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

Diagnosis: Dementia, abnormalities of gait and mobility, urinary incontinence

Treatment: Increase in Personal Care Worker (PCW) services to 7 days per week, 12 hours per day for a total of 84 hours per week

The insurer denied coverage for an increase in Personal Care Worker (PCW) services to 7 days per week, 12 hours per day for a total of 84 hours per week
The denial is overturned

This is a patient with chronic medical problems including dementia. She lives alone in a private home. She is currently approved for Personal Care Worker (PCW) services 8 hours/day, 7 days/week for a total of 56 hours/week. The patient is requesting an increase in Personal Care Worker (PCW) services, 7 days/week, 12 hours/day; totaling 84 hours/week, which is currently under review.  
  
Cognitive function is described as being "severely impaired- she never or rarely makes decisions." She requires maximal assistance for bathing, personal hygiene, dressing, and toilet use. She is frequently incontinent of bladder and continent of bowel. Her condition has declined over the past 90 days. Extensive assistance is required for bed mobility and ambulation. According to her treating physician, the patient has fallen several times and sustained rib fractures. This physician agrees with the patient's treating physician. The combination of the patient's cognitive deficits, significant functional impairments, and overall functional decline, support the medical necessity of the requested PCW services of 12 hours/day, 7 days/week.  

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

The insurer's denial of coverage for increase in Personal Care Worker (PCW) services to 7 days per week, 12 hours per day for a total of 84 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal/Back Pain
Treatment: Pain Management
The health plan denied the requested epidural steroid injections as not medically necessary. 
The health plan's determination is overturned.

This is a female who has severe right leg pain consistent with lumbar radiculopathy. This patient had bilateral (lumbar) L4 transforaminal epidural steroid injections and physical therapy (PT), which was only partially successful. A more recent magnetic resonance imaging (MRI) revealed a (lumbar/sacral) L5S1 disc herniation with severe narrowing of the right lateral recess and compression of the descending right (sacral) S1 nerve root. She was recommended to have a right sided transforaminal epidural steroid injection.
The issue is whether this right sided transforaminal epidural steroid injection is medically necessary.

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

Yes. this patient has severe radicular pain from a L5S1 disc herniation with severe narrowing of the right lateral recess and compression of the descending right S1 nerve root. She tried one epidural steroid injection and PT without adequate pain relief. Further interventions including a repeat epidural injection and possible surgery are considered medically necessary due to her severe radicular pain, and MRI findings of L5S1 disc herniation. Therefore, it should be attempted before surgery.
This recent MRI revealed a L5S1 disc herniation with severe narrowing of the right lateral recess and compression of the descending right S1 nerve root. Another epidural steroid injection is medically necessary to control her severe radicular pain.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left-Sided Weakness
Treatment: Inpatient admission
The insurer denied the inpatient admission
The denial is overturned

The patient is a woman with past medical history of lupus, atrial fibrillation, hypertension and idiopathic intracranial hypertension. She presented with left-sided weakness.

The patient's hospitalization workup was unremarkable. Neurological consultation thought that a stroke was unlikely and that the weakness was functional.

Coverage of the inpatient admission was denied by the health plan as not medically necessary. This denial is being appealed.

Yes, the Inpatient admission was medically necessary.
The patient had left-sided weakness, which was determined to cause functional impairment. According to MCG (Milliman Care Guidelines) guidelines, inpatient admission is indicated when there is weakness that causes functional limitations, which was the case in this patient requiring expedited workup. Although she did not have a stroke, atrial fibrillation is a strong risk factor for stroke, and therefore admission was indicated at the time of admission.

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

The patient met MCG (Milliman Care Guidelines) guidelines due to her weakness causing functional impairment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malignant neoplasm of the tongue.

Treatment is long term custodial care.

The insurer denied coverage for long term custodial care.
 
The denial is upheld.

This case involves a patient with a history of malignant neoplasm of the tongue, systemic sclerosis of the tongue status-post resection, chemoradiation, obsessive-compulsive disorder, deep vein thrombosis, and a gastrostomy tube.

It was noted that the patient refused to leave the facility. Everything was set for discharge.  However, the patient refused to pack belongings and leave the facility.  There was discussion regarding changing the patient's insurance. He was alert and responsive to all stimuli. He ambulated independently in his room with a steady gait. It was noted that he had received a cane for discharge planning. He was on as needed Dilaudid every 4 hours and lorazepam with good results. It was noted that everything had been set for the patient's discharge home. The patient was independent in daily decision making. His speech was mumbled. He was able to make some needs known. He reported feeling down or depressed, sleep cycle issues, and feeling tired or having little energy. No behaviors were reported. It was stated that discharge back to the community was feasible at this time.  

