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

Central Nervous System
Home health care

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift). The health plan's determination is overturned. 

The patient is a female with past medical history of osteoporosis, dementia, bladder incontinence, bowel incontinence, coronary artery disease, hypertension, glaucoma, and pressure ulcers of the skin who had been assigned Personal Care HHC - Level 2 Personal Care Services. 

Personal Care HHC - Level 2 Personal Care Services, per 15 minutes increase to 24 hours per day (split shift) is medically necessary for this patient.
There is documentation from the patient's family of the need for turning and repositioning every 2 hours. There is documentation from the plan's own assessment of at least 3 pressure ulcers with recommendation to turn and reposition the patient every 2 hours. Per clinical guidelines for treatment and prevention of pressure ulcers, the patient should be turned and repositioned every 2 hours as part of their treatment plan. It was noted the patient also had VNS (visiting nursing services) 2 times per week for skin care. The patient's assistance with activities of daily living (ADL) in the overnight hours would not allow a personal care aide 5 hours of uninterrupted sleep. The requested increase in personal care services is not solely for safety and supervision but to assist the patient with safe completion of ADL and Instrumental activities of daily living (IADL). The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, the requested services are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain, Nausea, and Emesis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The denial is upheld.

The patient is an adult male with end stage renal disease on dialysis and poor compliance with missed dialysis sessions. He presented to the hospital with abdominal pain and nausea. The inpatient level of care was denied. The physician is appealing the determination.

The proposed inpatient hospital admission was not medically necessary.

Based on available data there is no documentation of hemodynamic instability, severe hypertension, cardiac arrhythmias of immediate concern, or significant respiratory findings that are severe or persist despite observation care treatment. There was no clinically significant electrolyte abnormality or metabolic abnormality that was severe or persisted despite treatment at a lower level of care. Based on available data, the patient could have safely and effectively been managed at a lower level of care. The requested inpatient hospital admission was not medically necessary as it would be for the convenience of the patient or the practitioner.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Disease
Treatment: Consumer Directed Personal Assistance Program (CDPAP)/Personal Care Aide (PCA) Level 2: 13 hours per day - 7 days per week, a combined total of 91 hours per week.
The insurer denied the request for Consumer Directed Personal Assistance Program (CDPAP)/Personal Care Aide (PCA) Level 2: 13 hours per day - 7 days per week, a combined total of 91 hours per week.
The health plan's determination is overturned.

The patient is a female with a medical history notable for Parkinson's disease, incontinence, vertigo, and heart disease. The patient is approved for 12 hours per day, 7 days per week (total of 84 hours per week) of consumer directed personal care assistance program. The patient and her care team requested an increase to 13 hours per day (live-in) personal care aide, 7 days per week (91 hours per week) and the request was denied by the health plan.
A Uniform Assessment System (UAS) was completed and was available for review. The assessment was conducted in-person. The patient lives alone in her apartment. She was alert and oriented to person only and short term memory was impaired. She does not recognize caregivers and is not safe to direct her own care. For her Instrumental activities of daily living (IADL's), she requires total dependence for all. For her activities of daily living (ADL's), she requires total dependence for all. She is frequently incontinent of urine and stool. A task tool associated with the assessment recommended 70 hours per week to address her personal care needs. Compared to a prior assessment, she showed a decline in cognitive, functional, and continence status.

The requested health service of Consumer Directed Personal Assistance Program (CDPAP)/Personal Care Aide (PCA) Level 2: 13 hours per day - 7 days per week, a combined total of 91 hours per week is medically necessary for this patient.
The patient's most recent UAS demonstrates that the patient requires total dependence for IADL's and ADL's. She has advanced dementia and cannot direct her own care. She is incontinent of urine and stool. Her personal care needs are, by definition, continuous and unscheduled throughout the day and occasionally at night as well. Therefore, the task tool cannot be relied upon to accurately reflect her true level of need. This increased need is not merely for safety monitoring as the plan suggested, as she is expected to have continuous personal care needs such as toileting and transfers throughout the day and night. Therefore, the requested increase is medically necessary and reasonable for the patient.

