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

Diagnosis: Polyosteoarthritis, bone cancer, hearing loss, dizziness, and insomnia.
Treatment: Increase Personal Care Aide (PCA) Services for A Total Amount of 30 Hours Per Week.
The insurer denied: Increase Personal Care Aide (PCA) Services for A Total Amount of 30 Hours Per Week.
The denial is overturned.

The Increase Personal Care Aide (PCA) Services for A Total Amount of 30 Hours Per Week is not medically necessary.

Personal Assistance 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 personal care aide (PCA) services for a total amount of 30 hours per week is being appealed. The health plan approved 18 hours per week. This patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed last year shows she requires maximal assistance with meal preparation, housework, shopping, and bathing; extensive assistance with managing medications, dressing, and toilet transfer; limited assistance with managing finances, personal hygiene, walking, locomotion, and bed mobility; supervision with toilet use; and independent with eating. Compared to UAS (Uniform Assessment System) evaluation completed 2 years ago, there has been a decline with upper body dressing and batting. The patient is requesting additional hours due to increased impairment in functioning outside of the home due to worsening of gait, dizziness, and hearing loss. The information provided does not support that the patient's needs for assistance with ADLs (activities of daily living) cannot be met with the currently approved PCA (personal care aide) of 18 hours per week. There has been no significant decline between UAS (Uniform Assessment System) evaluations. PCA (personal care aide) is not indicated when no tasks are being performed or for supervision. The requested increase PCA (personal care aide) to 30 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain with Nausea and Vomiting
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an adult male. He presented with days of progressive abdominal pain associated with nausea and vomiting. His bowel movements were normal. Also, he reported elevated blood pressure. The patient's vital signs were stable, and he was afebrile. His blood pressure was elevated. His exam was remarkable for mild epigastric pain. CBC (complete blood count) and BMP (basic metabolic panel) were abnormal for WBC (white blood count) 12.7, creatinine 1.64, CPK (creatine 
phosphokinase) 2,659. Chest x-ray was with no acute disease. Abdominal ultrasound showed no acute disease. EKG (electrocardiogram) revealed normal sinus rhythm. The patient was admitted. Plan of care included pantoprazole and Maalox. He was given a liquid diet. Nifedipine was started for blood pressure. On day #2, his blood pressure was 157/96.
On day #3, his vital signs were stable. His blood pressure was 156/65, and CPK (creatine phosphokinase) 4,821. Creatinine was 1.15. Abdominal/pelvic CT (computed tomography) showed a small hiatal hernia. On day #4, the patient's vital signs were stable. The patient was feeling better. His diet was advanced. He was discharged on day #5.

The Inpatient Hospital Admission was not medically necessary.

This patient was admitted after presenting with vague abdominal pain. No etiology was identified with preadmission studies. He had elevated blood pressure but no end organ damage. His blood pressure was able to be controlled. He was not NPO (nothing by mouth). The MCG (Milliman Care Guidelines) Guideline for Abdominal Pain, Undiagnosed is not met for inpatient admission. The patient was hemodynamically stable. The patient did not have severe pain or peritoneal signs. Evaluation did not identify a source that required inpatient care. Imaging did not show obstruction or toxic megacolon. He did not have bacteremia. He was able to tolerate oral intake. He had not failed an observation level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: heart failure, hypothyroid and weakness

Treatment: Personal Care Aide (PCA) Level 2, 12 hours per day - 7 day(s) per week - for a total of 84 hours per week

The insurer denied coverage for Personal Care Aide (PCA) Level 2, 12 hours per day - 7 day(s) per week - for a total of 84 hours per week

The denial is overturned

 
This is a advanced elderly patient with medical problems that include heart failure, hypothyroid and weakness.  He lives alone in a 1-bedroom apartment.  The insurer approved personal care aide (PCA) 7.5 hours/day, 7 days/week (52.5 hours total) and the request is for 12 hours/day, 7 days/week (84 hours/week).

