Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Premature Coronary Artery Disease
Treatment: Lipoprotein (a) testing
The insurer denied coverage for lipoprotein (a) testing.
The denial is overturned.

This is an adult with hyperlipidemia and a family history of coronary artery disease. As part of the evaluation of hyperlipidemia, the patient had testing of lipoprotein (a) [Lp(a)].  
The scientific evidence in peer-reviewed literature supports a result of improvement health outcomes. Lipoprotein(a) level has been shown to be related to cardiovascular risk. It has been recommended to be tested once as part of the evaluation of hyperlipidemia in current European Cardiology Society (ESC) guidelines. Further, the current American College of Cardiology (ACC)/ American Heart Association (AHA) lipid lowering guidelines recognize Lp(a) as an independent cardiovascular risk factor. In summary, the higher the Lp(a) the higher the cardiovascular risk and the lower the Lp(a) the lower the risk. This risk appears independent from the risk associated with LDL-C (low density lipoprotein-Cholesterol).
Thus, the goal is to have the lowest Lp(a) as possible. Current medications such as statins and PCSK9 (Proprotein convertase subtilisin/kexin type 9) inhibitors (class of drugs that lower cholesterol) do lower LDL-C and to some extent Lp(a). However, there are no medications that specifically lower Lp(a) alone without affecting LDL-C. Further, Lp(a) level tends to be stable in the absence of a change in therapy. The current recommendation is to measure Lp(a) once as part of determining cardiovascular risk to evaluate baseline cardiovascular risk. It allows the provider to evaluate risk level for cardiovascular events and should be measured once, although at this time there are no specific agents that target Lp (a) alone.

Lipoprotein (a) testing is part of evaluation for the diagnosis of hyperlipidemia and has final approval from the appropriate regulatory bodies for this diagnosis.

The patient is a good candidate for testing, as it is part of the evaluation for diagnosis of hyperlipidemia. Lp(a) is not a treatment. It is a diagnostic test that was appropriate to measure at that time. Lp(a) is a blood test. There are no risks associated with testing.
As noted above, the measurement of Lp(a) once in the evaluation of a patient's hyperlipidemia such as this one is beneficial.

In summary, the denial of lipoprotein (a) testing and coverage for the requested service should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Premature Coronary Artery Disease
Treatment: Lipoprotein (a) testing
The insurer denied coverage for lipoprotein (a) testing.
The denial is upheld.

The patient is an adult with hypercholesterolemia. The patient had a lipoprotein (a) testing. Per appeal letter, medical studies support lipoprotein testing in patients with heart disease. There are a few studies in the medical literature that support an improved outcome with lipoprotein A testing. However, the evidence has not yet been incorporated into current applicable guidelines.
The lipoprotein (a) testing does not have final approval from the appropriate regulatory bodies for this diagnosis as the testing of lipoprotein has not yet been incorporated into clinical guidelines.
This patient is not a good candidate for lipoprotein (a) testing. Lipoprotein (a) may be useful certain clinical subpopulations and risk groups; however, it has not yet been approved for general population screening.

Lipoprotein (a) testing is not the best available treatment for this patient at this time. Low-density lipoprotein (LDL) testing and treatment to goal remains the standard treatment.

There are no clear adverse risks.

The requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. Standard lipid guidelines still remain the best strategy without adding lipoprotein (a) testing until the guidelines are updated.

Grundy, S.M. et al. (2019) write that, "Serum cholesterol and its lipoprotein carriers (LDL, very low-density lipoprotein [VLDL], and HDL [high density lipoprotein]) are known to be related to ASCVD (atherosclerotic cardiovascular disease). LDL-C (low density lipoprotein-Cholesterol) is the dominant form of atherogenic cholesterol. VLDL is the chief carrier of triglycerides, and VLDL cholesterol (VLDL-C) is also atherogenic. HDL-C is seemingly not atherogenic. Chylomicrons transport dietary fat; chylomicron atherogenicity is uncertain. The combination of LDL-C and VLDL-C is called non-HDL-C and is more atherogenic than either lipoprotein alone. The main protein embedded in LDL and VLDL is apolipoprotein B (apoB), and like non-HDL-C, apoB is a stronger indicator of atherogenicity than LDL-C alone."

