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

Central Nervous System
Home Health Aide

Diagnosis: Parkinson's
Treatment: Personal Care Services
The insurer denied Personal Care Services: 70 Hours per Week. The health plan's determination is upheld. 

This patient is a female. She has a past medical history for Parkinson's disease, depression, gait abnormality, hypertension, gastroesophageal reflux disease, osteoarthritis and hyperlipidemia. The patient has been approved for 17 hours per week. 

Under review is the medical necessity of Personal Care Services: 70 Hours per Week.

Personal Care Services: 70 Hours per Week is not medically necessary for this patient. 

The Patient is a female with multiple medical problems. She has a long-standing history of Parkinson's disease for at least 10 years. She has movement and gait abnormality secondary to Parkinson's disease along with several other conditions from the disease and complications of medical therapy. She is requesting additional home health services through her power of attorney. She suffered from coronavirus with complications resulting in long hospitalization and nursing home stay the previous year. She did eventually recover and returned home. Physical therapy and occupational therapy were offered but refused by the patient until she was vaccinated for coronavirus.

An office note by the patient's primary care provider states that the patient requires a rolling walker to ambulate. She is in no distress. A review of systems was negative for dizziness, weakness or headaches and negative for depression. Vital signs are stable. Neurological exam states no focal deficit, she is alert and oriented to person, place and time. Mental status is at baseline. Behavior is normal.

Neurological exam states that the patient walks slowly and may shuffle with short steps. Uniform Assessment System (UAS) State of New York recommended 17 hours per week of services. Personal hygiene was noted to be limited assistance. Bed mobility and eating were noted to be independent with set up only. The patient uses a wheelchair for long distance and a walker for short distance.

It is reasonable to say that the patient's medical needs are met by the amount of services listed. Additional services are requested to help the patient prevent falls and so that she would not be alone. They were not necessarily requested for additional tasking, activities of daily living (ADLs) or instrumental activities of daily living (IADLs). The services for ADLs and IADLs were met with the amount of time available as listed through the UAS and also the tasking tool. Additional services for "prevention of falls" for "monitoring" without services being provided are typically not indicated. In order for services to be considered medically necessary, the aid must be performing a service such as medically necessary ADLs or IADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Inpatient Hospital. 
The insurer denied inpatient hospital admission for medical necessity. 
The denial was upheld in whole.

The patient is a female who had no pertinent past medical history. The patient reported a 1-month history of intermittent headaches (2-5 per week). She had been seen by ophthalmology and was said to have papilledema. She was sent to the emergency room (ER), but the patient signed out against medical advice (AMA) from the emergency room (ER) at that time. On the date of presentation, the patient had been sent from ophthalmology for work-up/imaging.

Her initial vitals were a blood pressure at 133/81, heart rate (HR) was 69, temperature was 97.7F, respiratory rate (RR) was 16, and pulse oxygen saturation was 100% on room air (RA). Her initial physical exam was unremarkable. The patient indicated a preference for inpatient admission for performance of imaging and lumbar puncture versus outpatient referrals. According to the discharge note, in addition to headaches, the patient also reported daily episodes of blurred vision and "palpitations of the eyelids."

The discharge note indicated that the patient had grade 1-2 papilledema on ophthalmologic exam. The magnetic resonance imaging (MRI) scan and magnetic resonance venography (MRV) of the brain were negative. The lumbar puncture showed an opening pressure of 38, which decreased to 23 after removal of 25 cubic centimeter (cc) of cerebrospinal fluid (CSF). The CSF labs were normal. The patient was started on acetazolamide 500 milligrams (mg) twice daily (BID). Outpatient follow-up was arranged with neurology and ophthalmology.

At issue is the medical necessity of the inpatient stay.

The health plan's determination of medical necessity is upheld in whole.

The requested health service/treatment of inpatient stay was not medically necessary for this patient.

In this case, the patient had re-presented to the emergency room on the recommendation of ophthalmology. The patient had been referred for a finding of papilledema on exam. The patient had complaints of headaches, but no other neurological or systemic findings of concern. She was hemodynamically stable. The patient was otherwise clinically stable at the time of initial presentation and the patient was admitted due to a preference to have the evaluation done in the hospital rather than on an outpatient basis.

The patient's initial MRI scan and MRV of the head both returned negative/normal. She was hemodynamically stable from the time of her initial presentation thru discharge. She had no deterioration of her medical condition since the time of initial presentation. The patient had no changes in her neurological presentation. There was no worsening of the patient's vision or other finding that necessitated the inpatient care setting. The care provided did not require the inpatient level of care/service.