According to the Uniform Assessment System (UAS) report the patient's cognition is described as modified independent (however the clinical records are consistent with a more impaired cognitive ability).  He was recently hospitalized for pneumonia and had an extended stay in a skill nursing facility.  He uses nasal cannula portable oxygen.  He reports being totally dependent for much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping.  He reports requiring extensive assistance for bathing, personal hygiene and lower body dressing.  He is at the supervision level or independent for bed mobility and eating.  However, his mobility was not assessed as he is essentially bedbound and has fallen on several occasions.  The patient is also incontinent of bladder and bowel.  His activities of daily living (ADL) status has declined, and he has fallen over the prior 30 days.  The patient (who is nasal oxygen dependent, and bed bound) has functional deficits that are at a level or unpredictable as to require the requested PCA 84 hours/week.  Based on the records reviewed, the patient's health and safety are more appropriately provided and maintained with PCA Level 2, 12 hours/day - 7 days/per week - for a total of 84 hours/week. 

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide (PCA) Level 2, 12 hours per day - 7 day(s) per week - for a total of 84 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria
Treatment: Bilateral Breast Removal with Male Chest Reconstruction
The insurer denied bilateral breast removal with male chest reconstruction.
The health plan's determination is overturned. 

This is a female to male transgender. The patient has been on hormone therapy and has lived as a male. The patient's mental health professional diagnosed gender dysphoria and recommended top surgery as an appropriate treatment for the patient's condition. Top surgery (bilateral breast removal with male chest reconstruction) was performed.

Bilateral breast removal with male chest reconstruction was medically necessary for this patient.

Per the World Professional Association for Transgender Health (WPATH) "Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People" 7th Edition guidelines criteria for breast/chest surgery (one referral), criteria for mastectomy and creation of a male chest in FtM (female to male) patients:
1) Persistent, well-documented gender dysphoria; 2) Capacity to make a fully informed decision and to consent for treatment; 3) Age of majority in a given country (if younger, follow the SOC for children and adolescents); 4) If significant medical or mental health concerns are present, they must be reasonably well controlled.

Hormone therapy is not a prerequisite.

Regarding chest surgery for adolescents, WPATH guidelines are as follows: "Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent's specific clinical situation and goals for gender identity expression."

This patient meets these guidelines. The patient has well documented gender dysphoria and has the capacity to make an informed decision. The patient has been on hormone therapy for 12 months. Mental health concerns are managed by a therapist. The psychologist has recommended the mastectomies. The standard of care for adolescent top surgery is met.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity cellulitis
Treatment: Inpatient admission
The insurer denied coverage for Inpatient admission.
The denial is upheld.

Patient is an adult male with past medical history significant for hypertension, diabetes mellitus, hyperlipidemia, and peripheral neuropathy who presented to the emergency department with complaints of left lower extremity pain, erythema, and swelling. 

Vital sign on presentation included: Temperature 98.2 degrees Fahrenheit, Blood Pressure 145/80, Pulse 68, Respirations 18, Oxygen saturation 98% on Room Air. Laboratory results included the following: White blood cell (WBC) count 10.51, hemoglobin (Hgb) 12.4, hematocrit (Hct) 37.6, creatinine 0.8, glucose 108. 

The patient was started empirically on intravenous antibiotics (Ancef and clindamycin) for lower extremity cellulitis. Ultrasound was negative for deep vein thrombosis (DVT). Cultures remained negative and the patient remained afebrile, clinically, and hemodynamically stable. The patient was discharged to continue oral antibiotics as outpatient.

According to documentation, the patient presented with left lower extremity cellulitis. Otherwise, he was afebrile, hemodynamically stable. Laboratory results were unremarkable including a normal WBC (White blood cell). There was no evidence of disseminated infection and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management.

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 inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD)
Treatment: Hospital Admission for the Zephyr Valve Procedure
The insurer denied the hospital admission for the Zephyr Valve procedure as not medically necessary. The health plan's determination is overturned. 

The patient is a male former smoker with emphysema causing very severe oxygen dependent chronic obstructive pulmonary disease (COPD) with and forced expiratory volume 1 (FEV1) 25 percent (%) of predicted with hyperinflation, air-trapping and a reduced gas diffusion capacity. In addition, his six-minute walk distance is 200 meters with a dyspnea score of 3 based on his functional capacity. His current treatment includes Trelegy Ellipta, Ventolin Hydrofluoroalkane (HFA), Daliresp, Azithromycin, and oxygen supplementation. The patient is to undergo Zephyr endobronchial valve placement for very severe obstructive lung disease.

