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

Diagnosis: Sepsis

Treatment: Continued inpatient hospital admission

The insurer denied coverage for continued inpatient hospital admission.

The denial is overturned.

The patient has a past gastric cancer for which he had Roux-en-Y done and was treated with eight cycles of chemotherapy. He was admitted to the hospital for the evaluation of dysphagia to both solids and liquids, with vomiting and weight loss. He was kept on nothing by mouth (NPO) and aspiration precautions were maintained. An esophagram  noted that the patient had moderate aspiration with the barium swallow. There was delayed passage of contrast through the esophageal-jejunal anastomosis. A nasojejunal tube was placed for feedings, and the patient was started on feedings. Exploratory laparoscopy revealed diffuse peritoneal carcinomatosis. A rapid response team (RRT) was called for hypotension. Cefepime and Flagyl were started.

It appears that he was not able to maintain diet and hydration and was made NPO, requiring maintenance hydration. GI (gastroenterology) series showed a hold-up at the previous anastomosis, confirming obstruction, and he aspirated during that test. Two days after admission, he went into ICU (intensive care unit) for the sepsis diagnosis. Thus, the plan did not act in the best interest of the patient.      

The patient was not able to maintain any kind of nutrition, so he had to be placed on intravenous fluids to maintain hydration. The patient was started on tube feedings, but then experienced hypotension and required ICU intervention. Once the patient was stabilized and tolerating tube feedings, the patient was discharged.

"Patients undergoing treatment for esophagogastric or esophageal cancer are exposed to a considerably high risk of malnutrition due to early obstruction of the gastrointestinal passage. Presently most of the patients undergo modern multimodal therapies which require chemoradiation or chemotherapy ahead of surgery. Therefore, reconstruction of the obstructed gastrointestinal passage is considerably delayed. Surgery as the only curative option after neoadjuvant treatment is the mainstay of therapy in this setting. However, many patients are at risk for the development of postoperative complications associated with the complexity of the surgical procedure. Therefore, enteral feeding as a prerequisite to avoid malnutrition represents a special therapeutic challenge." (Reim, et al, 2016).

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

The insurer's denial of coverage for continued inpatient hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Apraxia, chromosomal abnormality, dermatitis, and molluscum contagiosum

Treatment: Consumer Directed Personal Assistance (CDAP) services, for a total of 30 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance (CDAP) services, for a total of 30 hours per week

The denial is upheld 

The patient is a female with a history of apraxia, chromosomal abnormality, dermatitis and molluscum contagiosum.  She lives with her parents and siblings. She was approved for Consumer Directed Personal Assistance Services (CDPAS) totaling 18 hours/week.  Under review is the medical necessity for requested increased of CDPAS for a total of 30 hours per week.

According to the Uniform Assessment System (UAS) report and due to her underlying condition, it takes longer time for the patient, with assistance of caregivers, to complete activities of daily living tasks including personal hygiene, dressing and toilet use.  She is currently in the process of being potty trained. There is no reported significant difficulty with bed mobility and for ambulation she uses a "baby walker in the home."  She is reportedly non-verbal and receiving speech therapy. There has been no recent functional decline. The approved CDPAS of 18 hours/week is clinically appropriate to meet the functional needs of this patient. The requested CDPAS for a total of 30 hours per week is not medically necessary. 

The healthcare plan acted reasonably, with sound medical judgment and 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, Consumer Directed Personal Assistance Services, for a total of 30 hours per week is not medically necessary for this patient.  

The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Consumer Directed Personal Assistance services, for a total of 30 hours per week is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: degenerative joint disease, arthritis, back pain, diabetes, PTSD (post-traumatic stress disorder), and cellulitis
Treatment: Increase Personal Care Services (PCS) 8 Hours A day 5 Days  A Week for a Total of 40 Hours Per Week
The insurer denied the Increase Personal Care Services (PCS) 8 Hours A day 5 Days  A Week for a Total of 40 Hours Per Week
The denial is overturned.

The patient is a male. His medical conditions include degenerative joint disease, arthritis, back pain, diabetes, PTSD (post-traumatic stress disorder), and cellulitis. Denial of increase personal care services (PCS) 8 hours a day, 5 days a week for a total of 40 hours per week is being appealed. The health plan approved PCS (personal care service) 5 hours a day, 5 days a week for a total 25 hours per week.

Uniform Assessment Systems (UAS) evaluation completed showed minimally impaired cognition and functional status: total dependence with housework; maximal assistance with meal preparation, and shopping; extensive assistance with managing finances and medications, bathing, personal hygiene, and dressing; limited assistance with phone use, walking, locomotion, and toileting; and independent with bed mobility and eating. The patient's functional status has declined in the past few months due to increased weakness. He has bowel and bladder incontinence.

