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

Diagnosis: symptomatic neurogenic orthostatic hypotension.
Treatment: Droxidopa.
The insurer denied: Droxidopa.
The denial is: Overturned.

The patient is a male diagnosed with symptomatic neurogenic orthostatic hypotension. The drug droxidopa was denied because the patient does not have neurogenic orthostatic hypotension due to a particular diagnosis. The patient has previously tried and failed midodrine due penile pain and bladder spasm. The patient also tried fludrocortisone but did not remember if it was effective. The subject under review is the medical necessity for droxidopa.

The health plan's determination is overturned.

The droxidopa is medically necessary for treatment of this patient. Droxidopa is Food and Drug Administration (FDA) approved and literature supported for use in neurogenic orthostatic hypotension which is secondary to certain conditions. These conditions include primary autonomic failure [Parkinson's disease (PD), multiple system atrophy and pure autonomic failure], dopamine beta-hydroxylase deficiency, and non-diabetic autonomic neuropathy. The records clearly demonstrate that the patient has non-diabetic autonomic neuropathy. Autonomic testing is provided demonstrating dysfunction of the sympathetic and parasympathetic nervous system. This dysfunction is neuropathy. The records also demonstrate that the patient has tried, failed, or had an incomplete response to other available treatments, which are considered first-line for the condition. These include midodrine and fludrocortisone. As the member has an approved indication and has failed other therapies, the use of droxidopa is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Osteoarthritis, hypertension, and dyslipidemia.
Treatment: Increase Social Day Care (SDC) Services for a Total Amount of Three Days per Week.
The insurer denied: Increase Social Day Care (SDC) Services for a Total Amount of Three Days per Week.
The denial is upheld.

The patient is an adult female with osteoarthritis, hypertension, and dyslipidemia.  She has requested an increase in Social Day Care to three days per week from two days per week.

A Person-Centered Service Plan notes that the patient is able to participate in activities they like inside and outside of the home and can visit friends and family if/when they want to.  The patient has access to home care for two hours per day, seven days per week and Social Day Care two days per week.  The Uniform Assessment System New York Comprehensive Community Health Assessment Report notes no indicators of possible depressed, anxious, or sad mood and that the patient is not lonely.

An adverse determination notes that the request was denied, noting that Social Day Care is provided as an added benefit and cannot represent the primary service offered by Center Plan for Healthy Living and also that the patient's "current status does not support a need for increasing your Social Day Care Services."  The member appealed this decision noting that they have depression.  The plan upheld the denial, noting that there was no change in the patient's functional or social status that would warrant a change in care.

Additional information submitted on appeal from the patient's physician notes that the patient's "conditions are worsening physically and mentally" and recommended social day care five days per week.

The proposed increase in social day care (SDC) services for a total amount of three days per week is not medically necessary.

Utilization of Social Day Care Services has been shown to have a favorable effect in function for elderly patients with chronic medical conditions (Lunt et al 2018).  These authors note that attendance of at least two days per week has been beneficial in some elderly populations, though the optimal frequency is not clear based on the literature.  

This patient has requested three days a week of Social Day Care Services from the currently approved two days per week.  The request for an increase is not supported by the submitted documentation.  While a physician note indicates a worsening in "physical and mental" conditions for this patient, the degree of deterioration, the implications on functional or social status, and the specific comorbidities which have worsened are not clearly elucidated.  There is no clinical data to show how or if an increase in Social Day Care would benefit the patient.  The most recent Uniform Assessment System evaluation notes that the patient has stable medical comorbidities and no evidence of mental health issues.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: History of falls, recent left hip fracture, dementia, and other chronic illnesses including atrial fibrillation, hypertension and diabetes
Treatment: Level 2 Personal Care Services, per 15 minutes, increase to 24 hours per day (live-in)
The insurer denied coverage for Level 2 Personal Care Services, per 15 minutes, increase to 24 hours per day (live-in)
The denial is overturned.

This is the case of an older patient with a history of falls, recent left hip fracture, mild dementia, and other chronic illnesses including atrial fibrillation, hypertension and diabetes. The patient is currently in a rehab center. A progress note states that the patient requires extensive assist x 1 with bed mobility, transfers, toileting, bathing and lower body dressing. The patient was able to ambulate 75 feet with extensive assist x 1 and a rolling walker. The recommendation was for discharge home with 24-hour care. 

