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

Diagnosis: syncope.

Treatment is an inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is upheld.

This case involves an elderly female who presented to the emergency department by ambulance. It was noted that the patient's spouse found her lying in the bathroom. The patient was unable to remember what happened. It was noted the patient was unconscious for approximately 10 minutes and was confused after being aroused. Past medical history was significant for myoclonic jerks and hypertension. Per the patient's spouse she ran out of clonazepam 2 days ago and had been ambulating less and acting differently. It was noted that the electrocardiogram (EKG) revealed biphasic T waves (interval on an EKG) inferolaterally. There was also initially minimally elevated troponin at 0.05. A repeated troponin level was .03 ng (nanogram)/ml. 

The treatment plan included an additional work-up including a computerized tomography (CT) scan. The history and physical noted a CT scan revealed chronic microvascular ischemic changes. A CT scan of the cervical spine noted diffuse degenerative changes with neuroforaminal narrowing. The patient was admitted for syncope likely cardiogenic versus neurological.  Treatment plan included neurology consultation and magnetic resonance angiography (MRA) of head and neck. Neurology consultation recommended an electroencephalogram (EEG) and magnetic resonance imaging (MRI) of the brain. Follow-up noted the patient was speaking clearly. An EEG was noted to be normal.  

Milliman Care Guidelines (MCG) recommends inpatient admission for syncope when there is hemodynamic instability, altered mental status that is severe or persistent, injury requiring hospitalization, severe/persistent dehydration, or cardiac disease that indicates necessity of immediate intervention. In this case, the patient presented to the emergency department status post syncopal episode with loss of consciousness. Initial evaluation included negative acute findings on the CT scan. There were biphasic T waves inferolaterally on the EKG. The Troponin levels were not consistent with an acute event. The patient remained hemodynamically stable and there was no evidence of persistent and severe altered mental status. There was a lack of documentation of acute cardiac disease or findings that necessitated immediate intervention.  

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an inpatient stay is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Potential overdose
Treatment is a full hospital admission
The insurer denied coverage for a full hospital admission
The denial is upheld

The patient is an adult male with a past medical history significant for traumatic brain injury, atrial fibrillation, asthma, and hypothyroidism who presented to the emergency room with complaints of "increased tiredness" after taking Xanax (three 1.0 mg (milligrams) tablets). 

Vitals on presentation included: Temperature 97.0 degrees F (Fahrenheit), Blood Pressure 138/80 mmHg (millimeters of mercury), Pulse 114 bpm (beats per minute), Respiratory Rate 16 bpm, oxygen saturation 100% (percent) on room air. Laboratory values were notable for the following: White Blood Cells (WBC) 8.0, hemoglobin (Hgb) 12.9, hematocrit (Hct) 38.0, creatinine 1.05 and a Glucose 96.

The patient was admitted to the hospital for a possible Xanax overdose. He tested COVID positive. A CXR (chest x ray) showed increased interstitial markings without a suspicious focal airspace opacity. He was fully COVID vaccinated. The patient remained afebrile and hemodynamically stable and was discharged to continue outpatient management.

He presented with tiredness after taking Xanax. Otherwise, he was afebrile, hemodynamically stable with normal oxygen saturation on room air. Laboratory findings were unremarkable including normal WBC. According to documentation, the patient was fully vaccinated for COVID and denied any "palpitation, dizziness, shortness of breath, any sick contacts, nausea, vomiting, diarrhea and any other acute symptoms. 

Documentation showed no hypoxia, and oxygen saturation of 95 % on room air, therefore he was not a candidate for remdesivir/dexamethasone. The admission for COVID was not supported.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dizziness
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male who presented with vertigo, nausea, and gait unsteadiness. The patient's computed tomography (CT) of the head did not show any acute changes. Magnetic resonance image (MRI) of the brain was performed which did not show any acute changes. Inpatient admission was denied by the plan as it did not meet level of care.

The inpatient admission was not medically necessary.

