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

Diagnosis: Coronary artery disease, pacemaker, small
bowel obstruction, COVID-19
Treatment:  treatment, PCA Level II - 24 hours per day - live-in per diem - seven days a week
Decision: Overturned

The patient is a male with significant past medical history of coronary artery disease status post coronary artery bypass grafting (CABG), pacemaker; small bowel obstruction; hypertension; abnormal chest x-ray suspicious for tuberculosis; history of cigarette use recently admitted for COVID-19 pneumonia.  The patient was admitted with COVID-19.  He was discharged to skilled nursing facility (SNF) where he received skilled care.  Subsequently the patient was discharged to home where he lives alone in a one-bedroom apartment.  The patient receives daily phone calls from his son and daughter-in-law, but otherwise lives alone.  The patient in the past has attended adult day care several days a week.  The patient received community assessment in home and telephonic assessment.  A significant change in the patient's ability to assist with adult daily living tasks exist since the patient was admitted for COVID-19 disease.  Significant changes in memory, cognitive function, ability to dress upper and lower extremities, personal hygiene, bed mobility, walking, locomotion, bathing, transfer to toilet, toilet use, bladder continence, bowel continence, falling, meal preparation, medical management and housework all have shown significant declines in the patient's ability to perform adult daily living tasks for himself.  The patient's primary care provider (PCP) recommends 24 hours per day seven days per week personal care worker Level II as the patient has demonstrated significant decline in physical and cognitive status after hospitalization for COVID-19.  

Yes, the proposed treatment, PCA Level II - 24 hours per day - live-in per diem - seven days a week, is medically necessary.
 
The health plan should increase the patient's personal care assistance Level II to 24 hours per day, seven days per week, live-in per diem.  A significant change in the patient's ability to assist with adult daily living tasks exist since the patient was admitted for COVID-19 disease.  Significant changes in memory, cognitive function, ability to dress upper and lower extremities, personal hygiene, bed mobility, walking, locomotion, bathing, transfer to toilet, toilet use, bladder continence, bowel continence, falling, meal preparation, medical management and housework all have shown significant declines in the patient's ability to perform adult daily living tasks for himself.  The proposed treatment is medically necessary to meet patient's physical and cognitive changes following recent infection with COVID-19.  Virtually all adult daily living skills have deteriorated requiring assistance by a personal care assistant.  Therefore, the proposed PCA Level II - 24 hours per day -live-in per diem - seven days a week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Crossbite.
Treatment:  Comprehensive orthodontic treatment of the adolescent dentition (D8080).

The insurer denied the Comprehensive orthodontic treatment of the adolescent dentition (D8080).  The denial is overturned. 

The patient is a male.  The request is for orthodontic benefits.

Yes, the proposed treatment is medically necessary.

The patient has an anterior crossbite of tooth # 22 (mandibular left canine), with attachment (gum) loss.  This is an automatic qualifier according to the handicapping index scale.  Withholding treatment will adversely affect the health of the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crossbite.
Treatment: Braces (D8080).
The insurer denied the braces. 
The denial is overturned.

The patient is a female. The request is for orthodontic benefits.

Yes, the Braces (D8080) are medically necessary.  The patient has an anterior crossbite with gingival attachment loss. This is an automatic qualifier according to the handicapping index scale. Therefore, the Braces (D8080) are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic short stature
Treatment: Humatrope 72-unit cartridge (two every 30 days) (Pre-Service)
The insurer denied the Humatrope 72-unit cartridge (two every 30 days) (PreService).
The denial is upheld.

This patient is a female diagnosed with idiopathic short stature (ISS). This request
is for Humatrope. The patient is on growth hormone (GH) therapy per chart. Her GH
stimulation test on with glucagon and L-dopa peaked at 12.

No, the proposed treatment with Humatrope 72 unit cartridge (two every 30 days) is
not medically necessary.

The peer reviewed literature, including consensus clinical guidelines, randomized controlled trials are summarized below:

Classic GH deficiency
Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH Research Society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, 3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3.0 standard deviations (SD) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2.0 SD below the mean and a height velocity over one year more than 1.0 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over one year in children over two years of age; 4) in the absence of short stature, a height velocity more than 2.0 SD below the mean over one year or more than 1.5 SD sustained over two years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than ten nanograms per milliliter (ng/mL).

The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than ten. 