The medical records demonstrate continued deterioration for this geriatric patient. His recent hip fracture has caused an increase in morbidity. There were recommendations from the Rehabilitation Director for full time services. There were recommendations from occupational therapy (OT) and physical therapy (PT) regarding lack of independence for ambulation and activities of daily living. The report of high risk for fall and additional injury has credence. The history of multiple falls and dementia with associated progressive senility supports the necessity of the requested service. It is likely additional episodes will result in hospitalization without appropriate supervision. 

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 Level 2 Personal Care Services, per 15 minutes, increase to 24 hours per day (live-in) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Autism Spectrum Disorder.
Treatment: 15 hours a week of direct ABA therapy, 1.5 hours a week of supervision and 7 hours of reassessment. 
The insurer denied: 15 hours a week of direct ABA therapy, 1.5 hours a week of supervision and 7 hours of reassessment. 
The denial is: Upheld

The patient is a non-binary individual diagnosed with autism spectrum disorder. An Applied Behavioral Analysis report describes that the patient was born following a normal vaginal delivery. There were no complications. Hearing and vision were satisfactory. The patient walked before 12 months. Speech articulation was delayed, but the patient was speaking in full sentences by 2.5 years. They received speech therapy. In elementary school the patient chewed pencil erasers and tapped their fingers. They were depressed and described wanting to kill themselves following being denied admission to a middle school performing arts program. The patient's mother died, and they came to live with their grandparents. During the Coronavirus 2019 (Covid) pandemic their grandmother provided homeschooling, but the patient did not cooperate. In high school, the patient is in gifted classes. They participate in color guard, dance and musical theater. They would like to study biology in college. The patient takes Sertraline and Trazodone. In the past their pediatrician diagnosed attention deficit hyperactivity disorder (ADHD) but there was no response to several medications.

Areas of challenge identified by their grandparents include task refusal, pacing, lying, excessive spending and using credit cards without consent. The patient is reported to have good conversational skills, and is able to identify areas in need of improvement.
The applied behavioral analysis (ABA) provider has requested 15 hours a week of direct ABA therapy, 1.5 hours a week of supervision and 7 hours of reassessment. This was denied by the health plan.

At issue in this case is whether 15 hours a week of direct ABA therapy, 1.5 hours a week of supervision and 7 hours of reassessment is medically necessary for the patient. The requested 15 hours a week of direct ABA therapy, 1.5 hours a week of supervision and 7 hours of reassessment is not medically necessary for this patient.

In a review of the medical literature, this reviewer was unable to find any literature supporting the medical necessity of applied behavioral analysis (ABA therapy) for adolescents with mild autism spectrum disorder without intellectual disability and without significant behavioral challenges. The behaviors of concern include lying, failure to complete tasks, excessive spending and use of credit cards without consent. These concerns do not appear primarily due to autism spectrum disorder.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease.
Treatment: Stelara.
The insurer denied: Stelara.
The denial is: Overturned.

The patient is a male with recently diagnosed ileal Crohn's disease (CD). He has tried and failed steroids. He is naive to biological therapy. He has tested negative for tuberculosis. Therefore, the attending gastroenterologist would like start him on Stelara to treat his severe Crohn's disease. The medical necessity for Stelara is the subject under review.

The requested treatment of Stelara is medically necessary for this patient. Current guidelines for the management of Crohn's disease recommend Stelara as a first line biological agent for the induction of remission of Crohn's disease.
There has been a change in the treatment goals for patients with Crohn's disease (CD). Previously, therapy for Crohn's disease was based on a "step-up" approach, in which biological agents are administered after the failure of steroids and immunosuppressants i.e., treatment was initiated mainly in reaction to acute flares of the disease aimed to improve clinical symptoms. However, recent studies have suggested that early introduction of biological agents with or without with immunosuppressants can modify the natural history of the disease and the focus now has changed to the prevention of damage to the intestinal wall. The prevention of structural damage by achievement of 'mucosal healing', however, is associated with the more 'aggressive' treatment and an earlier use of immunosuppressants and biologicals.

In biologic naive patients, the American Gastroenterological Association (AGA) recommends infliximab, adalimumab, or ustekinumab over certolizumab pegol (strong recommendation) and suggests the use of vedolizumab over certolizumab pegol (conditional recommendation).
Scott and colleagues showed that in a simulation based on a 35-year-old male patient with moderate to severe Crohn's disease, ustekinumab as the first-line biologic therapy yields greater Quality Adjusted Life Years (QALYs) at the end of 1 year than compared with use later in the CD treatment algorithm. Hence it is appropriate to use Stelara to treat this patient's Crohn's disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Supraventricular Tachycardia (SVT). 
Treatment: Inpatient Stay. 