It was suspected that the patient had a transient ischemic attack. Milliman Care Guidelines (MCG) 26th Edition - Neurology indicates that inpatient admission is medically necessary when neurologic deficits are severe or progressive. This was clearly not the case with this patient. The patient's computed tomography (CT) of the head did not show any acute changes. Magnetic resonance image (MRI) of the brain was performed which did not show any acute changes. The patient did not have severe or progressive neurologic deficits.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: advanced dementia.
Treatment: Personal Care Services 24 hours a day, 7 days a week of Split-Shift total of 168 hours per week.
The insurer denied: Personal Care Services 24 hours a day, 7 days a week of Split-Shift total of 168 hours per week.
The denial is: Upheld.

This is a case review for a female with medical history notable for advanced dementia, incontinence, and falls. The patient was approved for 24 hour per day, 7 days per week, split shift (168 hours) of personal care services. The patient's health plan reduced these services to 24 hour per day 7 days per week live-in (91 hours). The patient's care team is appealing this reduction, which is the subject under review. 

A Uniform Assessment System (UAS) was completed and was available for review. Cognition was severely impaired. She was alert but not oriented and unable to make her needs known. From a functional standpoint, she requires total dependence for nearly all Instrumental activities of daily living (IADLs). For her activities of daily living (ADLs), she requires maximal assistance for all (except for bed mobility which requires extensive assistance). She is incontinent of urine and stool with no control present. She requires hands on assistance for all transfers and for toileting.

The requested health service of Personal Care Services 24 hours a day, 7 days a week of Split-Shift total of 168 hours per week has not been demonstrated to be medically necessary for this patient.
The patient has been approved for 24-hour care (live-in). In order to qualify for the increase in services to split-shift, there must be a demonstrated personal care need that would preclude a 5 hours period of rest for the live-in aide. There is no clear medical documentation that the patient cannot go five hours at night without assistance. She has a history of wandering, but prevention of wandering is not a personal care function. There is no request for turning in bed due to pressure ulcer, and no requested nighttime incontinence care. Safety monitoring and supervision without a personal care function is not a covered service. Therefore, it has not been clearly demonstrated that increasing from live-in to split-shift 24 hour care is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite
Treatment: D8080 Braces, D8670 Monthly Visit
The insurer denied: D8080 Braces, D8670 Monthly Visit
The denial is overturned

The patient is an adolescent female. The request is for orthodontic benefits for treatment and monthly follow up visits. The patient's clinical history is not included in the submitted records. The health plan denied coverage of the request due to the patient scoring 20 on the handicapping index scale. The denial is being appealed.

The braces and monthly visits are medically necessary.

The patient has a crossbite of an anterior tooth (#10) with clinical attachment loss and recession of the gums. This is an automatic qualifier, according to the handicapping index scale.

Therefore, given the above, the braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Personal Care Aide (PCA) services, for a total amount of 79 hours/week
The insurer denied the PCA services, for a total amount of 79 hours/week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for dementia, gait dysfunction, and incontinence. The patient is currently approved for 10 hours/day, 6 days/week and 7 hours/day, 1 day/week (67 hours/week) of personal care services (PCS). The patient and her care team requested an increase to 12 hours/day, 6 days/week and 7 hours/day, 1 day/week (79 hours/week) and this request was denied by the health plan. 

The request for additional hours states the following: "Patient requires 2 additional hours of coverage Monday through Friday because no one is home to care for her until after 8 pm (both her daughter and son-in-law are self-employed and work 8 am to 8 pm at a minimum)." The request states that she has had several falls while home alone.

A Uniform Assessment System (UAS) was completed and was available for review. The patient lives with her daughter's family. The patient was alert and oriented to person and place only. Her recall was 0 out of 3 at five minutes and she is able to follow 2 out of 3 steps in a procedural command. She is unable to direct her own care. For her instrumental activities of daily living (IADLs), she has total dependence for meals, housework, finances, shopping, and transportation. She requires maximal assistance for medications, phone use, and stairs. For her activities of daily living (ADLs), she requires maximal assistance for bathing, hygiene, dressing upper body, dressing lower body, and toilet use. She requires extensive assistance for walking, locomotion, toilet transfers, and bed mobility. She requires weight bearing assistance for essentially all activities. She requires assistance with toileting and changing pullups. She is frequently incontinent of urine and occasionally incontinent of stool.

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The requested health service of personal care aide (PCA) services, for a total amount of 79 hours/week is medically necessary for this patient. The patient has care needs which can be expected to be continuous and unscheduled in nature. She has incontinence and needs assistance with toileting and managing incontinence care products. 