Therefore, the inpatient stay was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Snoring

Treatment: Polysomnogram

The insurer denied coverage for Sleep Study (95810 x 1) Diagnostic Testing

The denial is upheld 

The patient is a female with history of obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD) and asthma, who was referred for a sleep study by her medical doctor for evaluation of snoring.  The patient's physical exam revealed that she was afebrile and hemodynamically stable.  Oxygen (O2) saturations were 100%.  The patient was in no acute distress.  Lungs had scattered expiratory wheeze.  Cardiovascular System (CVS) s1 S2 was normal.  The patient was alert and oriented x3.  There was a non-focal neuro exam.

The patient's pulmonary function tests (PFTs) were consistent with restrictive Pattern.

The patient did not have any signs of severe lung disease requiring home O2.  There was no history of congestive heart failure (CHF) Class 3 or Class 4, or severe neurologic disease.

This patient did not need an in-Lab Polysomnography.  This patient could have had an in-home Sleep Study done.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for Sleep Study (95810 x 1) Diagnostic Testing is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gender dysphoria.
Treatment: Wendler glottoplasty/Unlisted larynx procedure (31599).

The insurer denied coverage for the Wendler glottoplasty/Unlisted larynx procedure (31599).  The denial is overturned. 

This is a transgender female (male-to-female) patient with a diagnosis of gender dysphoria. She has been living as a female full-time and started hormone therapy. The patient has received voice therapy. The patient was evaluated by an Otolaryngologist. Voice modification surgery has been recommended. 

Although these surgeries do not require referral by mental health professionals, such professionals can play an important role in assisting clients in making a fully informed decision about the timing and implications of such procedures in the context of the social transition. Although most of these procedures are generally labeled 'purely aesthetic,' these same operations in an individual with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a given patient's condition and life situation. This ambiguity reflects reality in clinical situations and allows for individual decisions as to the need and desirability of these procedures." This patient is embarrassed to speak due to the low pitch of her voice that identifies her as male. As speech communication is critical to functioning in the modern world, her phonation issues clearly represent a functional issue. According to a 2019 systematic review of the literature regarding voice surgery "The literature supports both voice therapy and phonosurgery, depending on a patient's magnitude of desired pitch change and tolerance for cost and potential complications."  The patient has been treated with voice therapy without sufficient improvement in her vocal frequency. Peer literature supports that vocal surgery is an effective treatment when voice therapy fails, and the patient's clinical condition of anxiety with speaking creates medical necessity for this procedure.

According to the World Professional Association for Transgender Health (WPATH) guidelines, pages 63-64: "Other surgeries for assisting in body feminization include reduction thyroid chondroplasty (reduction of the Adam's apple), voice modification surgery, suction-assisted lipoplasty (contour modeling) of the waist, rhinoplasty (nose correction), facial bone reduction, face-lift, and blepharoplasty (rejuvenation of the eyelid). Other surgeries for assisting in body masculinization include liposuction, lipofilling, and pectoral implants. Voice surgery to obtain a deeper voice is rare but may be recommended in some cases, such as when hormone therapy has been ineffective.

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

The insurer's denial of coverage for the Wendler glottoplasty/Unlisted larynx procedure (31599) is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental cleaning. 
Treatment: Dental Procedure D4341(LL), D4341(UL),  D4341(LR), D4341(UR)
The insurer denied the Dental Procedure D4341(LL), D4341(UL),  D4341(LR), D4341(UR). 

The denial is upheld. 

No, the proposed treatment was not medically necessary. 

The x-rays provided do not show any bone loss in the areas in question. Therefore, the scaling and root planning are not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ulcerative Colitis. 
Treatment: Antibody Testing. 

The insurer denied the antibody testing. The health plan's determination is overturned. 

The patient is a male with Ulcerative Colitis. He had been on Remicade for 25 years. He had recurrent flares with symptoms of uncontrolled disease. He had testing for infliximab level and anti-infliximab antibodies, with a finding of Remicade level of 3.3 and anti-Remicade antibody level of 1232. 

The antibody testing is likely to be more beneficial than any standard treatment or treatments for the insured's Ulcerative Colitis. The patient was taking Remicade, an anti-tumor necrosis factor (TNF) medication, for the treatment of Ulcerative Colitis. In this case, Remicade levels and anti-Remicade antibody levels were checked after the patient had uncontrolled symptoms of Ulcerative Colitis. 