Per the MCG (Milliman Care Guidelines) custodial care may be indicated for those with serious mental illness that resulted in moderate dysfunction in daily living related to admission diagnosis for at least 3 months. The documentation should identify that custodial care is needed for non-health related services such as active management needs including supportive activity of daily living, preparation of special diet, and self-administration of medication, rather than provision of skilled services. The health-related services are primarily for the purpose of meeting personal patient needs or maintaining level of function, when care needs are more continuous in nature and can be provided with intermittent home care.  It may be appropriate for patients who do not have caregivers who can provide supportive care needs. The patient was stable with his feeding regimen. There were no issues with placement as it was noted that there was a prior plan for discharge home with all outpatient needs in place. The patient could direct their own care and was independent with daily living activities. The documentation did not support that the patient's care could not be completed at a lower level such as with outpatient follow-up and/or home visits. Thus, the custodial care is not medically necessary. As such, the denial of coverage for long term custodial care was appropriate and is upheld.

The insurer's denial of coverage for long term custodial care is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Face pain
Treatment is an inpatient admission 	
The insurer denied coverage for an inpatient admission 
The denial is upheld

The patient has the medical diagnosis of face pain. The patient has been seen and treated for facial pain in the emergency service department. The patient was seen in the ED (emergency department) after falling off his bike, hitting his face. The patient had face pain, jaw pain, and hand pain. The patient had a tooth fracture. A computerized tomography (CT) scan of the head, computerized tomography (CT) scan of the maxillofacial and an x-ray of both hands were performed STAT (immediately). A computerized tomography (CT) of the head showed ventriculomegaly with a possible cyst in the third ventricle. The magnetic resonance imaging (MRI) of the brain shows a large third ventricular arachnoid cyst producing architectural deformity and advanced chronic ventriculomegaly. The patient was seen by neurosurgery and deemed unstable for discharge. The patient was admitted for inpatient evaluation, treatment and monitoring. Neurological assessments were performed and there were no deficits. The patient denied memory issues, incontinence or balancing trouble. The patient had no evidence of papilledema. Hospital admission was for neurologic abnormalities including one or more of the following hydrocephalus. 

The patient improved sooner than anticipated. The patient was seen in the Emergency Department (ED) for pain in the face. The patient fell riding his bike when he hit a bump and struck his face. Unsure if he had loss of consciousness (LOC). The patient denied headache, blurred vision, and difficulty ambulating. A neurologic examination was entirely normal. The patient was seen by NS (neurosurgery) and no emergent intervention was recommended. Exam shows no abnormalities. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.      

Inpatient hospital admission was not medically necessary for this patient

The patient was without symptoms or signs of neurologic abnormalities that would indicate need for hospital admission. The patient was stable. The imaging findings were chronic in nature, not emergent. Therefore, the request is denied and not medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Orthopedic/Musculoskeletal. - Psoriatic Arthritis. 
Treatment: Pharmacy/Prescription Drug. 
The insurer denied Xeljanz. 
The denial is upheld. 

The patient is a male with psoriatic arthritis. The issue in this case is Xeljanz XR 11 milligrams (mg) daily is being denied by the health plan. Per the health plan's policy, Xeljanz is allowed if the patient has a documented inadequate response or intolerance to at least one tumor necrosis factor (TNF) inhibitor. Per a letter from the patient's provider the patient he 'is in recovery and has severe apprehensions about self-injections.' Prior treatment: he has failed methotrexate (MTX), Plaquenil and sulfasalazine.
The subject under review is the medical necessity for Xeljanz.

The health plan's determination is upheld.

The requested health service/treatment of Xeljanz XR 11mg is not medically necessary for this patient. The patient does not have a contraindication to trying a TNF inhibitor. Per the plan's policy, Xeljanz is allowed if the patient has a documented inadequate response or intolerance to at least one TNF inhibitor. The patient does not have a contraindication to trying a TNF inhibitor, such as an active infection, hepatitis B, tuberculosis, heart failure, or multiple sclerosis.
According to UpToDate, in patients with psoriatic arthritis (PsA) 'whose joint counts do not improve substantially after three months of treatment with a conventional non-biologic disease modifying anti-rheumatic drug (DMARD) (e.g., methotrexate [MTX]) or who still have more than three tender and swollen joints, we recommend a TNF inhibitor'. There are myriad studies supporting the use of TNF's in PsA. For example, a study published in J Rheumatology in 2007 concluded that 'patients who had active PsA and a previous, inadequate response to DMARD therapy, adalimumab was well tolerated and significantly reduced the signs, symptoms, and disability of PsA during 12 weeks of blinded and 12 weeks of open-label therapy. Adalimumab also improved psoriasis in these patients'. Another study published in the Lancet in 2000 found that 'etanercept offers patients with psoriatic arthritis and psoriasis a new therapeutic option for control of their disease'.
Appeal type: Medical necessity
Decision: Upheld