Her falls during times without any PCA are evidence of unmet personal care needs. Her family provides assistance during many hours of the week, and if they cannot provide informal support, then it is medically necessary for her to be provided with personal care assistance to cover these additional hours. Failure to provide coverage could result in skin breakdown and/or infection.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cellulitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is overturned

The patient is elderly with past medical history significant for hypertension, hyperlipidemia, right bundle branch block (RBBB), type II diabetes mellitus, neuropathy, anemia, gastroesophageal reflux disease (GERD), and possible dementia who was referred to the emergency department with complaints of worsening left wrist pain, swelling and decreased range of motion.

Vitals on presentation included: Temperature 97.6 F (Fahrenheit), Blood Pressure 226/101, Pulse 94, Respiratory Rate 22, and oxygen (O2) saturation 98% (percent) on room air. Laboratory results included the following: white blood cell count (WBC) 10.4, Hgb (hemoglobin)-12.5, Hct (hematocrit)-37.9, glucose-137, creatinine-0.53, C reactive protein (CRP)-28.11, and an erythrocyte sedimentation rate (ESR)of 47.

The patient was started empirically on intravenous antibiotics (vancomycin and Zosyn). An X-ray of the left wrist showed no evidence of an acute fracture or dislocation; but saw osteopenia, calcific tendinitis, and chondrocalcinosis. A Computed tomography (CT) scan of the left upper extremity noted mild diffuse subcutaneous edema with a tiny peripherally enhancing fluid collection immediately adjacent to the hamate. Orthopedics was consulted- "no concern for septic wrist joint at this time. No acute orthopedic surgical intervention at this time." Infectious Diseases also consulted and recommended antibiotics. The patient remained afebrile and hemodynamically stable. She was discharged to continue follow-up as an outpatient.       

According to documentation, the patient was admitted with a left wrist infection. She was afebrile, but hemodynamically unstable (blood pressure 226/101). The patient was described as "in distress," reporting 10 out of 10 pain. Laboratory abnormalities including elevated glucose and increased inflammatory markers (CRP and ESR). She required intravenous antibiotics and a surgical evaluation. Based on the above findings in a high-risk patient with multiple co-morbid conditions, hospital admission was medically necessary. 

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 the inpatient hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Autism
Treatment: Personal Care Assistance (PCA) care: 17 hours/week
The insurer denied the PCA care: 17 hours/week.
The health plan's determination is overturned.

This is the case of a child with autism spectrum disorder, who is nonverbal (Bengali speaking). The patient currently receives 13 hours/week PCA (personal care assistance) services to assist with activities of daily living (ADLs). She attends a school for children with disabilities (6:1:3 class) where she receives speech, physical therapy (PT), and occupational therapy (OT) services. Records indicate that the patient needs direct supervision at all times for personal safety. She uses a communication book to indicate needs but is inconsistent with use. Assistance is needed with toileting, feeding, bathing, and dressing in addition to maintaining safety.

The requested PCA of 17 hours/week is considered medically necessary for this patient. Per Centers for Medicare and Medicaid Services (CMS) guidelines, personal care services are designed to keep individuals in their homes rather than nursing homes or institutions. Based on the conditions noted above, PCA of 17 hours/week is reasonable and medically necessary. This patient with profound autism is unable to communicate needs or to remember complex tasks. She requires assistance with all ADLs. Comorbidities include developmental/language delays and anxiety.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is overturned.

This is a male patient with a history of moderate persistent asthma. His presenting complaints were shortness of breath, wheezing, cough, and chills. He had used albuterol inhalers and duonebs at home without relief. On arrival to the emergency department (ED), the patient's vital signs were blood pressure 110/49, heart rate 112, and respiratory rate 18, with an oxygen saturation of 94 percent (%) on room air. The physical exam was notable for rhonchi and diffuse wheezes. Lab results were notable for influenza A positivity. Radiology was notable for a chest x-ray with mild bronchial wall thickening. The patient was treated for an asthma exacerbation secondary to influenza in the ED, and on re-evaluation still had not achieved clinical improvement. He was then admitted to an inpatient level of care for further treatment. At issue is the medical necessity of an inpatient hospital stay.

The requested inpatient hospital stay was medically necessary.