According to the American Gastroenterological Association (AGA) Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease, "In adults with active inflammatory bowel disease treated with anti-tumor necrosis factor agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes." According to the AGA Clinical Care Pathway guidelines for the treatment of Ulcerative Colitis, drug concentration and anti-drug antibody levels should be checked if there is a loss of response to an anti-TNF medication such as Remicade, with a subsequent change in management (switch within drug class, assess for inflammation, or increase dose) [AGA Institute]. The American College of Gastroenterology guidelines for Ulcerative Colitis also recommend the testing, stating "In patients with moderately to severely active Ulcerative Colitis who are responders to anti-TNF therapy and now losing response, we suggest measuring serum drug levels and antibodies to assess the reason for loss of response." Current medical literature concurs, recommending drug level monitoring based on studies showing that anti-TNF drug levels predict response to therapy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ulcerative Colitis. 
Treatment: Antibody Testing. 

The insurer denied the antibody testing. The health plan's determination is upheld. 

The patient is a male under evaluation and management for Ulcerative Colitis. The patient has been on Remicade for several years with a normal colonoscopy. The patient underwent testing for infliximab levels and antibody levels - drug level was low and the antibody titer was high. A repeat assessment found similar results. 

The antibody testing is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

In this specific case, the patient had an assessment where he was found to have a high antibody titer to infliximab. Without a change in medications (e.g. adding a thiopurine), it would not be expected that the antibody titer would change significantly. Thus, the testing is not indicated. The result from the assessment, confirmed in the following year, indicated that the patient had to switch to another agent for treatment.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Ulcerative Colitis. 
Treatment: Antibody Testing. 

The insurer denied the antibody testing. The health plan's determination is upheld. 

The patient is a male with ulcerative colitis requesting antibody testing. The appeal describes that the patient was on Remicade, having symptoms, with drug and antibody testing performed. The appeal letter states the patient has been on Remicade for 25 years. Because of a flare, the antibody testing was needed to assess whether infliximab was working. The testing was needed to decide upon therapy. A progress note describes low trough levels and positive antibody levels. 

The proposed antibody testing is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. 

The testing in this case was not indicated. The progress notes show that the patient was in clinical and endoscopic remission. No flare or worsening symptoms were described. The presence of antibodies did not lead to a change in therapy since the patient was doing well clinically. The antibody testing did not dictate management but rather the clinical and pathologic data determined therapy. Despite the presence of antibodies, the Remicade was continued since the patient had been in remission for many years. The colonoscopy and pathology data was described as normal. 

Although antibodies to infliximab can occur and lead to resistance to therapy, routine assay of antibody levels to infliximab has no proven effectiveness in the peer reviewed literature. Data regarding the clinical utility of Anser adalimumab (ADA) and Anser infliximab (IFX) is still emerging. There is no clear evidence at this time that these tests improve health outcomes over standard clinical management.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Speech and Feeding Delays.
Treatment: 8 outpatient visits of speech therapy.
The insurer denied coverage for 8 outpatient visits of speech therapy.
The denial is upheld

This case review concerns a patient who has received 80 sessions of Speech Pathology treatment, provided to address both feeding therapy and articulation therapy. The Speech Language Pathologist has written an appeal letter stating that she is using the Sequential-Oral Sensory approach to feeding therapy. This is an evidence-based and typically a multidisciplinary approach to pediatric feeding therapy. The evidence base for this Sequential-Oral Sensory approach is available on the website www. sosapproachtofeeding.com/why-sos-approach-feeding.  

The Speech Language Pathologist provider also has described in the letter that she is working with this child on his articulation skills, and has sent the results of articulation testing that show that the child has made measurable articulation progress over the 80 sessions that were done.  

The reviewer has read the letters from the provider, and also from the physician.  

The American Speech-Language Hearing Association website provides professional best practice and medical necessity information regarding pediatric feeding therapy (https://www.asha.org/practice-portal/clinical-topics/pediatric-dysphagia/). According to American Speech-Language Hearing Association, proof of medical necessity related to provision of continued services for pediatric feeding therapy should focus on four factors:

1)	Presence of feeding disorder secondary to physiological dysfunction of the oral mechanism.
2)	Improvement with treatment.
3)	Maintenance of weight while receiving this treatment and ability to tolerate fluids and certain oral foods.
4)	Tolerance for foods initially refused and steady progress with treatment.
Although the last three factors appear to be documented in this case appeal, the reviewer cannot find any statement or evidence that the first factor has been documented. In order to meet the standard of medical necessity, an assessment should be included with the documentation. The assessment should document details of the feeding disorder, including a description of the child's oral motor muscle function related to feeding, any evidence of oral or oropharyngeal dysphagia, any evidence of esophageal dysfunction [such as pediatric gastroesophageal reflux disease], and a description of any sensory dysfunction related to feeding. This documentation is needed in order to make the case for medical necessity, and also to provide evidence that the skilled services of a Speech Language Pathologist are required.