Pregnancy/childbirth
Infertility treatment

Diagnosis: infertility
Treatment: In-vitro fertilization
The insurer denied In-Vitro Fertilization. The health plan's determination is upheld. 

The patient is female who presents with secondary infertility. Her other pregnancies and deliveries were with a prior partner. A HSG (hysterosalpingogram) showed bilateral tubal blockage and uterine polyps. She had a history of chlamydia and an intrauterine device (IUD).
Labs showed AMH (anti-mullerian hormone) 0.03; and follicle-stimulating hormone (FSH) 30.6. She has undergone 3 cycles of in vitro fertilization (IVF) with poor stimulation and no embryos to transfer. Her spouse is azospermic. Sperm is from a testicular biopsy sample. The patient is requesting coverage for IVF. 

The patient does not meet criteria to move forward with IVF. At her age, her chances of a live birth are < (less than) 5%. She has evidence of diminished ovarian reserve based on stimulation results and her AMH of 0.03. Her AMH level is below minimal values to qualify for IVF. Her antral follicle count is < 7.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: infertility
Treatment: In-Vitro Fertilization
The insurer denied In-Vitro Fertilization. The health plan's determination is upheld. 

The patient is female who presents with secondary infertility. Her other pregnancies and deliveries were with a prior partner. A HSG (hysterosalpingogram) showed bilateral tubal blockage and uterine polyps. She had a history of chlamydia and an intrauterine device (IUD).
Labs showed AMH (anti-mullerian hormone) 0.03; and follicle-stimulating hormone (FSH) 30.6. She has undergone 3 cycles of in vitro fertilization (IVF) with poor stimulation and no embryos to transfer. Her spouse is azospermic. Sperm is from a testicular biopsy sample. The patient is requesting coverage for IVF. 

The patient does not meet criteria to move forward with IVF. At age 50, her chances of a live birth are < (less than) 5%. She has evidence of diminished ovarian reserve based on stimulation results and her AMH of 0.03. Her AMH level is below minimal values to qualify for IVF. Her antral follicle count is < 7.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Skin Disorders- Excess Skin
Treatment: Surgical Services-Panniculectomy
The health plan denied the requested service of Panniculectomy as not medically necessary. 
The reviewer has upheld in whole the health plan's determination.

This patient complains of excess abdominal skin. She complains of back pain and chronic rashes in the folds under her pannus. She has depression due to the appearance of her pannus. She has treated her rashes with powders and creams with no improvement Her surgeon recommends abdominoplasty with liposuction. Photos show a female with an abdominal pannus. Panniculectomy is planned. 

The panniculectomy is not medically necessary. The patient is reported to have back pain and rashes. Records documenting a workup for back pain are not provided for review. With regard to rashes, the medical records do not provide documentation in the form of primary care physician (or provider) or dermatology progress notes that describe ongoing clinically significant dermatologic problems that have either 1) never responded to physician directed topical therapy or 2) despite initial response, have recurred and caused significant functional impairment. The patient is not sick from her excess skin, and has not had ulcerations, panniculitis, or sepsis from her infections. A dermatologist has not evaluated the rashes. The patient has not required hospitalization or treatment with intravenous (IV) or oral antifungal or antibiotic medications. The excess skin has not jeopardized her health. Physician supervised treatment is the simplest, safest, and most cost-effective method of managing this patient's problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. 
In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi et al. the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, conservative, non-operative treatment would be recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. Summary treatment letters and member appeal testimonies in the absence of physician office note documentation of specific dates of treatments and medications prescribed do not provide sufficient documentation to confirm the failure of medically supervised care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) Accident
Treatment: Non Emergency Air and Ground Ambulance
The insurer denied the Non Emergency Air and Ground Ambulance
The denial is overturned

The patient is a male with history of Motor Vehicle Accident (MVA). He sustained
brain and cervical spine injuries that included subarachnoid hemorrhage, intra-
ventricular hemorrhage, fractured nasal bones and the maxilla with
fractured/displaced nasal septum, hemorrhage in the ethmoid and maxillary
sinuses, minimally displaced fracture of C2 (second cervical spine vertebra) right
transverse process with extension into the vertebral canal, apical emphysema, etc.

