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

Diagnosis: Major depression, schizoaffective disorder, posttraumatic stress disorder, and obsessive compulsive disorder
Treatment: Increase in Consumer Directed Personal Assistance Service (CDPAS) to 23 hours per week 
The insurer denied the increase in CDPAS to 23 hours per week. 
The denial is overturned.

The patient is a female. She reportedly has major depression, schizoaffective disorder, post-traumatic stress disorder, and obsessive compulsive disorder. The request is for an increase in Consumer Directed Personal Assistance Service (CDPAS) to 23 hours per week.

Yes, the increase in CDPAS to 23 hours per week is medically necessary.

The patient has diagnoses of major depression, schizoaffective disorder, post-traumatic stress disorder, and obsessive compulsive disorder. Due to her underlying diagnoses, she is unable to maintain and do ADLs (activities of daily living). She has significant memory loss and cannot take medications on her own. She does better when her aide is around.

The increase in hours is medically necessary to avoid symptoms exacerbation and prevent hospitalizations.

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The patient has underlying neurologic diagnoses and needs help with all her tasks. Her cognitive functions have been declining. An increase in hours are needed and medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Platinum Resistant Ovarian Cancer and Two(2) Sites of Colon Obstruction. 
Treatment: Fixed Wing Air Ambulance Transfer. 

The insurer denied the Fixed Wing Air Ambulance Transfer. 
The denial is upheld. 

The patient in this case was a female with platinum resistance at the time of the events in this case.  Records indicate that she had been treated with multiple lines of prior therapy and was hospitalized in another state.  Records also indicate that she had two sites of malignant colonic obstruction without any good surgical option for diversion.  She had undergone placement of a cecostomy tube for palliative purposes. 

The patient was admitted to the hospital with anemia, hypokalemia and persistent symptomatic malignant obstruction.  She had pain, drowsiness and delirium. Imaging done during that admission revealed progressively worsening colonic dilation.  She was treated with pain medication. No further cancer treatment was planned and hospice care was planned. 

Records indicate that the initial plan was for a commercial flight back to New York. Records also noted that family members were driving to the state where she was.  It was subsequently decided to transport her back to New York via fixed wing air ambulance.  According to a written pre-authorization request she required air ambulance transport because she was in need of transportation to New York and her extensive medical needs precluded commercial air travel.  It was also noted that the 1,344 mile drive was also not feasible given her complex medical needs.  Therefore, she was transported to New York via fixed wing air ambulance for hospice care at home. 

No, the proposed fixed wing air ambulance transfer was not medically necessary.
This patient had end-stage ovarian cancer without any further cancer treatment planned.  She was transported back to New York for hospice care.  Records clearly indicate that no further cancer treatment was planned.  She was hospitalized for inpatient palliative care due to worsening colonic obstruction, pain, delirium and other medical issues. 

The patient clearly had multiple significant symptoms and complex medical needs.  However, those complex medical needs were all being adequately addressed at the out of state facility, which is well regarded tertiary cancer center.  There was no medical service she required which was not available either the facility she was at or at another nearby center. 

While it is appreciated that the transport in this case was to allow the patient to continue hospice care at her home, that is not sufficient grounds to justify the medical necessity of air ambulance transport.  Air ambulance transport is meant for critically ill patients who require transport to higher level facilities for care that cannot be given at either the originating facility or a nearby facility accessible via ground transport.  Air ambulance transport for continuation of hospice care is not medically necessary. 

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fall Risk. 
Treatment: Home Health Care. 

The insurer denied Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 24 Hours per Day, Live-In (91 Hours per Week). The health plan's determination is overturned. 

The patient is a female with past medical history of peripheral vascular disease, permanent pacemaker, coronary artery disease, chronic bilateral lower extremity edema, chronic systolic/diastolic heart failure, urinary incontinence, bowel incontinence, hypertension, hyperlipidemia, cognitive decline, history of subdural hematuria who had been assigned Consumer Directed Personal Assistance Services (CDPAS). 

Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 24 Hours per Day, Live-In (91 Hours per Week) medically necessary for this patient. 
There is documented cognitive and functional decline following the patient's recent hospitalization and subsequent rehabilitation stay. The patient requires assistance with all activities of daily living (ADL) including walking, locomotion, transfer toilet, and toilet use. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies as suggested by the insurer. The requested increase in CDPAS is not solely for safety and supervision but to assist the patient with safe completion of ADLs and instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Consumer Directed Personal Assistance Services (CDPAS): 7 Days per Week, 24 Hours per Day, Live-In (91 Hours per 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: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension.
Treatment: Edarbi 80 mg (milligrams).