Without evidence of the first factor required, the reviewer finds that the test of medical necessity for the additional 8 sessions has not been met, and the denial must be upheld.

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

The insurer's denial of coverage for 8 outpatient visits of speech therapy is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute appendicitis.
Treatment: Inpatient admission.

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

This male patient has a history of COVID infection (3 weeks prior to presentation). He presented via ambulance to the Emergency Department (ED)  for evaluation of severe abdominal pain, nausea and fever. The white blood cell count (WBC) was 21,000. Intravenous (IV) fluids, IV antibiotics, pain control, Zofran and Pepcid were administered and a computed tomography (CT) scan showed acute appendicitis. The patient was found to be COVID-positive on pre-op screening (asymptomatic). The patient was admitted and underwent a laparoscopic appendectomy. He failed a trial to void multiple times, and Urology was consulted for acute urinary retention.  The patient voided, his pain improved, his WBCs trended down and he tolerated clear liquids. He was discharged home.

Per MCG Health Appendectomy, without Abscess or Peritonitis, by Laparoscopy RRG, inpatient admission may be needed for urinary complications. An extended stay beyond the goal length of stay may be necessary until the patient is voiding adequately or with urinary catheter, percutaneous suprapubic tube, or plan for intermittent self-catheterization, and management regimen in place that is performable at next level of care. There is no indication that the patient was not able to perform self-catheterization and management at the next level of care. Therefore, an extended inpatient admission was not necessary. Admission may also be necessary for patients with severe systemic illness (eg, sepsis), poorly controlled comorbidities (eg, chronic obstructive pulmonary disease, chronic heart failure), or complications from the procedure (eg, infection, bleeding) that require more than 24 hours of postoperative care. This patient did not have any immediate complications documented after the surgery. The patient's diet was advanced as tolerated. According to clinical documentation, the patient could have been treated under observation standards. Peer-reviewed literature also indicates that laparoscopic appendectomy can successfully be performed as an outpatient procedure in those with uncomplicated appendicitis.

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: Overturned

Diagnosis: Pulmonary Embolism. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission.  The denial is overturned. 

The patient in this case is a female with a prior history of anemia and pulmonary embolism. She was on treatment with Xarelto.  She presented to the emergency department with acute onset of chest pain associated with mild shortness of breath. Electrocardiogram (ECG) was unremarkable. Troponin level was elevated. Cardiology was called and they recommended treating the patient as if she was having a non-ST elevation myocardial infarction with aspirin, Plavix and intravenous (IV) heparin.  It was decided to admit her to telemetry. 

The patient had a computed tomography (CT) of the chest done while she was in the emergency department, and it was resulted after that conversation with cardiology and it revealed multiple acute pulmonary emboli with evidence of right heart strain. She was admitted to the hospital with telemetry monitoring and was continued on intravenous (IV) heparin.  However, given that she was diagnosed with pulmonary embolism, aspirin and Plavix were discontinued.  Treatment with tissue plasminogen activator (tPA) was not recommended. 

The patient was doing well and remained hemodynamically stable.  She was transitioned to enoxaparin and was seen by hematology.  She was felt to have treatment failure and was continued on enoxaparin. Her troponin level improved. 

The patient was discharged home on enoxaparin. 

Yes, the hospital admission was medically necessary. 

This patient was admitted to the hospital with pulmonary embolism, and she had multiple acute pulmonary emboli.  She had no hemodynamic instability at the time of admission but did have evidence of right heart strain on computed tomography (CT).  She had some elevation in troponin but at the time of admission was not felt to have active coronary ischemia.  Hospital admission was appropriate at that time given the identification of right heart strain on computed tomography and given that she had multiple pulmonary emboli (submassive pulmonary embolism).  On the day after admission, however, she was feeling well and was hemodynamically stable with falling troponin level.  Chest pain had resolved. She was transitioned to enoxaparin.  Continued monitoring was appropriate in this case given that she had large and multiple pulmonary emboli.  She was appropriately discharged the following day.