The patient was intubated. He was placed on Mechanical ventilation. He was on
PT/OT/SLP (physical therapy/occupational therapy/speech language pathology)
rehabilitation. He was alert and oriented x 1 and requiring moderate-maximum
assistance while unable to ambulate more than 2 steps.

The patient was transferred by air ambulance from the Medical facility out of the
country to a location close to the patient's family, to a rehabilitation for Traumatic
Brain Injury. This is a distance of approximately 1,600 miles without option for a
ground transportation. The alternative would have been by boat, which would have
been high safety risk for the patient, because of his injuries and the longer time it
will take for transportation.

Yes, the Non Emergency Air and Ground Ambulance was medically necessary.

The requested air transportation in this instance is medically necessary based on
standard guidelines. It was in accordance with generally accepted standards of
Medical practice for transportation of that type of patient with such type of condition
over such a long distance of transportation. Therefore, it is clinically appropriate, it
is not mainly for the convenience of his physician or any other health care provider,
and not more intensive than an alternative mode of transportation, which has to be
other forms of air transportation applicable in this instance.

It is applicable in this instance because the patient was transferred from the Medical
facility out of the country to location close to family in a rehabilitation for Traumatic
Brain Injury, which is a distance of approximately 1,600 miles without option for a
ground transportation. The alternative would have been by boat, which would have
been high safety risk for the patient because of his injuries and the longer time it will
take for transportation. The need to move him is to enable him to be close to his
family and health-care, which are an essential part of recovery and rehabilitation of
those with Traumatic Brain Injury, and therefore making this medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the
best interest of the patient.
The denial by the heath plan to cover the air transportation would deny the patient
with huge cognitive defect due to Traumatic Brain Injury access to resources and
family members that can quickly help him towards recovery.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: s/p (status post) Accident
Treatment: Non Emergency Air and Ground Ambulance
The insurer denied the Non Emergency Air and Ground Ambulance
The denial is overturned

The patient is a male with history of Motor Vehicle Accident (MVA). He sustained brain and cervical spine injuries that included subarachnoid hemorrhage, intra-ventricular hemorrhage, fractured nasal bones and the maxilla with fractured/displaced nasal septum, hemorrhage in the ethmoid and maxillary sinuses, minimally displaced fracture of C2 (second cervical spine vertebra) right transverse process with extension into the vertebral canal, apical emphysema, etc.

The patient was intubated. He was placed on Mechanical ventilation. He was on PT/OT/SLP (physical therapy/occupational therapy/speech language pathology) rehabilitation. He was alert and oriented x 1 and requiring moderate-maximum assistance while unable to ambulate more than 2 steps.

The patient was transferred by air ambulance from the Medical facility out of the country to a location close to the patient's family, to a rehabilitation for Traumatic Brain Injury. This is a distance of approximately 1,600 miles without option for a ground transportation. The alternative would have been by boat, which would have been high safety risk for the patient, because of his injuries and the longer time it will take for transportation.

Yes, the Non Emergency Air and Ground Ambulance was medically necessary.

The requested air transportation in this instance is medically necessary based on standard guidelines. It was in accordance with generally accepted standards of Medical practice for transportation of that type of patient with such type of condition over such a long distance of transportation. Therefore, it is clinically appropriate, it is not mainly for the convenience of his physician or any other health care provider, and not more intensive than an alternative mode of transportation, which has to be other forms of air transportation applicable in this instance.

It is applicable in this instance because the patient was transferred from the Medical facility out of the country to location close to family in a rehabilitation for Traumatic Brain Injury, which is a distance of approximately 1,600 miles without option for a ground transportation. The alternative would have been by boat, which would have been high safety risk for the patient because of his injuries and the longer time it will take for transportation. The need to move him is to enable him to be close to his family and health-care, which are an essential part of recovery and rehabilitation of those with Traumatic Brain Injury, and therefore making this medically necessary.

Yes, the health plan did act reasonably, with sound medical judgment, and in the best interest of the patient.
The denial by the heath plan to cover the air transportation would deny the patient with huge cognitive defect due to Traumatic Brain Injury access to resources and family members that can quickly help him towards recovery.