The patient presented with signs and symptoms consistent with a moderate asthma exacerbation, with dyspnea, cough, wheezing. Outpatient therapy with nebulizers and inhalers was unsuccessful in alleviating his symptoms. He was treated with steroids, magnesium, and nebulizer therapy in the ED over about 6 hours but did not achieve clinical improvement. He remained dyspneic and wheezing. Given his persistent symptoms despite initial therapy in the ED, inpatient hospital admission was medically necessary to carefully treat his symptoms, respond to clinical worsening, and monitor him carefully.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Congestive heart failure 
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) Services for a total of 168 hours/week (split shift) 
The insurer denied an increase in CDPAP services for a total of 168 hours/week (split shift). 
The denial is overturned. 

This is an appeal of the denial of an increase in consumer directed personal assistance program (CDPAP) services for a total of 168 hours/week (split shift) for this elderly female. The plan approved 52.5 hours/week. The plan notes that UAS (Uniform Assessment System) evaluation performed 3 months ago shows decline in upper body dressing, personal hygiene, bed mobility, and eating compared to UAS evaluation completed last year. A letter from the member's daughter notes the member has congestive heart failure with lower extremity edema, history of back injury, difficulty standing, osteoarthritis, abdominal hernia, and pain. She has frequent urination due to diuretic medications. She uses a walker for ambulation. She uses a CPAP (continuous positive airway pressure) and requires assistance with adjusting her oxygen concentrator. She has memory loss. She needs assistance with medications. Letters from the provider note the member has been progressively declining. She lives alone and requires total support with personal care and IADLs (instrumental activities of daily living). She had multiple falls while attempting to transfer or ambulate. She requires verbal cueing. She requires assistance intermittently overnight. A letter from another provider notes the member requires continuous supplemental oxygen and nocturnal non-invasive ventilation. 

The proposed treatment is medically necessary. 

Personal care service (PCS) is necessary when assistance cannot be met from use of informal caregivers, by formal services, or by adaptive or specialized equipment or supplies. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. This member has multiple several chronic conditions. She is appealing the denial of an increase in CDPAP services for a total of 168 hours/week (split shift). The plan approved 52.5 hours/week. The UAS evaluation performed 3 months ago shows declining in upper body dressing, personal hygiene, bed mobility, and eating compared to UAS evaluation completed last year. Appeal statements indicate that the member is functionally declining. She requires both day and nighttime assistance with ADLs (activities of daily living), including ambulation and toileting. The information supports that the member has significant impairment that cannot be met with the approved CDPAP of 52.5 hours/week. Therefore, the increase in CDPAP services for a total of 168 hours/week (split shift) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Type 1 diabetes.
Treatment: Insulin Pump.
The insurer denied: Insulin Pump.
The denial is overturned.

The patient is a male with type 1 diabetes. The patient has been on multiple daily insulin injections for the past year. He was previously on an insulin pump with warranty expiration date almost a year ago. Glycated hemoglobin (A1C) was 8.3%. Time it was in range was 24%. The subject under review is the medical necessity for an insulin pump which was denied by the plan.

The requested insulin pump is medically necessary for this patient for the management of type 1 diabetes. This patient's current pump is out of warranty. The patient has been on multiple daily insulin injections for the past year with marked hyperglycemia with a time in range of 24%, which is well below the target of 70%, and an elevated A1C of 8.3%. The use of insulin pump therapy in this clinical situation is supported by the Endocrine Society guidelines and the American Diabetes Association clinical guidelines. The insulin pump has been shown to significantly reduce hyperglycemia. Without the requested insulin pump, this patient will be at high risk of ongoing hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Episodic Migraine.
Treatment: Aimovig.
The insurer denied: Aimovig.
The denial is: Upheld.

The patient is a female with episodic migraine. She has tried and failed antidepressants, anticonvulsants, and beta-blockers for prevention of migraine. Aimovig is prescribed. The drug was denied because the member has not tried and failed Ajovy and Emgality. The provider appealed the determination.

Ajovy and Emgality have not been tried and failed. Ajovy and Emgality are effective for prevention of episodic migraine. The drugs are Food and Drug Administration (FDA) approved for the prevention of episodic migraine and literature supported for this indication. There are no data to show that Aimovig is superior to treatment with Ajovy and/or Emgality.