The requested health service/treatment of hospital admission for the Zephyr Valve procedure (CPT code 31651) is medically necessary for this patient. The Zephyr valve is an endobronchial valve (EBV) made of a nitinol skeleton and a silicone body with a "duckbill" valve on the proximal end. The US Food and Drug Administration (FDA) has approved the Zephyr Endobronchial Valve System for bronchoscopic implantation in lung regions with little to no collateral ventilation to treat patients with hyperinflation associated with severe emphysema. Based on the inclusion criteria for the pivotal clinical trials, candidate selection for Zephyr EBV placement will include a modified Medical Research Council (MRC) dyspnea score greater than or equal to 2, FEV1 between 15 and 45 percent predicted, total lung capacity (TLC) greater than or equal to 100 percent predicted, residual volume (RV) greater than or equal to175 percent predicted,  diffusing capacity of the lungs for carbon monoxide (DLCO) greater than or equal to 20 percent predicted and a six-minute walk distance (6MWD) between 100 and 500 meters.
According to the most clinical information enclosed, the patient has a diagnosis of oxygen dependent very severe emphysema, he is on maximal medical therapy, has completed a full course of pulmonary rehabilitation despite this he continues to be very symptomatic. Based on the physician's notes and testing, he has an MRC dyspnea score 3 based on his functional capacity, FEV1 25% of predicted with hyperinflation (TLC 138%), air-trapping (RV 246%), a reduced gas diffusion capacity (DLCO 25%) and a six-minute walk distance of 200 meters. In addition, the High-Resolution Computed Tomography (HRCT) demonstrates centrilobular emphysema and has been evaluated for fissure completeness. This is based on the patient's procedure not being low risk and the patient's anesthetic risk being high as indicated by symptomatic chronic lung disease with very severe oxygen dependent chronic obstructive pulmonary disease (COPD).
 
The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back Pain
Treatment: Pain Injections (x2)
The insurer denied Pain Injections (x2)
The determination is upheld.

This is a male patient diagnosed with chronic back pain. The records provided show that a request for 2 sacroiliac joint injections was denied as policy criteria was not met, specifically continuation of injections beyond 12 months is not medically necessary.
There is a letter of appeal from the patient's sister who has power of attorney and legal health care proxy stating that the patient was denied additional back injections (27096 times [x] 2). She states that the patient has absolutely pursued an abundance of other methods and he has not had 4 injections at the same site within 12 months. He has received zero injections for the low back pain in 16 months. It was noted the patient previously received injections for the low back that were approved and these injections provided immediate and substantial relief. It was noted that the patient has previously had chiropractic therapy multiple times and the patient had prior physical therapy which provided approximately 10 percent (%) reduction in his chronic back pain but he still suffers from debilitating back pain. They are requesting reconsideration for approval of 2 injections. Multiple therapy notes were provided for review. Additional information, an updated physician progress report containing a current physical examination and imaging studies demonstrating the patient to have documented inflammatory sacroiliitis of the SI joints and outlining extenuating circumstances that suggest the patient should be approved for these injections despite having exceeded the 12 month timeframe allowed, was requested. A letter was received. At issue is the medical necessity of pain injections times 2.

No, the requested health service/treatment of pain injections (x2) is not medically necessary for this patient. Records provided indicate the patient has a history of chronic back pain and has previously failed conservative treatment. However, it appears the patient has previously received sacroiliac (SI) joint injections. The policy specifically notes that continuation of injections beyond 12 months is considered not medically necessary because effectiveness and safety has not been established. There were no current physician progress notes provided outlining the patient's current exam or imaging studies suggesting the SI joints to be the primary pain generator or noting any exceptional circumstances that would warrant additional injections outside of the policy criteria.
Additional pain injections x 2 are not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Insomnia.
Treatment:  Belsomra.

The insurer denied Belsomra. The health plan's determination is overturned. 

The patient is a female with diagnosis of primary insomnia, whose physician is requesting Belsomra. Coverage was denied by the health plan because the patient did not meet coverage criteria for Belsomra, due to lack of documentation that the patient is unable to take the required number of formulary alternatives due to contraindication or intolerance, or that she has tried and failed the required 3 formulary alternatives, which are ramelteon, zolpidem, and zolpidem extended release.

A formulary exception is indicated in this case.