The insurer denied the inpatient stay. The health plan's determination is upheld. 

The patient is a male who presented for scheduled supraventricular tachycardia (SVT) ablation. The patient previously was diagnosed with WPW (Wolff-Parkinson-White) syndrome. The patient had history of palpitations lasting for one minute, worse with excitement or exercise. His palpitations started about 5 years ago. Now, he feels palpitations 1-2 days every week. The patient had history of syncope. There were no other cardiac symptoms or cardiac history. 

The Inpatient Hospital Admission was not medically necessary for this patient. 
The patient is a male who had episodes of supraventricular tachycardia (SVT) due to WPW syndrome. The patient had short episodes lasting for a minute, but was symptomatic. The patient otherwise did not have any cardiac history or cardiac symptoms. The patient was scheduled for ablation as an elective procedure. His left ventricular ejection fraction (LVEF) was mildly depressed based on echocardiogram. 
His vital signs and physical examination were normal upon presentation. His vital signs remained stable throughout the procedure and post procedure period. He tolerated the procedure well, there were no complications. His vital signs next morning remained stable. 

Electrophysiologic (EP) procedure is an invasive procedure and there were possible complications. However, this patient did not suffer any complications and was stable. He was appropriately monitored, but did not meet criteria for inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

cardiac
inpatient hospital

Diagnosis: supraventricular tachycardia (SVT)
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a male who presented for scheduled supraventricular tachycardia (SVT) ablation. The patient previously was diagnosed with WPW (Wolff-Parkinson-White) syndrome. The patient had history of palpitations lasting for one minute, worse with excitement or exercise. His palpitations started about 5 years ago. Now, he feels palpitations 1-2 days every week. The patient had history of syncope. There were no other cardiac symptoms or cardiac history.

The Inpatient Hospital Admission was not medically necessary for this patient.
The patient is a male who had episodes of supraventricular tachycardia (SVT) due to WPW syndrome. The patient had short episodes lasting for a minute, but was symptomatic. The patient otherwise did not have any cardiac history or cardiac symptoms. The patient was scheduled for ablation as an elective procedure. His left ventricular ejection fraction (LVEF) was mildly depressed based on echocardiogram.
His vital signs and physical examination were normal upon presentation. His vital signs remained stable throughout the procedure and post procedure period. He tolerated the procedure well, there were no complications. His vital signs next morning remained stable.
Electrophysiologic (EP) procedure is an invasive procedure and there were possible complications. However, this patient did not suffer any complications and was stable. He was appropriately monitored, but did not meet criteria for inpatient admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive sleep apnea.

Treatment: oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment, code E0486; and code 21110 application of interdental fixation device for conditions other than fracture or dislocation, includes removal; code 21085 Impression and custom preparation; oral surgical splint.

The insurer denied coverage for oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment, code E0486; and code 21110 application of interdental fixation device for conditions other than fracture or dislocation, includes removal; code 21085 Impression and custom preparation; oral surgical splint.

The denial is overturned
 

The following is the American Academy of Sleep Medicine (AASM) policy:  

"We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea (OSA) who are intolerant of continuous positive airway pressure (CPAP) therapy or prefer alternate therapy" 

Since this patient has not wanted CPAP, and preferring Oral appliance (OA), the patient should be trialed on the oral appliance or Mandibular Advancement Device (MAD). 

The evidence supports the use of custom, titratable OAs over other types of appliances. Although the reduction in apnea - hypopnea index (AHI) and oxygen desaturation index (ODI) are similar for both custom, titratable and custom, non-titratable OAs. 

Neither custom nor non-custom OAs have been shown to significantly affect sleep architecture and sleep efficiency. However, the overall improvement in other physiologic sleep parameters with the use of custom OAs in adult patients with OSA should result in an improvement in daily function and quality of life.

The available data also suggest that OAs effectively improve daytime sleepiness. The mean change in the Epworth Sleepiness Scale (ESS) with custom, titratable OAs is moderate but not inferior to CPAP. The reduction in subjective daytime sleepiness achieved with custom titratable OAs is not inferior to that reported with CPAP therapy. 

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 oral device/appliance used to reduce upper airway collapsibility, adjustable or non-adjustable, custom fabricated, includes fitting and adjustment, code E0486; and code 21110 application of interdental fixation device for conditions other than fracture or dislocation, includes removal; code 21085 Impression and custom preparation; oral surgical splint services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Back pain
Treatment: Peripheral nerve stimulator (PNS)
The insurer denied coverage for peripheral nerve stimulator (PNS)
The denial is upheld.

