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

Diagnosis: Asthma And Rhinosinusitis
Treatment: Dupixent, Pre-service
The insurer denied the Dupixent, Pre-service
The denial is overturned

The patient is female with moderate to severe persistent asthma as well as nasal polyposis is prescribed Dupixent. The patient has tried and failed xolaris, symbicort, advair, incruse ellipta, prednisone, montelukast, nasal fluticasone and hypertonic saline. The Dupixent is denied because patient has not tried and failed Nucala.

The proposed treatment is "medically necessary".
The patient has moderate to severe persistent asthma as well as nasal polyposis who has tried and failed many therapies. The dupixent is prescribed as it will treat both disease processes. However, it is denied by health plan because patient has not tried and failed nucala as well as flunisolide nasal spray, as well as other over the counter nasal spray available for sinus polyposis.

The use of dupixent in this case is medically necessary as patient has tried and failed xolair, multiple long acting inhaled corticosteroids, prednisone, and nasal sprays. Dupilumab has been shown to increase lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma irrespective of baseline eosinophil count. For nasal polyposis, dupilumab reduced polyp size, sinus opacification, and severity of symptoms and was well tolerated.  Since dupixent can treat both disease processes in this patient, it is likely to produce superior outcomes than nucala along with other nasal inhalers for polyposis. It's use is medically necessary.

The use of dupixent in this case is medically necessary as patient has tried and failed xolair, multiple long acting inhaled corticosteroids, prednisone, and nasal sprays. Dupilumab has been shown to increase lung function and reduced severe exacerbations in patients with uncontrolled persistent asthma irrespective of baseline eosinophil count. For nasal polyposis, dupilumab reduced polyp size, sinus opacification, and severity of symptoms and was well tolerated.  Since dupixent can treat both disease processes in this patient, it is likely to produce superior outcomes than nucala along with other nasal inhalers for polyposis. Its use is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Urinary incontinence, gait ataxia with frequent falls, depression and dementia.
Treatment: Increase in Personal Care Assistance Services to 24 Hours Per Day, 7 Days Per Week.
The insurer denied the Increase in Personal Care Assistance Services to 24 Hours Per Day, 7 Days Per Week.
The denial is overturned.

The patient is a female with a history of hypertension, urinary incontinence, gait ataxia with frequent falls, depression and dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review has been requested for potential approval of personal care assistance services 24 hours per day, 7 days per week (live in) for approximately six months to offer increased activity of daily living support.

Yes, the proposed personal care assistance services 24 hours per day, 7 days per week (live in) for approximately six months is deemed medically necessary.
This is a female with a history of hypertension, urinary incontinence, gait ataxia with frequent falls, depression and dementia. Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). Although an assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed that the currently approved plan of 56 hours per week of personal assistance services is sufficient to meet the patient's current needs, the patient's primary care provider, relates that this reduced schedule leaves her home alone, unassisted for numerous hours throughout the day. This is problematic as she requires total assistance with her activities of daily living (ADLs) including bathing, dressing, grooming, skin care and toileting, and she is at high risk for falls. The patient is incontinent with recurrent urinary tract infections (UTIs) with a history of hospitalization and has frequent toileting needs and requires assistance with transfers. The patient has a pressure ulcer and requires frequent repositioning when in bed. Furthermore, she requires prompting to take medications and eat and drink throughout the day.

Hence, provision of personal assistance services 24 hours per day, 7 days per week (live in) for approximately six months can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. The approved plan of 56 hours per week of personal care assistance services is insufficient to meet the patient's needs. For these reasons, the proposed personal care assistance services 24 hours per day, 7 days per week (live in) for approximately six months is deemed medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines. 
Treatment: Ubrelvy (Pre-Service). 

The insurer denied the Ubrelvy (Pre-Service). 
The denial is upheld. 

The patient is a female with migraine headache disorder. Failed preventative treatment has included topiramate (tingling), clonazepam, propranolol and amitriptyline. She started Ajovy and discontinued it after three months due to severe rash at the injection site. The patient has also tried and failed eletriptan and sumatriptan for abortive therapy. A prior authorization request form almost includes notation of failure of rizatriptan. 

According to the follow-up encounter, there was discussion of switching to Emgality. The patient did not want to take Aimovig due to a history of constipation and she wanted to avoid triptans due to lack of efficacy and side effects. The patient spoke with her neurologist in the city and explored Botox as a last resort. 