The patient meets criteria for a formulary exception for Belsomra. The treating physician indicates the patient has tried and failed all three of the formulary medications, which include ramelteon, zolpidem, and zolpidem extended release, due to ineffectiveness. A non-formulary agent can be approved when the patient cannot be switched to a formulary drug, has tried and experienced therapeutic failure or intolerance to the formulary medications, is requesting the non-formulary drug for an Food and Drug Administration (FDA) -approved indication, and the prescribed dosing falls within the FDA-approved labeling. Since Belsomra meets these criteria, a formulary exception is indicated.

Additionally, a review of the medical literature indicates that orexin receptor antagonists, including suvorexant (Belsomra) have been shown in multiple studies to be both more effective, better tolerated, and to have a better safety profile than the formulary medications zolpidem immediate/extended release and ramelteon. For this reason, the formulary drugs would not be as effective as Belsomra and would be more likely to cause adverse effects.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive decline

Treatment: 7 days per week, 12 hours per day; 84 hours per week of personal care worker (PCW) services

The insurer denied coverage for 7 days per week, 12 hours per day; 84 hours per week of personal care worker (PCW) services

The denial is overturned
 

Reviewer Findings:

This case involves an elderly male who was requesting coverage for personal care worker (PCW)services 7 days a week, 12 hours/day for total of 84 hours/week. The patient lives alone in a 1-bedroom basement apartment, 5 steps at the entrance. The patient's judgment is off per his daughter's report, and he has to be reminded to complete tasks correctly. He often found difficulty finding words or finishing thoughts causing some difficulty with communication.  He had adequate hearing and minimal difficulty with vision. The patient required maximal assistance with meal preparation, required total dependence for ordinary housework and managing finances with extensive assistance needed for managing medications, using a phone, navigating stairs, with total dependence for shopping and transportation.  He needed maximal assistance with equipment management and extensive assistance with bathing and dressing the upper and lower body.  He needed limited assistance with personal hygiene, but extensive assistance with activities of daily living, walking, locomotion, toileting transfers, toileting use, and supervision with bed mobility.  He needed limited assistance with eating and used an assistive device for walking.  He was receiving physical therapy outpatient on a weekly basis.  He had frequent bladder incontinence and occasional bowel incontinence.  His primary diagnosis was Alzheimer's disease with secondary diagnoses of anxiety, depression, and cancer.  The patient had no reported falls in the last 90 days, but endorsed dizziness, unsteady gait, and difficulty falling asleep or staying asleep.  He reported dyspnea when performing moderate activities and had minimal fatigue with diminished energy while completing normal day-to-day activities.  He complained of intermittent pain that was adequately controlled with a therapeutic regimen.  There were no reported hospitalizations within the last 90 days.  

Currently, the patient has a home health aide for only 5 hours a day.  The patient received a notice of adverse determination regarding personal care worker (PCW) services 12 hours a day 7 days/week for 84 hours/week.  The patient received approval for 6.5 hours/day, 7 days/week for a total of 45.5 hours/week.  An appeal was submitted stating that because of the patient's cognitive issues, it was not safe for him to remain alone for prolonged periods of time..

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 7 days per week, 12 hours per day; 84 hours per week of PCW services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: postpartum hypertension
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a female who presented to the emergency room on postpartum day 5 with severe hypertension. She came in because of severe blood pressures found at home. The patient required intravenous (IV) antihypertensives and magnesium. She was admitted to the hospital and treated with oral antihypertensives. 

Inpatient Hospital Admission was medically necessary for this patient with postpartum preeclampsia with severe features.
This patient presented with severely elevated blood pressures. She was unstable. There was no question she needed admission and intensive management that included antihypertensives. Magnesium was appropriately administered to prevent eclamptic seizure - a complication that can lead to death or disability. Currently, though preeclampsia is less common in the postpartum period, eclamptic seizures are actually more common after delivery. The reason for that is that we are aggressive with use of magnesium and other anti-epileptics in the antepartum setting, but there is less opportunity for treatment after the patient has left the hospital. This patient's providers were appropriately concerned about the possibility of seizure and took aggressive action to prevent that outcome. Normal labs were only modestly reassuring - it is the severe hypertension that dictated care in this case. In addition to seizures, cerebrovascular accident and cardiomyopathy would have been rare but devastating possibilities with systolic blood pressures in the 160's range. According to professional standards, the inpatient admission of this critically ill patient was medically necessary.