In summary, the denial of lipoprotein (a) testing and coverage for the requested service should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risk are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Premature Coronary Artery Disease
Treatment: Lipoprotein (a) testing
The insurer denied coverage for lipoprotein (a) testing.
The denial is overturned.

This is a case of an adult with a history of hypercholesterolemia, ectopic atrial arrhythmia, family history of atherosclerotic cardiovascular disease (ASCVD) and borderline hypertension. The patient's cardiologist ordered Lipoprotein(a) testing in order to assess Lp(a) [lipoprotein (a)] mediated risk of cardiovascular disease.

The scientific evidence in peer-reviewed literature supports a result of improvement in health outcome. Lipoprotein A has been shown to have atherogenic potential (References 1,2). The AHA (American Heart Association) cholesterol clinical practice guidelines consider elevation of Lp(a) a risk-enhancing factor (Reference 3).

Lipoprotein (a) testing has approval from the appropriate regulatory bodies for diagnosis. Indications for measurement include a family history of coronary artery disease (Reference 3). The US (United States) National Lipid Association and the European Society of Cardiology guidelines recommend testing for Lp(a) in patients with premature coronary artery disease and/or a strong family history of ASCVD (References 4,5). Based on guidelines, this patient is a good candidate for these tests.

Multiple clinical trials have reported an elevated level of major adverse cardiac events in patients with good reduction in LDL (low density lipoprotein) cholesterol and elevated Lp(a) (References 6,7). Assessment of Lp(a) is the best available treatment for the patient at this time. There are no apparent adverse risks to these tests. In fact, testing will be useful for guiding therapy.

In summary, the denial of lipoprotein (a) testing and coverage for the requested service should be overturned. This treatment is likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: D8080 braces and D8670 monthly visit
The insurer denied coverage for D8080 braces and D8670 monthly visit
The denial is upheld

Upon review of the submitted documentation including lateral cephalometric 
radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, treatment records, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to anterior crossbite with gingival attachment loss, among other clinical findings. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index as required among other and has chosen the automatically qualifying condition of cross bite of individual anterior teeth (mandibular left canine) when clinical attachment loss and recession of the gingival margin are present, to support orthodontic necessity. 

Upon review of the submitted documentation, (study models were not provided for review), it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labia-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present. This reviewer finds that this automatically qualifying condition criterion is not met as there is no evidence of gingival attachment loss or gingival recession and therefore does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. This is confirmed by several studies referenced below. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent in appropriate approach for assessing orthodontic need. 

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

The insurer's denial of coverage for the D8080 braces and D8670 monthly visit is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rosacea
Treatment: Ivermectin 1% (percent) EX (external) CREA (cream)
The insurer denied coverage for Ivermectin 1% EX CREA.
The denial is overturned.

The patient has a diagnosis of rosacea. The patient is noted to have failed topical metronidazole and Finacea as well as oral doxycycline 100mg (milligrams) and 50mg daily. The requested medication is topical Ivermectin cream.

The patient has failed topical therapy with metronidazole and Finacea as well as commonly used over the counter washes. The patient has also been treated with oral doxycycline. The addition of Ivermectin cream is within the rosacea guidelines and would be a reasonable additional treatment to the patient's rosacea regimen. The use of topical Ivermectin is within the standard of care.

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 the Ivermectin 1% EX CREA is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute appendicitis
Treatment: Full hospital admission
The insurer denied coverage for full hospital admission.
The denial is overturned.

According to the medical records, this is a child who was brought into the Emergency Room (ER) with a 2-day history of sleeplessness due to abdominal pain, nausea and vomiting, and a temperature at home of 103 degrees F (Fahrenheit). A computerized tomography (CT) scan showed a fluid filled enhanced wall thickened appendix.  White blood cells (WBC) were 19.3. There apparently were no incidences or complications intraoperatively or postoperatively. The appendix was retrocecal and suppurative but not ruptured. He did well and was discharged to office visit follow up. The full admission was denied on the basis of lack of acuity. This admission was justified as the patient, with a leukocytosis and left shift as is demonstrated here, is on the verge of becoming septic with a not yet ruptured appendix.