This adult patient has chronic low back pain. The patient takes Fentanyl patches and ZTLidocaine patches for pain. The patient has had sacroiliac (SI) joint injections, Medial branch blocks and Radiofrequency ablation (RFA), Trigger point injections as well as Epidural Steroid injections. The request is for bilateral Lumbar (L) 3 multifidus muscle insertion of Sprint peripheral nerve stimulator (PNS).

The Sprint PNS system has been approved by the Food and Drug Administration (FDA) for chronic pain from peripheral nociceptive pain, post traumatic and post-operative pain. The FDA labeling does NOT discuss its use for chronic low back pain.

Both Emergency Care Research Institute (ECRI) (1) and Hayes (2) conducted systematic reviews of the PNS Sprint system and found it was deemed effective for specific peripheral neuropathies. The trials that demonstrate effectiveness for non-dermatomal low back pain are limited to case series which are company sponsored. 

Hayes (2) specifically noted there is an insufficient quantity of published, peer-reviewed, human clinical data to evaluate the use of either the StimRouter System or the SPRINT PNS System (SPR Therapeutics) for treatment of chronic pain in a health technology assessment (HTA).

Clinical practice guidelines (3) state:

There is Level I evidence supporting the efficacy of PNS for treatment of chronic migraine headaches via occipital nerve stimulation; chronic hemiplegic shoulder pain via stimulation of nerves innervating the trapezius, supraspinatus, and deltoid muscles; failed back surgery syndrome via subcutaneous peripheral field stimulation; and lower extremity neuropathic and lower extremity post-amputation pain.

The use of Sprint for low back pain is not addressed.

The patient has several evidence-based therapies available and there are no comparative studies suggesting that this technology is in any way superior to standard therapies, such as Spinal Cord stimulator.

Long-term effectiveness and complication rates are not well established, and it is not certain that the requested procedure has the same or lower risks than standard therapies.

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

The medical necessity for peripheral nerve stimulator (PNS) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lumbar Stenosis.
Treatment: Inpatient Stay.
The insurer denied: Inpatient Stay.
The denial is: Upheld.

The patient is a female who presented for lumbar (L) 4-sacral (S)1 laminectomy due to lumbar stenosis that was refractory to treatment. Past surgical history (PSH) significant for left (L) L5/S1 microlumbar discectomy with incomplete resolution of pre-operative left lower extremity (LLE) pain. She was taken to the operating room (OR) where she underwent L4-S1 laminectomy. No intraoperative complications occurred. One intraoperative drain was placed. Post-operatively the patient received peri-operative antibiotics. She was able to tolerate a regular diet. Foley catheter was removed and she was able to void spontaneously. Acetylsalicylic acid (ASA) was given for deep vein thrombosis (DVT) prophylaxis. Physical therapy (PT) and hospitalist teams were consulted for post-op rehabilitation and medical management respectively. With upright posture and walking, patient experienced dizziness on postoperative day (POD) zero (0) and POD 1. On POD 2, the patient was cleared by PT for discharge to home. Her operative drain was removed. The patient was subsequently safely discharged home. The patient was admitted as an inpatient by the treating facility. The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The patient underwent L4-S1 laminectomy. Her hospital course was uncomplicated and she was safely discharged home on POD 2. The patient's admission was not appropriate for the inpatient level of care. Admission and surgery are appropriate for a lower level of care status for the treatment dates under review. Consistent with the standard of care is to perform this procedure as an outpatient procedure. Request for inpatient stay does not meet medical necessity barring any unforeseen post-operative complications or complex medical co-morbidities which were not present for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Nasal Obstruction
Treatment: Repair of Internal Nasal Valve Stenosis with 
Cartilage Graft (30465)
The insurer denied: Repair of Internal Nasal Valve Stenosis with 
Cartilage Graft (30465)
The denial is overturned

The patient is an adult male with chronic nasal airway obstruction. The patient is noted to have nasal valve stenosis in addition to a deviated septum and turbinate hypertrophy on examination. Valve collapse is demonstrated in attached photographs. Nasal endoscopy confirmed the findings. The patient has failed conservative medical management.

The proposed treatment is medically necessary.

For patients with both significant nasal valve collapse and septal deviation with turbinate hypertrophy, addressing both elements of airway obstruction is medically necessary. Such surgery meets medical standards of care and is not for the convenience of provider or patient.