A letter from the patient's provider notes the patient is currently in inpatient rehabilitation since hospitalization for cellulitis. He has been in the bed for several months. He has difficulty walking since the infection.

Yes, the Increase Personal Care Services (PCS) 8 Hours A day 5 Days  A Week for a Total of 40 Hours Per Week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
Personal Care Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of increase per PCS (personal care service) 8 hours a day, 5 days a week for a total of 40 hours per week, is being appealed. The health plan approved PCS (personal care service) 5 hours a day, 5 days a week for a total 25 hours per week.

The patient has several chronic conditions, including a recent admission for cellulitis. He is in inpatient rehabilitation. Uniform Assessment Systems (UAS) evaluation completed showed the patient requires assistance with ADLs (activities of daily living) except bed mobility and eating. He has bowel and bladder incontinence. A letter from his provider notes that he has difficulty walking since infection. This patient has functional limitations that have deteriorated since recent cellulitis. Assistance with his functional limitations cannot be met with the approved 25 PCS (personal care service) hours per week. 

The proposed increase to PCS (personal care service) 40 hours per week is medically necessary to meet this patient's needs for assistance with ADLs (activities of daily living) and personal care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis.
Treatment: Tremfya, pre-service.

The insurer denied the Tremfya, pre-service.  The denial is overturned.

The patient is a man with psoriasis affecting the scalp, trunk, and extremities. His psoriasis is inadequately controlled with Cosentyx injections and topical medications. Tremfya (guselkumab) injections are requested.

Yes, the requested Tremfya (guselkumab) is medically necessary.
Tremfya (guselkumab) has proven to be more effective in the treatment of psoriasis than the health plan's preferred alternatives.

Two phase 3, multicenter, randomized, double-blind, placebo and active comparator-controlled studies, VOYAGE 1 AND VOYAGE 2, evaluated the efficacy and safety of TREMFYA (guselkumab) compared to placebo and adalimumab in patients with moderate to severe plaque psoriasis (PsO). In both studies, significantly more patients receiving TREMFYA (guselkumab) achieved the coprimary endpoints of an IGA (Investigator's Global Assessment) score of cleared (0) or minimal (1) and 90% improvement in Psoriasis Area and Severity Index (PASI 90) response at week 16 vs placebo. IGA (Investigator's Global Assessment) 0, IGA (Investigator's Global Assessment) 0 or 1, and PASI (Psoriasis Area and Severity Index) 90 responses were also significantly higher in patients receiving TREMFYA (guselkumab) vs. (versus) adalimumab throughout the studies.

A Network Meta-Analysis (NMA) compared first-in-class interleukin (IL)-23 inhibitor TREMFYA (guselkumab) to all advanced therapies approved for active psoriatic arthritis using data from 33 Phase 3 randomized clinical trials. The NMA (network meta-analysis) concluded TREMFYA (guselkumab) ranked highest for skin clearance based on Psoriasis Area Severity Index (PASI) 90 response among 23 treatment regimens (15 unique treatments including IL [interleukin]-23 inhibitors like TREMFYA (guselkumab) and risankizumab, subcutaneous tumor necrosis factor inhibitors, and Janus kinase inhibitors).

Therefore, given the above, the requested Tremfya (guselkumab) is medically necessary.

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

Tremfya (guselkumab) has better efficacy data in psoriasis than the health plan's preferred alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Traumatic brain injury. 
Treatment: Consumer directed personal assistance program (CDPAP) 12 hours per day-7 days per week: 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week. 
The insurer denied coverage for CDPAP (split shift)- for a total of 168 hours per week. 
The denial is overturned. 

The patient had a fall and suffered a traumatic brain injury (TBI). There is a request to increase CDPAP to 12 hours per day- 7 days per week: 12 hours per day 7 days per week (split shift)- for a total of 168 hours per week. 

An appeal stated the patient has TBI after having fallen, which renders the patient totally dependent for activities of daily living (ADLs), such as bathing and toileting. The note indicates the patient is unsafe at home without supervision and needs 24-hour-a-day assistance to manage his safety and ADLs. The patient is currently getting 24.5 hours per week. 

An assessment indicates that the patient lives with his sister on the third floor, and that he is severely impaired. The patient has knowledge deficit in taking his medications, and the deficit will last more than 120 days. The patient does not recognize family members, is occasionally agitated, and has childlike affect. 

The plan offered 3.5 hours per day. Given the severity of the patient disability, a need exists for 24 hour-a-day assistance for this patient. 

This individual had been an independent healthy machinist until he fell and injured his brain, for which he now has TBI, rendering him completely dependent for ADLs, as noted by his physician. The patient is noted to have increased weakness and a dramatic cognitive decline, which has resulted in child-like behavior and affect, resulting in unsafe behavior, and a need for increased hours. Given this scenario, the request for CDPAP split shift- for a total of 168 hours per week is medically necessary. 

