cancer. 
Treatment: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT). 
The insurer denied Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT). 
The determination is overturned. 

This is a female patient with recurrent vulvar cancer who has been recommended to proceed with a course of reirradiation with curative intent. She previously was treated to her vulva and groins to a cumulative dose of 57 gray (Gy). The request is for approval of stereotactic body radiation therapy (SBRT) employing proton beam radiotherapy and this is under review for medical necessity. 

The requested SBRT utilizing proton beam radiotherapy is medically necessary. The provider supplied a proton/photon plan comparison which reveals that the photon plan is unable to provide adequate safety/precision with regard to the patient's bowel. If delivered, the photon plan would lead to an unacceptable and unnecessary risk for high grade bowel toxicity, potentially requiring hospitalization and/or operative intervention. The proton radiation plan was able to significantly minimize the bowel exposure to within known safe tolerance limits, thereby minimizing the risk for serious toxicity. Proton radiation is widely utilized and supported by the American Society for Radiation Oncology (ASTRO) Model policy in the reirradiation setting when it is shown that photon radiation cannot meet nationally accepted treatment planning objectives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Perianal abscess
Treatment: Pelvis Magnetic Resonance Imaging (MRI)
The insurer denied Pelvis Magnetic Resonance Imaging (MRI)
The health plan's determination is overturned. 

The patient is a man with a history of perianal abscess status post drainage several years ago. He then presented to the emergency department (ED) with a large perirectal abscess that extended to the base of the scrotum. He was treated with exam under anesthesia and incision and drainage of the perianal abscess. He was subsequently evaluated with colonoscopy that was negative for findings of inflammatory bowel disease. The anorectal exam that included rigid proctoscopy revealed tenderness and deep induration in the left lateral position. 

The Pelvis Magnetic Resonance Imaging (MRI) is medically necessary for this patient.
This patient presented with an infection related to perianal abscess. He was evaluated in the ED at this time and was treated with surgical incision and drainage of a perianal abscess. Subsequent clinical records document that the patient has persistent or recurrent perianal infection as supported by physical exam findings of tenderness and a deep perianal mass/induration in the left lateral position. The patient has ongoing symptoms of pain and an indurated deep perianal mass. This patient has a suspected ongoing infection or inflammatory condition within the perianal area. Therefore, the requested MRI is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for mobility issues, gait instability, coronary artery disease, incontinence, and blindness. The patient's physician provided a letter of support for this appeal. The letter states that the patient suffers from complete blindness, degenerative joint disease, venous insufficiency, gait instability, urinary incontinence, and other medical issues. The patient requires assistance in the nighttime due to frequent toileting needs, repositioning and transfers due to degenerative joint disease, and assistance with all activities due to category 5 blindness.

The requested Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours is medically necessary for this patient.

The documentation provided demonstrates that the patient has personal care needs which are continuous and unscheduled throughout the day and night. She has been forced to stay in a single diaper overnight for 12 hours without the ability to leave her bed or toilet independently. Her personal care needs can be expected to occur periodically throughout a 24-hour day. She may be a candidate for a live-in personal care aide, but due to living in a studio apartment this is not possible. Therefore, Personal Care Services (PCS): 24 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours is medically necessary for the patient. Failure to address her personal care needs could result in skin breakdown and/or infection.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia

Treatment: Consumer directed personal assistance services (CDPAS), 84 hours over 7 days

The insurer denied coverage for consumer directed personal assistance services (CDPAS), 84 hours over 7 days

The denial is overturned

This is a patient with chronic medical problems including spinal stenosis, urinary tract infections and depression. The patient lives alone in a private residence. The insurer approved consumer directed personal assistance services (CDPAS) 70 hours/week (10 hours/day, 7 days/week). The request is for CDPAS 84 hours/week (12 hours/day, 7 days/week), leading to an external review. 

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as minimally impaired. The patient is reportedly total dependent for completing much of their Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping. The patient is also total dependent for locomotion, toilet transfer/use and ambulation. The patient is reportedly non-ambulatory and a Hoyer lift is used for transfers. Maximal assistance is reportedly needed for bathing. Extensive assistance is reportedly needed for personal hygiene, dressing and bed mobility. The patient is independent for eating. The patient's ability to perform activities of daily living (ADLs) has reportedly declined over the prior 90 days. The patient is frequently incontinent of bladder and continent of bowel. There have been no reported falls over the prior 90 days. 

The patient's condition and functional deficits are at a level or unpredictable as to require the requested increase in CDPAS hours to 84 hours/week. The patient's functional ability has significantly declined as a result of a recent hospitalization and subsequent transfer to a skilled nursing facility. The patient was discharged to home. The associated discharge summary documents the patient's continued need for home care services and limited functional mobility. Based on the clinical records, the patient's health and safety are more appropriately provided and maintained at home by increasing CDPAS from 70 to 84 hours/week. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based). 

From a physical medicine and rehabilitation perspective, increasing CDPAS to 84 hours per week, 12 hours per day, 7 days per week is medically necessary.  

Based on the above, the insurer's denial must be reversed. 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 consumer directed personal assistance services (CDPAS), 84 hours over 7 days is substantiated.