The insurer denied coverage for Edarbi 80 mg.  The denial is upheld. 

This male patient has a history of hypertension and type I diabetes mellitus. Blood pressure has been well controlled [120/80 mm/Hg (millimeters of mercury)] on Edarbi [Azilsartan 80 mg (milligrams)]. The patient's physician has requested that the patient be continued on this medication and provides documentation that the patient's blood pressure has been stable on this regimen for many years. No documentation is provided regarding treatment with formulary alternatives.

The use of angiotensin receptor blockers to treat hypertension has been well described and is recommended by the AHA (American Heart Association) and ACC (American College of Cardiology). [Reference 1] Azilsartan is an angiotensin receptor blocking agent and this family of medications reduce cardiovascular morbidity and mortality in patients with hypertension. [Reference 2] Moreover, they reduce albuminuria in patients with diabetes mellitus. [Reference 2] Comparison of efficacy between different angiotensin blocker agents, including those on formulary, show no appreciable difference in controlling blood pressure. [Reference 3] 

The formulary drugs are not likely to cause an adverse reaction for this patient. There is no evidence that the formulary drugs have been utilized and or failed to control the patient's blood pressure. There is no evidence that the requested drug would be more effective than any of the formulary drugs. In conclusion, the requested drug should not be approved.

The insurer's denial of coverage for Formulary Exception for Edarbi 80 mg is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plaque Psorasis. 
Treatment: Taltz. 

The insurer denied Taltz. 
The determination is upheld. 

The patient has psoriasis. The body surface area affected is 70%. She has tried and failed Humira, Cosentyx, clobetasol, triamcinolone, halobetasol, and coal tar. The medication under review for medical necessity is Taltz. 

The requested health service/treatment of Taltz is not medically necessary for this patient. There is no documentation provided that the patient has tried and failed, has a contraindication to, or intolerance to the preferred therapies such as Enbrel, Renflexis, Inflectra, and Avsola, which have been shown to be effective for psoriasis.  It is noted in a provider's letter since the patient has already failed Humira, Enbrel would not be effective since she has already experienced refractory responses.  However, this is not a contraindication or reason not to preclude the trial of Enbrel in this patient.  It has been noted throughout the literature that Enbrel is effective for psoriasis.  Moreover, they do not have the exact same mechanism of action. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the preferred medicines Enbrel, Renflexis, Inflectra, and Avsola covered by the patient's insurance plan are effective treatments for the management of psoriasis (1, 2). Kivelevitch writes regarding Enbrel "Anti-tumor necrosis factor (TNF)- agents are currently considered as first line biological therapies for the treatment of moderate to severe psoriasis and psoriatic arthritis" (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 initiating Taltz. It is noted that the patient has tried and failed several therapies. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Taltz prior to the formulary alternatives such as Enbrel, Renflexis, Inflectra, and Avsola. Therefore, the Taltz is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease.
Treatment: Personal Care Aide (PCA) Services: 70 Hours per Week (10 Hours per Day / 7 Days per Week).

The insurer denied Personal Care Aide (PCA) Services: 70 Hours per Week (10 Hours per Day / 7 Days per Week).  The health plan's determination is overturned.

The patient is a male with past medical history of congestive heart failure, coronary artery disease, permanent pacemaker, hyperlipidemia, atrial fibrillation, chronic anticoagulation, urinary incontinence, occasional stool incontinence, hypertension, transient ischemic attack (TIA), depression, osteoarthritis, obstructive sleep apnea, chronic kidney disease, osteoporosis, breast cancer, and dementia who had been assigned PCA (personal care aide) services.

Personal Care Aide (PCA) Services: 70 Hours per Week (10 Hours per Day / 7 Days per Week) are medically necessary for this patient.