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

Diagnosis: Chest pain, non-ST elevation myocardial infarction (NSTEMI)
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with no past medical history (PMH) who was admitted with complaints of (c/o) chest pain, weakness, nausea, and fatigue after a night of binge drinking and ecstasy intake. His vital signs were notable for tachycardia. The physical exam was notable for awake, alert, oriented times three (AAOx3), no focal deficits. The patient was diagnosed with cocaine-induced chest pain, non-ST elevation myocardial infarction (NSTEMI), rhabdomyolysis and acute kidney injury (AKI) and treated with acetylsalicylic acid (ASA), telemetry and acute coronary syndrome (ACS) rule out (r/o), and intravenous fluids (IVF) with creatinine monitoring. The mildly elevated troponin was thought secondary to demand ischemia, not ACS. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.
The admission was medically necessary at an acute inpatient level of care. This patient presented to the emergency department (ED) with complaints of (c/o) chest pain, weakness, nausea, and fatigue after a night of binge drinking and ecstasy intake. The patient's lab work demonstrated an acute kidney injury with a significant increase of the creatinine with a profoundly increased creatine kinase (CK), and this correlates to a drop in glomerular filtration rate (GFR) of almost 50 percent (%) from baseline. The patient's clinical status was further complicated by cocaine-induced chest pain, severe metabolic acidosis (CO2 15), and NSTEMI II. He required close monitoring for adverse sequela such as electrolyte abnormalities and telemetry for arrhythmia monitoring. This patient suffered from AKI, NSTEMI II, and metabolic acidosis, requiring aggressive hydration and biochemical monitoring, and the severity of these conditions and risk of complications indicates a lower level of care medically inappropriate to monitor and treat. The patient had a suspected etiology needing inpatient care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ectopic pregnancy

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission.

The denial is overturned.

 
The patient is an adult female who presented with abdominal pain and findings suggestive of an ectopic pregnancy. She underwent an emergency laparotomy with left salpingectomy. The operative procedure was uncomplicated. Post operatively, the patient was stable. She signed against medical advice and left the hospital.

The patient presented with a straightforward diagnosis of an ectopic pregnancy necessitating immediate surgical management. The patient underwent a laparotomy. Laparoscopies are ambulatory procedures, laparotomies are not. The standard of care is for patients who undergo an open procedure to stay in hospital for 48 hours.

According to Milliman Care Guidelines (MCG), inpatient stay is needed for open procedures.
Please note that the patient left against medical advice (AMA), less than 24 hours after the procedure which is less than the majority of patients who undergo a laparotomy and whose average stay is 48 hours.

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

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

The patient is a female who was admitted for submandibular abscess. During the admission, a consulting interventional radiologist (IR) aspirated/drained the abscess. The patient was also admitted for intravenous (IV) antibiotics, supportive measures, and monitoring. During the admission, the patient was stable with no worsening of her condition.

Inpatient hospital services were not medically necessary. 
At the time of admission, the patient was having a sore throat that was progressing to painful swelling of the throat. The patient was complaining also of hoarseness. In the emergency room, the patient had an elevated white blood cell (WBC) count and an outside computed tomography (CT) scan that noted a small abscess in the submental area. A flexible scope performed by the ear, nose, and throat (ENT) service noted some edema but no specific airway obstruction.
During the inpatient admission, the abscess was thought to be an infected thyroglossal duct cyst and was drained by IR.
The patient had no airway compromise at the time of emergency room (ER) evaluation. She was speaking clearly with no muffled voice. No drooling was noted. The patient could have been admitted to observation and then monitored. The patient's condition continued to improve following the IR drainage. The IV antibiotics could have been also given under a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces, monthly visits, retainer.
The insurer denied braces, monthly visits, retainer.
The determination is overturned.

This is a female patient with a Class I malocclusion. She has severe maxillary crowding due to a supernumerary left lateral incisor in her arch. She has a 6-millimeter (mm) overjet and 5 mm overbite. She is treatment planned for 30-36 months of orthodontics with extraction of the supernumerary tooth to correct her malocclusion. At issue is the medical necessity of braces, monthly visits, retainer.

Teeth number (#) 8 and #9 (and the supernumerary tooth) are protruding forward within the dental arch. This makes them more prone to trauma. The patient has an excessive overjet despite her Class I occlusion due to the presence of the erupted supernumerary maxillary lateral incisor. There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (1) Evidence shows early treatment will reduce the chances of damage to the maxillary incisors and the associated morbidity of repairing these teeth. There is scientific evidence that oral health quality of life is reduced in patients with 6 plus (+) millimeter (mm) overjet (2), which this patient has. Orthodontic treatment to correct her excessive overjet will reduce the risk of trauma and improve her quality of life. 
For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis. 
Treatment: Inpatient level of care admission. 
The insurer denied the inpatient level of care admission. 
The health plan's determination is upheld. 