"Treatment / Management in the emergency department, the patient must be kept nil per mouth (NPO) and hydrated intravenously with crystalloid, and antibiotics should be administered intravenously as per the surgeon. The responsibility for the consent falls on the surgeon. The gold-standard treatment for acute appendicitis is to perform an appendectomy. Laparoscopic appendectomy is preferred over the open approach. Most uncomplicated appendectomies are performed laparoscopically. Several studies have compared the outcomes with the laparoscopic appendectomy group and patients who underwent open appendectomy." (Jones, MW. et al. 2021)

"Acute appendicitis (AA) develops in a progressive and irreversible manner, even if the clinical course of AA can be temporarily modified by intentional medications. Reliable and real-time diagnosis of AA can be made based on findings of the white blood cell count and enhanced computed tomography. Emergent laparoscopic appendectomy (LA) is considered as the first therapeutic choice for AA. Interval/delayed appendectomy at 6-12 week after disease onset is considered as unsafe with a high recurrent rate during the waiting time. However, this technique may have some advantages for avoiding unnecessary extended resection in patients with an appendiceal mass. Non-operative management of AA may be tolerated only in children. Postoperative complications increase according to the patient's factors, and temporal avoidance of emergent general anesthesia may be beneficial for high-risk patients." (Hori, T. et al. 2017)

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 full hospital admission is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression, anxiety
Treatment: Increase Social Day Care (SDC) Services for a Total Amount of 3 Days Per Week
The insurer denied the Increase Social Day Care (SDC) Services for a Total Amount of 3 Days Per Week.
The denial is upheld.

The patient is an adult male. Per Uniform Assessment System evaluation, cognitively, the patient is independent. He is maximal assistance for meal preparation, and total dependence for ordinary housework. He is limited assistance with stairs, extensive assist with bathing, independent with personal hygiene and dressing upper body. He is extensive assistance with toilet use. He is frequently incontinent of bladder.

The request is for Increase Social Day Care (SDC) Services for a Total Amount of 3 Days Per Week. The health plan approved 2 days per week.

The requested increase in social day care services to 3 days per week is not medically necessary.

Based on the records in the recent nursing assessment, the patient's physical needs are met with the current services. There is no change in the assessment, the current services are sufficient to provide the care the patient needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain

Treatment: Inpatient hospital services

The insurer denied coverage for inpatient hospital services.

The denial is upheld.

The patient presented with abdominal pain and vomiting. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. There was no leukocytosis. The liver enzymes were elevated. An ultrasound found a large hepatic cyst. An abdominal computerized tomography scan showed gastric distention and an endoscopy was advised. There was a suspicion of duodenal ulcers. Raglan was given for possible gastroparesis. A clean based duodenal ulcer was found at endoscopy. 

Clinical indications for admission for Undiagnosed Abdominal Pain per Milliman Care Guidelines (MCG) M-05 include hemodynamic instability, peritoneal signs, inability to maintain oral hydration after observation care, and the need for a procedure that cannot be performed on an ambulatory basis. The patient did not have these conditions.

This patient had abdominal pain and there was a suspicion of ulcer disease. She required an endoscopy and responded to medical therapy. She was stable to have had the endoscopy performed on an ambulatory basis. She could have been treated with observation status. She did not meet MCG criteria for Undiagnosed Abdominal Pain. 

The insurer's denial is upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for inpatient hospital services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Bronchiolitis
Treatment: Inpatient hospital admission
The insurer denied coverage for inpatient hospital admission.
The denial is upheld.

This is a female toddler who presented to the emergency room (ER) with complaints of trouble breathing. She had a cough, fever, and wheezing. The patient was given nebulizer treatments and symptoms persisted. She was admitted with respiratory distress secondary to viral bronchiolitis. The patient was given nebulizer treatments every four hours and steroids. Her condition improved and she was discharged.  