The provider is requesting Ubrelvy. The requested medication was denied coverage as the patient has not exhausted all formulary alternatives. 

No, the health plan should not cover the proposed treatment with Ubrelvy. 

There is no reason the patient cannot be treated with the preferred formulary agents.  Trying to avoid triptans, previous failure of other triptans and anticipatory side effects do not preclude the use of the preferred agents. All of the preferred agents are Food and Drug Administration (FDA) approved for acute treatment of migraine headaches and are considered first line, standard of care, abortive agents. (Thorlund et al., Tepper) There are no high quality clinical trials or standard of care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: obstructive sleep apnea

Treatment: Private Duty Nursing (PDN) services 12 hours per day, 7 days per week

The insurer is denied coverage for Private Duty Nursing (PDN) services 12 hours per day, 7 days per week.

The denial is upheld. 

This female patient has a history of tricuspid regurgitation, obstructive sleep apnea (OSA), down's syndrome, and nocturnal enuresis.

The patient does not need daily mechanical ventilation and there is no tracheostomy.  There is no need for daily pulmonary toilet or VEST treatment, obstructive sleep apnea diagnosis does not need private duty nursing. Continuous positive airway pressure (CPAP) is the treatment for OSA and this can be done in a simple way by the caretakers. CPAP care is done by the dedicated Durable Medical Equipment company and they have respiratory therapists to help their clients.
 Also, the caretakers should be adept at the custodial and medical needs at this time. 
The shift report suggests an almost stable course without any recent respiratory compromise.   

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

The carrier's denial of coverage for the Private Duty Nursing (PDN) services 12 hours per day, 7 days per week is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder. 
Treatment: Braces and periodic orthodontic treatment visit. 

The insurer denied braces and periodic orthodontic treatment visit. 
The determination is upheld. 


The patient has a diagnosis of Class I malocclusion, 5 millimeter (mm) overjet and 2 mm overbite. The upper and lower arches are both moderately crowded. She is treatment planned for 24-30 months of orthodontics to correct her malocclusion. The provider is appealing on the grounds that tooth 23 is in crossbite with gingival attachment loss. At issue is the medical necessity of braces and periodic orthodontic treatment visit. 

The patient has an appropriate overbite and overjet. There is crowding but that alone does not rise to the threshold of medically necessary. The photos do not support a diagnosis of a crossbite of tooth 23 with tooth 7, and the gingival margin of 23 appears to be the same as tooth 26. There does not appear to be attachment loss. There is no indication of functional problems on the diagnostic records or the orthodontic treatment plan. The diagnosis states the patient has a skeletal Class I relationship which is the most efficient jaw relationship for mastication. (2) If her teeth were aligned, it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. 

For these reasons, treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain.	
Treatment: Inpatient admission.

The insurer is denied coverage for inpatient admission.  The denial is upheld. 

This male patient has a history of coronary artery disease (CAD), hypertension, asthma, gout, obesity, alcoholism, gastritis, and polysubstance abuse.

This patient presented with chest pain without dynamic ECG (electrocardiogram) changes or elevation in cardiac enzymes. Based on history and presentation alone, this patient had a low short-term risk of death and nonfatal cardiac ischemia. (1) In the past year the patient had a cardiac catheterization that revealed no evidence of obstructive coronary artery disease. Such findings are consistent with a low one year mortality and a low probability of significant new coronary artery disease. (2) Utilizing the HEART (History, ECG, Age, Risk Factors, and Troponin) score he is considered low risk. (3) Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score he also had a low risk of developing major adverse cardiac events in the subsequent 30 days (TIMI score=1). (4) 

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG was reviewed by Hedayati et al. (4) Using the HEART and TIMI risk scores, this patient would have a low risk of major cardiac events [defined as all- cause mortality, myocardial infarction (MI), and severe recurrent ischemia requiring urgent revascularization] within the two weeks following presentation. Ultimately the patient developed a gout attack of the left ankle and was discharged several days after presentation. This patient could have been managed at a lower level of care.