The patient is a male with a past medical history of atrial fibrillation on Eliquis, chronic obstructive pulmonary disease (COPD) requiring home oxygen at a rate of 3L/min (liters/minute), hyperlipidemia, and active tobacco use, who presented to the emergency department with complaints of lower leg wounds and discharge persisting for 2 weeks. The patient reported worsening bilateral lower limb wounds with purulent discharge during this period but denied experiencing fever, chills, nausea, or vomiting. Additionally, he denied any shortness of breath or chest pain. 

The inpatient hospital admission was not medically necessary. 
The patient presented with infection in the lower extremities associated with purulent cellulitis. In general, admission at the acute inpatient level of care is indicated for patients with soft tissue infection and cellulitis who failed outpatient therapy. In this particular case, there was no mention that outpatient therapy was tried and failed. 
Admission at the acute inpatient level of care is also indicated for cases of cellulitis and soft tissue infection associated with limb-threatening infection, or rapid progression of the infection that necessitated high-intensity monitoring, high-risk comorbid conditions such as immunocompromised state, symptomatic heart failure, asplenia, neutropenia, uncontrolled diabetes mellitus or liver cirrhosis. There was no mention that the patient had any of the conditions listed above. 
Admission at the acute inpatient level of care is also indicated for patients with cellulitis and soft tissue infection associated with bacteremia, altered mental status, hemodynamic instability, suspected necrotizing soft tissue infection, orbital infection, or oral cellulitis, or when patients need a surgical procedure not amenable to outpatient or emergency department care, cases of cutaneous gangrene, or when patients have severe pain requiring acute inpatient management, inability to maintain oral hydration, in cases of compartment syndrome, or some other conditions that were not relevant to this clinical case. 
The review of the medical records did not show evidence that the patient had any of the circumstances justifying admission at the acute inpatient level of care for the treatment of cellulitis/soft tissue infection. 
Observation was reasonable to ensure a response to antibiotics and to decide about antibiotic treatment after discharge. This could have been done at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Shortness of Breath and Wheezing (asthma attack).
Treatment:  Inpatient Hospital Admission.

The insurer denied: Inpatient Hospital Admission.  The denial is overturned.

This patient is an adolescent male with a diagnosis of severe persistent asthma, who was admitted to the hospital with an acute asthma exacerbation. He has a history of status asthmaticus and severe exacerbations requiring PICU (Pediatric Intensive Care Unit) admissions, and bilevel positive airway pressure support, which would put him at risk for additional episodes of status asthmaticus and respiratory failure. During assessment in the emergency department for this admission, the patient received at least three back-to-back nebulizer treatments of Albuterol (a beta agonist), systemic steroids, and IV (intravenous) magnesium. The medical team felt he required inpatient admission based on a venous blood gas, with a PCO2 (partial pressure of carbon dioxide) of 51, which was concerning for respiratory failure. The health plan is denying the inpatient admission based on documentation not demonstrating that the patient met criteria for inpatient admission from InterQual 2022 Guidelines. 

The requested health service of an Inpatient Hospital Admission is considered medically necessary. 

Admission to the hospital is an appropriate decision based on standards of care for asthma exacerbation, as this patient was requiring Albuterol treatments more often than every four hours, and he additionally has a history of status asthmaticus and PICU (Pediatric Intensive Care Unit) admissions. Many children's hospitals will not discharge a patient to home until the patient is able to tolerate Albuterol treatments every four hours. In addition, this patient had a venous blood gas with a PCO2 (partial pressure of carbon dioxide) of 51. Per the National Asthma Education and Prevention Program Expert panel report three: Guidelines for the Diagnosis and Management of Asthma, a venous blood gas with a PCO2 (partial pressure of carbon dioxide) of (more than) > (greater than) 45, may serve as a screening test for severe airflow obstruction and heightened risk of respiratory failure. It is reasonable for an inpatient admission, as not every hospital has the capability to closely monitor this situation in other settings, versus an inpatient unit (i.e., no observation unit).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis, psoriatic arthritis, and ulcerative colitis. 
Treatment: Skyrizi 150 mg (milligrams) every 8 weeks. 
The insurer denied coverage for Skyrizi 150 mg every 8 weeks. 
The denial is overturned. 