The child presented at the second day of onset of symptoms. As indicated it is well known that peak symptoms of bronchiolitis are the third or fourth day. Even at the third day which may be the peak, there was no documentation of oxygen saturation (SpO2) less than 90 consistently. There was no documentation that the patient required continuous positive airway pressure (CPAP) or high flow nasal canula (HFNC). The patient had only mild respiratory distress as her respiratory rate (RR) was less than 60. The Emergency Department (ED) doctor mentioned also "nontoxic" appearance. The RR was 30 by the time the admission History and Physical (H&P) examination was done. There was no significant acidosis nor respiratory acidosis in the initial labs. There was also no need for multiple boluses for severe dehydration nor shock. The patient did not have underlying chronic lung disease nor congenital heart disease nor any neuromuscular deficits. 

The hospital course was representative of an 'as expected' clinical course. The trajectory showed improving respiratory status. Also, there was no evidence of the patient needing continuous nebulizers, epinephrine injection nor terbutaline drip. Intravenous (IV) fluids and nebulizers could be administered in observation status. Due to the above facts, the patient could have been managed as observational status.

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

The insurer's denial of coverage for inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alzheimer's disease.
Treatment: Consumer directed personal assistance services (CDPAS) 24 hours per day, 7 days a week - split shift.
The insurer denied coverage for CDPAS 24 hours per day, 7 days a week - split shift. 
The denial is modified.

This is a patient with chronic medical problems including Alzheimer's disease. She lives with her son in a private 2-story residence. The patient is currently approved by the insurer for CDPAS 70 hours/week and is requesting an increase of CDPAS to 24 hours/day, 7 days a week - split shift.

According to the Uniform Assessment System (UAS) report, the patient cognition is described as "severely impaired." The patient requires maximal assistance for bathing. Extensive assistance is required for dressing, personal hygiene, toilet transfers and ambulation (uses a cane). She requires only supervision for bed mobility and eating. The patient is frequently incontinent of bowel and bladder. The patient's functional status is much the same as it was recorded in the prior UAS report, with modest decrease in cognition, bathing, ambulation and toilet transfer. The combination of the patient's cognitive deficits and functional impairments support the medical necessity of increasing CDPAS to 84 hours/week. Her condition and functional needs are not at a level or unpredictable as to require the requested (CDPAS) 24 hours/day, 7 days a week - split shift. This physician would agree the patient may require 24-hour monitoring, particularly due to her episodes of wandering. However, safety monitoring under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety can be appropriately provided and maintained by the increasing CDPAS to 84 hours/week.  

From a physical medicine and rehabilitation perspective, the requested increase CDPAS 24 hours per day, 7 days a week - split shift, is not medically necessary.  However, increasing CDPAS to 84 hours/week is medically necessary.  

The insurer's denial of coverage for consumer directed personal assistance services (CDPAS) 24 hours per day, 7 days a week - split shift is modified. Medical Necessity is partially substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral vascular accident (CVA) with left hemiplegia, gastric tube placement and end staged renal disease (ESRD on hemodialysis). 
Treatment: Level 2 Personal Care Aide (PCA) Services of 21 hours per week. 
The insurer denied coverage for Level 2 PCA Services of 21 hours per week. 
The denial is overturned. 

This is a patient with right CVA with left hemiplegia, gastric tube placement and ESRD on hemodialysis. He lives alone on the 1st floor of a single-family home. The insurer previously approved PCA services 24 hours/day, 7 days a week. The insurer recently approved 21 hours/week that was subsequently decreased to 13 hours/week. Under review is the medical necessity of the previously approved Level 2 PCA Services of 21 hours per week. 

According to the recent Uniform Assessment System (UAS) report, the patient's cognition is described as "moderately impaired." He requires maximal assistance for bathing and lower body dressing. Extensive assistance is required for personal hygiene, and toilet transfers. Limited assistance is required for toilet use. He is continent of bowel and bladder. This patient requires only supervision for ambulation. He is totally dependent for eating due to his gastric tube feedings. The combination of the patient's cognitive status, medical condition and functional impairments support the medical necessity of the PCA Services of 21 hours per week currently under review. 

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 Level 2 PCA Services of 21 hours per week is overturned. Medical Necessity is substantiated.