There is documentation by the patient's PCP (primary care provider) of functional decline following a fall. The patient had documented increase in assistance needs with task of transfer toilet when comparing the  assessments. There was noted improvement in tasks of meal preparation and stairs indicating there was likely an underestimation of the patient's care needs as there is other documentation of functional decline. The patient's PCP has documented medical necessity of increased PCA services. The patient's informal helper is his spouse who has her own medical issues and frailty and is unable to provide assistance for the total time outside of the currently assigned PCA services. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The patient's cardiologist also noted the patient has a complex medication regimen that spans many hours over the day and his wife is unable to assist fully with this regimen. The requested increase in PCA services is not solely for safety and supervision but to assist the patient with safe completion of activities of daily living (ADL) and Instrumental activities of daily living (IADL). Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 10 hours/day, 7 days/week, to total 70 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: Formulary Exception
Decision: Upheld

Diagnosis: Atrial fibrillation. 
Treatment: Eliquis. 
The insurer denied the Eliquis (Pre-Service). 
The denial is upheld. 

The patient is a male with history of atrial fibrillation. He was being treated with a beta blocker and Multaq. Eliquis is under review. 

No, the health plan should not cover the proposed treatment, Eliquis. 

Those with atrial fibrillation can be at elevated risk of an associated cerebrovascular accident (CVA), and in some individuals anticoagulation is indicated.  Warfarin has been proven effective for atrial fibrillation stroke prevention.  A new generation of anticoagulants, including Eliquis and Xarelto, have been developed for atrial fibrillation stroke prevention. All agents have an associated increased risk of both major and minor bleeding.  The newer medications have generally been demonstrated as or more effective than warfarin for stroke prevention and are generally safer.  Additionally, Eliquis has not been definitively established as standard of care, directly compared to Xarelto, towards improved atrial fibrillation outcomes.  Also, there is no contraindication to Xarelto in this case.  Therefore, Eliquis is not considered medically necessary. The formulary drug, Xarelto, would be as effective as the nonformulary drug, and in this case Xarelto has not been demonstrated to be ineffective.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Developmental Delay. 
Treatment: Pediatric medical day care 5 days per week. 

The insurer denied coverage for pediatric medical day care 5 days per week. 

The denial is modified. 

This is a female patient with speech and developmental delay. The patient has been receiving physical, occupational, and speech therapy services. Prognosis is documented as fair. The patient is enrolled in a Pediatric daycare and is requiring assist for all mobility, and self-care. The patient is medically stable, per records. 

As per the appeal "the child requires at least 3 days per week of service to provide all needed therapies, mealtime, therapeutic recreation and nursing care. [Physical Therapy] PT, [Occupational Therapy] OT, [Speech Therapy] ST plus the rest cannot be managed in 2 days." 

"Delay in development occurs when the child fails to attain developmental milestones as compared to peers from the same population. It is caused by impairment in any of the following distinct domains, such as gross and fine motor, speech and language, cognitive and performance, social, psychological, sexual, and activities of daily living (ADL). It can be isolated (involving a single domain), multiple (involving two or more domains, or global (affecting most developmental areas). In order to avoid long term disability, early detection, and intervention is warranted. This activity reviews the role of the interprofessional team in the comprehensive evaluation of developmental delay using standardized developmental surveillance and screening instruments in addition to lab workup and imaging." (Khan, et al., 2021). 

The health care plan did not act reasonably in part with sound medical judgment and in the best interest of the patient. The approved two days per week by the insurer is not sufficient to provide services to this patient, three days would be more appropriate for PT/OT and ST services.                                                    

The insurer's denial of coverage for pediatric medical day care 5 days per week is modified to allow for 3 days of pediatric medical day care. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cystic Fibrosis.
Treatment: Durable medical equipment (vest system).

The insurer denied the Durable medical equipment (vest system).  The denial is overturned.

The patient is a male with cystic fibrosis. The patient is on trikafta and pulmozyme and has bronchiectasis due to cystic fibrosis. The patient was prescribed vest therapy. The patient has been on vest therapy since childhood. The patient has tried and failed manual chest physiotherapy.

This request was denied due to lack of medical necessity. This denial is being appealed.

Yes, the proposed treatment is "medically necessary."

This patient with cystic fibrosis on trikafta and pulmozyme who has bronchiectasis due to cystic fibrosis was prescribed vest therapy. The patient has been on vest therapy since childhood. The patient has tried and failed manual chest physiotherapy. 

This request was denied due to lack of medical necessity based on the durable medical equipment (DME) guidelines. However, it is medically necessary as the patient has been on the vest therapy since childhood and the current device is over ten years old. The patient has had worsening pulmonary symptoms when off vest therapy. The continuation of vest therapy is medically necessary. Not continuing vest therapy is likely to lead to negative outcomes including hospitalization, acute respiratory failure and possible premature death.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Vest therapy is medically necessary as the patient has been on the vest therapy since childhood and the current device is over ten years old. The patient has had worsening pulmonary symptoms when off vest therapy. The continuation of vest therapy is medically necessary. Not continuing vest therapy is likely to lead to negative outcomes including hospitalization, acute respiratory failure and possible premature death.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered mental status.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned. 