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

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

Trauma/Injury
Inpatient Hospital

Diagnosis: Laceration.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a woman with a history of diabetes, hypertension, and gout who presented to the Emergency Department (ED) for an emergency evaluation due to severe, progressively worsening left hand pain, swelling, and discharge. The medical record indicates that her symptoms had progressively worsened after undergoing a recent laceration repair in which the patient had failed to follow up for suture removal and subsequently developed new-onset yellow discharge with increasing pain. Her symptoms had progressively worsened despite attempted outpatient treatment with topical and oral antibiotics with mupirocin and doxycycline. On initial presentation, the patient was tachycardiac (pulse of 94 beats per minute) and hypertensive (blood pressure of 154/91). On examination, the patient had a 3 x 3 centimeter (cm) tender, edematous, and necrotic wound overlying the left palmar hand. Laboratory studies were remarkable for leukopenia and urine toxicology screen positive for alcohol. 

The the inpatient hospital admission was not medically necessary. According to the Milliman Care Guidelines (MCG), 25th Edition, "General Admission Criteria", the patient did not meet inpatient criteria.
This patient had a hand infection that was readily treated with antibiotics and surgical drainage. She was clinically stable and responded well to surgery. She did not have any significant physiologic or surgical complications following the procedure. She could have been managed at a lower level of care. Observation is not a location within the hospital, but rather a short period when the same active diagnostic and therapeutic services used during an inpatient hospitalization are provided to gather more information and assess the response of the patient. Typically, it is 48-hours or less, but can be up to 72-hours in certain situations. This patient was medically stable and needed only antibiotics and surgical drainage. She could have been safely managed at the lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chest pain.
Treatment: inpatient hospital admission.
The insurer is denied coverage for inpatient hospital admission.
The denial is upheld. 

This female patient has a history of hypertension, hyperlipidemia, diabetes, atrial fibrillation, cerebrovascular accident (CVA), asthma, and obesity.

There is no evidence that this patient required an acute inpatient hospitalization to determine that her chest discomfort was not related to acute coronary syndrome or to perform coronary angiography.  Evaluation for acute coronary syndrome should have been completed in the ED(emergency department) or at an observation level of care, followed by coronary angiography as a same day procedure.  

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

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

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient hospital stay

Diagnosis: Digestive System/Gastrointestinal-Abdominal Pain/Gallbladder Problem.
Treatment: Inpatient hospital stay.
The health plan denied the inpatient stay as not medically necessary.
The reviewer has upheld in whole the health plan's determination.

The patient presented to the hospital emergency department (ED) on with upper abdominal pain and vomiting of 1-day duration. She had recently had a positive Covid diagnosis. At the time of presentation, the patient was without fever and vital signs showed a heart rate of 75/minute and blood pressure of 157/101 millimeters of mercury (mmHg). She was tender in the upper abdomen. The white blood cell count was 11 thousand(K). The complete metabolic panel identified normal aspartate aminotransferase (AST), alanine aminotransferase (ALT), and Bilirubin. A computed tomography (CT) scan showed cholelithiasis and findings of cholecystitis.
She was initially treated with intravenous (IV) fluid and antiemetics. Surgical consultation was obtained. The surgical service decided that urgent surgery was not required, and the patient was treated with antibiotics with plans for interval cholecystectomy.
The patient tolerated oral intake. She was discharged from the inpatient setting with instructions for outpatient surgical follow up. 

An inpatient level of care was not medically necessary in this case. This patient  presented to the ED with abdominal pain. Evaluation identified gallstones and findings of cholecystitis. She was hemodynamically stable at the time of presentation. The WBC count was slightly elevated at 11K. The patient had recently had Covid infection. The surgical service advised that urgent cholecystectomy was not required. The patient remained hemodynamically stable during the period of monitoring. A lower level of care status would have allowed for overnight monitoring, confirmation of clinical stability, and diet advancement.
A lower level of care would have been appropriate. There is no documentation of hemodynamic, pulmonary, neurological, or metabolic reason for an acute inpatient level of care at the time of presentation. This lower level of care would have been consistent with generally accepted standards of care. This would have allowed for surgical assessment, treatment with IV fluid and antibiotics, and arrangements for outpatient follow up.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a male with a past medical history significant for COPD (chronic obstructive pulmonary disease) - not on home O2 (oxygen), throat cancer, status post RT (radiotherapy) and hypothyroidism. He presented to the ER (emergency room) for evaluation of dyspnea and chest pain, which was reproducible on palpation.