The patient is an adult male with a diagnosis of psoriasis, psoriatic arthritis, and ulcerative colitis. The patient has a significant past medical history for erythema nodosum and Remicade induced lupus. He has failed therapy with infliximab, Humira, Tremfya, Otezla, Stelara, Cimzia, and prednisone. The request is for dose modification of Skyrizi to every 8 weeks to improve efficacy as the patient is flaring every 6 weeks post injection. 

Based on the submitted documentation, Skyrizi is medically necessary. The patient has failed numerous systemic agents and has severe inflammatory disease. The patient has improved with Skyrizi, but flares at 6-week intervals necessitating the dosing increase.  Numerous prior biologics have failed, and a dose increase of a successful one, Skyrizi, is medically appropriate and within the standard of care. Skyrizi is Food and Drug Administration (FDA) approved for treatment of psoriasis vulgaris and it is reasonable to attempt this treatment option. 

In this case, Skyrizi at a frequency adjusted dosing is a reasonable next therapy for the treatment of the patient's disease and is medically necessary having failed multiple systemic biologics. As such, Skyrizi is approved, and the decision is overturned based on the current evidence-based medical literature. 

Based on the above, the insurer's denial must be reversed. 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 Skyrizi 150 milligrams (mg) every 8 weeks is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease

Treatment: Rinvoq 45 mg (milligrams) + 30 mg

The insurer denied coverage for Rinvoq 45 mg (milligrams) + 30 mg

The denial is overturned

The patient has had Crohn's disease for several years. The patient has abdominal pain and bloody stools. The patient has failed treatment with Remicade and Humira. Afterwards, the patient was treated with Stelara but remained with severe colonic inflammation including a stricture and fistula. Inflammation persisted even after the Stelara dose was increased to every 4 weeks. The patient's physician is now requesting to give both Skyrizi and Rinvoq. 

The physician has referenced articles to support the use of dual biologic therapy. Inflammatory Bowel Disease Volume 27 Issue 8 July 2021 has an article titled "Dual Biologic and Small Molecule Therapy For the Treatment of Refractory Pediatric Inflammatory Bowel Disease." In this study 75% (percent) of patients achieved steroid free clinical remission in 6 months in an extremely refractory group. 

Clinical Gastroenterology and Hepatology March 2022; 20(3):e361-379 has an article titled "Dual Biologic or Small Molecule Therapy Of Inflammatory Bowel Disease: A Systematic Review and Meta analysis." It was advised that in patients with very refractory disease one should consider this option. 

Alimentary Pharmacology and Therapeutics 2020 Jun;51(11):1031-1038 has an article titled "Efficacy and Safety of Simultaneous Treatment with Two Biologic Medications in Refractory Crohn's Disease." The conclusion was that in this study dual biologic therapy was associated with clinical, biomarker, and endoscopic improvement in selected patients with refractory Crohn's disease. 

This patient has already failed multiple biologic therapies for Crohn's disease. The patient has already required intestinal surgery and the physician believes that without additional biologic therapy they will continue to require surgeries and have a very poor prognosis. There is support in the medical literature for giving dual biologic therapy. It has been documented that this is a particularly refractory case of Crohn's disease. 

Based on the above, the insurer's denial must be reversed. 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 Rinvoq 45 mg + 30 mg is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache and left sided facial numbness
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a female patient who presented to the emergency room with a headache and left sided facial numbness. The patient also had some subjective weakness in the left arm. The patient has a prior history of a right supraclinoid internal carotid artery aneurysm that underwent pipeline embolization. A computed tomography (CT) scan of the head and computed tomography angiography (CTA) of the head and neck were unremarkable. The patient was admitted to the hospital for further evaluation. The patient underwent a diagnostic cerebral angiogram that showed obliteration of the prior aneurysm and no other acute findings. The patient was recommended to take aspirin and a short course of Brilinta. She was subsequently discharged from the hospital. At issue is the medical necessity of an inpatient stay.
Inpatient admission is not medically necessary for treatment of this patient.
The patient presented to the hospital with a headache and left-sided symptoms. She had a history of an aneurysm which raised concern about the security of the aneurysm.. However, a CT scan of the head, CTA head and neck, and diagnostic cerebral angiogram did not show any evidence of an acute finding or a remaining aneurysm from the patient's prior embolization. No acute issues were found and it is possible that the patient's symptoms were related to migraine rather than a neuromuscular issue. The patient was subsequently discharged on aspirin and Brilinta.