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 Consumer directed personal assistance program (CDPAP) 12 hours per day-7 days per week: 12 hours per day- 7 days per week (split shift)- for a total of 168 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, sleep apnea, dizziness, gait abnormality, orthostatic hypotension, frequent falls, and urine incontinence.
Treatment: Increase in Personal Care Services (PCS) to 12 Hours/Day, 7 Days/Week, For a Total of 84 Hours/Week.

The insurer denied the increase in PCS to 12 hours/day, 7 days/week, for a total of 84 hours/week.  The denial is upheld.

The patient is a female. She has multiple chronic conditions, including hypertension, sleep apnea, dizziness, gait abnormality, orthostatic hypotension, frequent falls, and urine incontinence. Denial of increase in personal care services (PCS) to 12 hours/day, 7 days/week, for a total of 84 hours/week is being appealed.

A letter from the patient's provider notes that the patient requires assistance with ADLs (activities of daily living) and needs contact guard assistance with transferring. She presented for an urgent visit after a fall with head trauma. She uses a walker for ambulation.

No, the increase in PCS to 12 hours/day, 7 days/week, for a total of 84 hours/week is not medically necessary.

Personal Care Services provide hands-on assistance to individuals to include: assistance with ADLs, health maintenance activities, and routine support services. Denial of increase in PCS to 12 hours/day, 7 days/week, for a total of 84 hours/week is being appealed. The Plan denied the increase in hours because the Uniform Assessment System evaluation and Hours Evaluation for Paraprofessional Support tool do not support the increase in PCS hours.

This patient has multiple chronic medical conditions. The provider note indicates the patient needs assistance with ADLs and transfers due to falls. The information provided does not support services being performed 12 hours per day. PCS are not indicated for supervision or when no services are being performed.

Therefore, given the above, the requested increase in personal care service hours 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: Upheld

Diagnosis: Transient Ischemic Stroke (TIA)
Treatment: inpatient stay
The insurer denied the inpatient stay.
The health plan's determination is upheld.

The patient is a male with a past medical history of migraine, and myocardial infarction (MI), who presented for reports of left-sided weakness, left arm heaviness and slurred speech. Review of system was negative for additional clinical symptoms.
He was afebrile and was described as alert and awake and in no acute distress. His blood pressure was 140/93, pulse rate of 96, respiratory rate of 18, and oxygen saturation of 98% on room air. Physical examination was unremarkable for positive clinical findings. The patient was admitted for Transient Ischemic Attack (TIA) and rule out stroke. The patient was treated with aspirin and statin. A computed tomography (CT) angiogram of the head and neck were negative. The patient was evaluated by the neurologist and his symptoms were thought to be related to TIA versus hemiplegic migraine. 

The requested inpatient hospital admission was not medically necessary. The care could have been safely rendered at a lower level.
The patient was admitted for Transient Ischemic Stroke (TIA). The patient was admitted for subjective symptoms that were concerning for a stroke versus TIA. The patient had no objective focal neurologic deficits that represented a central nervous system (CNS) etiology [National Institute of Health (NIH) stroke score was zero], and imaging studies were unremarkable for acute neurologic finding. The patient's symptoms were thought to be related to TIA versus hemiplegic migraine. In this case, a lower level of care would have been appropriate to monitor the patient and rule out of a stroke.
The documentation does not support inpatient level of care given the lack of positive findings on imaging and presence of hemodynamic stability. The patient did not require intravenous treatment, procedural interventions, or Tissue Plasminogen Activator (TPA). Although the CT perfusion showed mismatched volume of the inferior right frontal region, the magnetic resonance imaging (MRI) was negative and the patient did not have active symptoms.
Patients with neurologic symptoms consistent Transient Ischemic Attack (TIA) or minor stroke are at increased risk for recurrent stroke, and therefore require urgent evaluation to assess the need for immediate intervention. The American Heart Association and American Stroke Association recommends admission to the hospital for patients with TIA who meets certain criteria based on risk stratification and evidence-based guidelines. There is a risk stratification score called the ABCD2 score which can help identify patients at high risk for short-term stroke. In this case, patient's ABCD2 score is calculated at 1 point, which estimates a 1.0% 2-day risk of stroke after a suspected TIA. Given the low-risk stratification, patient could have been safely monitored for 24-48 hours at a lower level.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: neck pain
Treatment: epidural spinal injection (ESI)
The insurer denied an epidural spinal injection. 
The health plan's determination is overturned. 