The patient is a female with Down syndrome who presented with worsening altered mental status for the past several months. Review of system was positive for drooling, body twisting and 20 lb (pound) weight loss. The patient was afebrile (Temperature of 99.6). She was described as non-toxic appearing and in no acute distress. Her blood pressure was 127/78, pulse rate of 78, respiratory rate of 18, and oxygen saturation of 94% on room air. Physical examination was unremarkable for positive clinical findings. The patient was admitted for altered mental status with posturing. 

The inpatient admission was medically necessary. The care could not have been safely rendered at a lower level of care.

The patient was admitted for chronic worsening of mental status in the setting of Down's syndrome. The documentation describes chronic altered mental status with worsening features with pre-existing Down syndrome. The workup necessitated an inpatient level of care for magnetic resonance imaging (MRI), cerebrospinal fluid (CSF) studies and expert consultations.
Patients with Down syndrome are prone to infections such as encephalitis and dementia. Dementia is among the most serious public health concerns faced by elderly adults, with disease progression having devastating impacts on independent functioning and quality of life. Both congenital hypothyroidism and acquired hypothyroidism are common in patients with Down syndrome, with an estimated community prevalence varying from 9% to 35%. In this case, the patient had a low thyroid stimulating hormone (TSH) and was at risk for alerted mental status requiring dementia workup. An Inpatient level of care was necessary for worsening and chronic progression of mental status changes.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Respiratory System/Asthma
Treatment: Pharmacy/Prescription Drugs - Xolair
The health plan denied the requested medication, Xolair, as not medically necessary. 
The health plan's determination is overturned.

The patient is a woman who was prescribed Xolair by an allergist/immunologist to treat severe persistent asthma. She has received Xolair 375 mg (milligrams) every 2 weeks with dramatic improvement in asthma control. The patient is no longer requiring oral steroids bursts outside of viral infections. She has access to Symbicort.

At issue is the medical necessity for the requested medication, Xolair.

The health plan's determination is overturned, in whole.

Xolair was previously denied due to lack of documented improvement with Xolair use and the lack of documented inhaled corticosteroid use. 

Provider documentation supports that both criteria for continuation of therapy have been met. Xolair is medically necessary. The patient has had sustained clinical improvement with Xolair and has access to inhaled corticosteroid therapy for maintenance and rescue asthma therapy. Xolair is considered the standard of care for severe persistent allergic asthma uncontrolled on standard inhaled asthma therapies. [1]
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hip fracture
Treatment: Skilled nursing facility subacute rehabilitation level 1
The insurer denied skilled nursing facility subacute rehabilitation level 1.
The determination is upheld.


The patient has a history of right femoral neck fracture treated with right open reduction internal fixation (ORIF) hip surgery. At issue is whether the requested health service/treatment of skilled nursing facility subacute rehabilitation level 1 is medically necessary for this patient.
The requested health service/treatment of skilled nursing facility subacute rehabilitation level 1 is not medically necessary for this patient.
The patient has a history of a right femoral neck fracture treated with right ORIF hip surgery. She was alert and oriented. She was on a regular diet. She was independent with set up for eating and hygiene She was continent of bowel and bladder. The physical therapy notes indicate that she was independent with bed mobility. The physical therapy notes indicate that she could ambulate 200 feet using a two wheeled walker.  The occupational therapy notes indicate that she was independent with toilet transfers and could perform lower extremity dressing with setup or clean up assistance. The physical therapy notes stated that she was independent with chair/bed to chair transfers and ambulated 13 steps with supervision or touching assistance. The patient could participate in a home exercise program to include strengthening, range of motion, and functional exercises.
The requested health service/treatment of skilled nursing facility subacute rehabilitation level 1 is not medically necessary as she had functional independence with bed mobility, transfers, ambulation, dressing, feeding, hygiene, and toileting. The peer-reviewed medical literature in the United States at this time would not include the requested health service/treatment of skilled nursing facility subacute rehabilitation level 1. Further the medical standard of care in the United States at this time would not include the requested health service/treatment of skilled nursing facility subacute rehabilitation level 1.