Idiopathic Short stature
Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4, 5, 6, 7, 8, 9]. FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient does not have a pretreatment height less than or equal to -2.25 SD. The patient therefore does not meet idiopathic short stature criteria. 

The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pregnancy, Abdominal Pain
Treatment Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a patient who was pregnant and presented to the emergency room with right upper quadrant pain for two weeks. She also complained of constipation, chronic abdominal pain, chronic back pain and reflux. She had a history of diabetes and hyperlipidemia. She was admitted. An abdominal ultrasound was negative. Lab results were normal. Magnetic resonance imaging (MRI) was normal. She was provided intravenous fluids and pain management. She was discharged. At issue is the medical necessity of an inpatient stay.
The inpatient stay is not medically necessary for this patient.
The patient had increased abdominal pain with a history of chronic abdominal pain. Her vital signs and physical exam were normal. A pelvic ultrasound and MRI were normal and there were no acute complications on her laboratory tests. She had no preterm labor, rupture of membranes nor hemorrhage. She had no end-organ damage, hemodynamic instability nor any comorbidity that would assume increase or acute risk with the need for inpatient admission. This work up could have been accomplished at a lower level of care. She received no treatment that could not have been achieved with monitoring at a lower level of care. Therefore there was no medical necessity for the acute, inpatient hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis. 
Treatment: Personal care aide. 

The insurer has denied coverage for a Personal Care Aide (PCA) Level ll; 126 hours per week; 18 hours per day, 7 days per week. The denial is overturned. 

This female patient has multiple chronic conditions (rheumatoid arthritis, osteoarthritis, coronary heart disease, hypertension, irritable bowel syndrome, neuropathy, spinal stenosis, carpal tunnel, and urinary retention) causing various types of pain/discomfort and restriction of mobility, which has resulted in significant functional impairment. She lives alone. The available records indicate the patient's disability has progressively increased, with limited effective treatments that she can tolerate due to side effects. The patient was indicated as having total dependence for meal preparation and ordinary housework, and independent with walking, locomotion, toilet transfer, bed mobility, and eating. The patient has reached a point where she needs caregiver support for a more extended period of the day. Some of the activities of daily living (ADL) tasks needing assistance can be limited to certain times of the day (bathing, dressing). Other ADLs occur at various and unscheduled times of the day and into the evening/nighttime hours (transfers, walking, toileting); and some ADLs can be scheduled, but occur several times per day (eating, dressing, personal hygiene). It is also necessary to have a plan in place for some type of intervention for pain. This is especially important for a person who has a history of chronic pain and has difficulty providing treatment to relieve pain when she is alone. 

Considering the patient's extensive medical history causing substantial symptoms and restricted mobility, it is medically necessary for the patient to have a caregiver present throughout the day and at least into the evening. Assistance from informal caregivers is voluntary as per New York State regulations for personal care services. The patient advocate indicated the son and daughter are not able to provide care to the patient on a regular basis, but are available for emergencies. When informal caregivers are not available to provide care on a regular basis, then personal care services are indicated to provide assistance with daily activities when needed throughout the day. The son requested personal care aide (PCA) services 18 hours per day. The patient's care needs between approximately midnight and 6 am are not clearly identified. If the patient sleeps most nights during this time period then 18 hours may be adequate, but further re-assessment will be needed to determine whether the patient needs assistance through the night (e.g. toileting, assisting patient with pain relief). 

Personal Care Aide Level II; 126 hours per week, 18 hours per day, 7 days per week is medically necessary. The health plan did not act reasonably with sound medical judgment. 

The carrier's denial of coverage for Personal Care Aide (PCA) Level ll; 126 hours per week; 18 hours per day, 7 days per week is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: COVID-19 infection.
Treatment: Continued skilled nursing stay. 
The insurer denied the continued skilled nursing stay.
The denial is upheld. 

The patient is a male with history of COVID-19 infection and general debility after prolonged stay in acute hospital. His relevant past medical history includes hypertension, Type 2 Diabetes Mellitus, GERD (gastroesophageal reflux disease), Hyperlipidemia, Dysphagia, Tachycardia, Dysphagia s/p (status post) gastrostomy, insomnia, and anxiety disorder. No further information was provided.

Information on the patient's living circumstance and state of ADLs (activities of daily living) prior to admission were not provided.

The patient was admitted to SNF (skilled nursing facility). No documentation provided of extent of participation or progress in Physical therapy, Occupational Therapy and Speech language therapy. 