This is a male patient who has chronic neck pain with radiating pain to bilateral upper extremities. His pain is throbbing, sharp and stabbing with tingling and numbness sensation. He underwent physical therapy (PT), chiropractic manipulation and massage therapy with minimal pain relief. A prior cervical epidural injection gave him 80% of pain relief. Unfortunately, his pain had returned, which was documented on his office visit. A cervical magnetic resonance imaging (MRI) showed multilevel cervical degenerative disc disease (DDD), no significant central canal stenosis, moderate to severe bilateral foraminal stenosis at C (cervical) 5-6, severe left foraminal stenosis left C6-7.

Epidural Steroid Injections (Spine) are medically necessary for this patient.
This patient has severe neck pain with compromised activities of daily living (ADL). Further medical interventions are medically necessary to improve his pain and function. The prior cervical epidural injections provided him significant pain relief. It is appropriate and medically necessary for a repeat cervical epidural injection. A repeat cervical epidural injection is medically necessary to control his pain. The alternative is cervical decompression surgery, which carries significant more risks and complications than an epidural injection.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic Constipation. 
Treatment: Trulance. 

The insurer denied coverage for Trulance. 

The denial is overturned. 

The patient has abdominal pain and constipation. She had previous surgery for endometriosis and is felt to have adhesions. She had initially responded to Motegrity, but it was no longer effective. She has been using Lactulose. A letter from her physician states that she has also been treated with Linzess. 

UpToDate has an article titled "Management of chronic constipation in adults." The article discusses pharmacological therapy. Linaclotide, Plecanatide, Lubiprostone, and Prucalopride are all Food and Drug Administration (FDA) approved treatments for chronic constipation. The safety and efficacy of Plecanatide has been studied. It has been shown to be superior to placebo in clinical trials and results in improvement in frequency of complete spontaneous bowel movements. 

This patient has chronic constipation. She has already tried and failed multiple formulary medications including Linzess, magnesium citrate, and Miralax. She has now also failed to respond to Motegrity. Under these circumstances giving the patient Plecanatide (Trulance) is appropriate. The formulary alternatives are not likely to cause the patient an adverse reaction. However, the formulary drugs have been ineffective according to the physician's letter. Since there are alternatives to the formulary drugs that have not yet been tried, such as Trulance, it is hopeful that it will be effective. 

The insurer's denial of coverage for Formulary Trulance is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Inpatient Hospital. 
The insurer denied an inpatient stay. 
The denial is upheld. 

The patient is a female who presented to the emergency department with complaints of possible pregnancy and dizziness. The patient underwent an ultrasound which noted no intrauterine gestation, and the findings were concerning at that time for early intrauterine gestation, failed pregnancy or a cold ectopic gestation. The patient had normal-sized ovaries with vascular flow and a right-sided corpus luteum. The patient underwent a transvaginal ultrasound which noted the uterus to measure 9 x 4.5 x 5.8 centimeter (cm) in an anteverted position. There was an endometrial echo complex measuring 1.7 in thickness that was heterogeneous and there was no gestational sac, yolk sac or embryonic pole noted. The cervix was closed and 3.5 cm long. The right adnexa was noted to have Doppler flow with a 2.2 x 1.2 x 1.7 cm corpus luteum. The left ovary was noted to have normal Doppler flow and no cystic structures. The cul-de-sac noted a minimal amount of pelvic fluid. 

The patient was taken to the operating room with a normal physical exam and stable ectopic pregnancy with a normal hemoglobin and hematocrit. The plan was for a right salpingectomy. The patient was taken to the operating room and the surgery was completed. There were no complications of anesthesia during the management of the patient in the operating room. The patient underwent an uncomplicated laparoscopic salpingectomy on the right side with a tubal ectopic noted that was intact. This was hemostatic after removal and the estimated blood loss was minimal. The patient received 1.5 liters (L) of fluid and had 400 cubic centimeters (cc) of clear urine. There were no complications of the surgery. The patient was taken to the post-anesthesia care unit (PACU) in stable condition with normal vital signs and was discharged to home with outpatient follow-up scheduled. The patient was on a regular diet and tolerating oral pain medication without difficulty. 

The subject under review is the medical necessity for the inpatient stay. 
The acute inpatient stay was not medically necessary for this patient given the diagnosis of stable right sided ectopic pregnancy with stable vital signs. 

The American College of Obstetrics and Gynecology (ACOG) recommends that the care for right salpingectomy for ectopic pregnancy should be a lower level of care and does not require acute inpatient medical care. In this case, the patient met the ability to have pain controlled with oral medications, tolerate regular diet, and ambulate. She had no limitations to understanding post operative instructions. Thus, she could have been cared for at a lower level of care. Based upon a review of the medical records and the procedures and course of care, there would be no medical necessity for acute inpatient level of care for a postoperative stay after right salpingectomy due to ectopic pregnancy.