The patient was hemodynamically stable. The ECG (electrocardiogram) revealed no acute ischemic changes. Troponins were normal. The patient was admitted to rule out ACS (acute coronary syndrome). 2D (two dimensional) echo was obtained and revealed normal LV (left ventricle) function with no wall motion abnormality. There was no significant valvular pathology. The patient left the hospital AMA (against medical advice).

No, the Inpatient admission was not medically necessary.
The proposed treatment is not "medically necessary".

This patient presented for evaluation of chest pain. The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative. There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  ECG (electrocardiogram), echo and cardiac enzymes were unremarkable.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission. The care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder. 
Treatment: Home Health Care. 

The insurer denied split shift 24 hour personal care services (two 12 hour shifts) for total of 168 hours. The denial is upheld. 

The patient is a female with past medical history of cerebrovascular accident (CVA), coronary artery disease (CAD), hypertension, hyperlipidemia, heart failure, chronic anticoagulation, mild cognitive impairment, osteoarthritis, urinary incontinence, insomnia, and depression who had been assigned Personal Care Assistance (PCA) services 24 hours/day, live-in, 7 days/week with request to increase PCA services undergoing assessment tool via telephone assessing the patient at total assistance with meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, equipment management, and locomotion while maximum assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, transfer toilet, toilet use, and bed mobility. Activity did not occur for tasks of walking and patient was assessed at extensive assistance with eating. Notes from the assessment stated the patient lived alone in her own home and was homebound, non-ambulatory and wheelchair-bound, propelled by others. The patient wanted to stay in bed most of the time. The patient had a hospital bed but needed assistance with changing position and turning in the bed. 

The health plan's determination is upheld. 

Although the patient had a decline in functional and cognitive status following hospitalization, documentation provided does not support split-shift services. There is no documentation of overnight care logs to document the need of split- shift services. In addition, there is no documentation of need for frequent turning and repositioning in the overnight hours. Lastly, there is no documentation of overnight care needs that would not allow a personal care aide to obtain at least 5 hours of uninterrupted sleep. Taking into account all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split shift (two 12-hour shifts), to total 168 hours/week are not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Migraines
Treatment: Formulary exception for Ubrelvy 50mg, Pre-service
The insurer denied the Formulary exception for Ubrelvy 50mg, Pre-service
The denial is upheld.

The patient is a male with migraine headache disorder. He has tried and failed rizatriptan. The provider is requesting Ubrelvy for the acute treatment of migraine.  The requested medication was denied coverage, as the patient has not tried and failed three preferred agents.

No, the health plan should not cover the formulary exception for Ubrelvy.
There is no documented reason as to why the patient cannot be treated with the preferred formulary agents. All of the preferred agents are FDA (United States Food and Drug Administration)-approved for acute treatment of migraine headaches and are considered first-line, standard-of-care, abortive agents (Thorlund et al.). There are no high-quality clinical trials or standard-of-care guidelines supporting the preferential use or superiority of Ubrelvy relative to the preferred agents.

Therefore, given the above, the health plan should not cover the formulary exception for Ubrelvy.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: flank pain.
Treatment: Inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is overturned.

The patient is a woman with a history of renal colic who presented with right flank pain for the past one hour prior to arrival. She had a lithotripsy procedure earlier that week due to known kidney stones. On imaging in the emergency department, she was found to have hydroureter and hydronephrosis. Vital signs showed heart rate 63, blood pressure 133/96, respiratory rate 18, and temperature 98.8 Fahrenheit. On physical exam, heart was regular, breath sounds were normal and the abdomen was soft and diffusely tender to palpation. Labs showed sodium 138, potassium 3.5, creatinine 0.98, glucose 110, white blood cell count (WBC) 21.9, hemoglobin 14.3, and platelets 347. Urinalysis was negative for evidence of infection. The patient was admitted with nephrolithiasis and hydronephrosis. 

The inpatient hospital admission was medically necessary for this patient. She was at increased risk of developing infection, sepsis, pyelonephritis, and other complications in the setting of a postoperative obstruction due to retained fragments of kidney stone with subsequent hydronephrosis. Urology was consulted and she required a urologic procedure. In addition, she required IV(Intravenous) opioids due to poorly controlled pain. Overall, the inpatient hospital admission was medically necessary due to the patient's complexity.