No, the Continued skilled nursing stay is not medically necessary.

There is no documented evidence that any continued SNF stay for any length of time forward was reasonably expected to be health beneficial for the patient, or that discontinuing SNF is reasonably expected to affect the patient's health adversely. He is clinically stable, and the lack of evidence of participation or progress in rehabilitation makes this custodial care.

The results of the prior COVID test and the last one were not provided. As such, there is no basis to hold on to the patient due to their being COVID-positive.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type II Diabetes.
Treatment: Formulary Exception for Afrezza.  
The insurer denied the Formulary Exception for Afrezza. 
The denial is overturned. 

This is a male with type II diabetes. He has been on insulin, Trulicity, metformin, and Actos. He has tried and failed Farxiga and Cycloset. His A1C is 9.4%. Afrezza has lowered his A1C to 7.4%. He is unable to bring insulin or needles into the correctional facility where he works without clearance. Such a clearance would enable others to be aware of his diagnosis and treatment and could put him at risk for physical harm. Request for Afrezza is under review. 

Yes, the health plan should cover the proposed treatment, Afrezza.

Afrezza has a much shorter onset of action and offset of action than injectable rapid-acting insulin analogs, including the formulary alternatives Fiasp, Novolin R, and Novolog. This allows for more rapid correction of hyperglycemia with Afrezza as compared to the formulary alternatives. 

This patient's glycemic control has significantly improved on Afrezza, Without Afrezza, this patient is at risk of worsening hyperglycemia. Hyperglycemia would increase his risk for retinopathy, neuropathy, and nephropathy. In addition, this patient has unique circumstances in that he works at a correctional facility. Due to this work environment, insulin and needles would have to be stored in a separate secured area. This may impact his adherence to taking insulin and he is also is concerned about his safety if it is discovered that he has diabetes. Afrezza is an inhaled insulin that does not need to be secured and he is able to use Afrezza more discretely. Therefore, yes, the health plan should cover the proposed Afrezza.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Gait abnormality, osteoarthritis, dementia

Treatment: Level 2 Personal Care Services, per 15 minutes, 84 hours per week

The insurer denied coverage for Level 2 Personal Care Services, per 15 minutes, 84 hours per week. The denial is overturned.

This patient is a male with diabetes, hypertension, urinary incontinence, osteoarthritis, gait abnormality, dementia and coronary artery disease.  His primary care physician (PCP) notes that he needs an increase from 8 to 12 hours/d of Level 2 care due to the need for total assistance with transfers, ambulation, bathing and dressing.  

A UAS done notes extensive assistance with ADLs. Frequent urinary incontinence is noted. He gets 3-4 hours/day of family help in addition to 8 hour/day aide. In comparison to the UAS the patient needs maximal, not limited, assistance with all ADLs. 
In a Final Adverse Determination Letter the insurer denied an increase in Level 2 hours from 56 to 84/week. They stated there has been no change in tasking tool scores. He has been stable for the last several months. 

In an Appeal Letter it is noted that while tasking tool scores have not changed the patient has needed more than 56 hours/week all along. He has multiple medical problems, needs assistance with multiple functions and his spouse is unable to provide all of them. He has worsening urinary incontinence, gait problems and dementia.

Reference is made to New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016:
(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

There is documentation that the patient is frequently incontinent and needs extensive assistance with transfers and ambulation. He is not falling, but the risks of complications of incontinence can be high. He also has Parkinson's. He would not be able to clean his bed or the floor if needed. The frequency of incontinence would be unpredictable. Currently between aides and family (excluding his wife) he has coverage for 10-12 hours/day.  Given his lower level of function and physical problems an increase in hours of aides to 12/day is justified. 

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

Based on the above, the medical necessity for Level 2 Personal Care Services, per 15 minutes, 84 hours per week is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: D&C (dilatation & curettage) with diagnostic hysteroscopy 
Treatment: Hysteroscopy in the outpatient hospital setting (58558) The insurer denied the Hysteroscopy in the outpatient hospital setting (58558). 
The denial is overturned. 

The patient is a woman. She underwent a D&C (dilatation & curettage) with diagnostic hysteroscopy.

Yes, the Hysteroscopy in the outpatient hospital setting (58558) was medically necessary.

The medical records and medical literature were thoroughly reviewed. D&C with hysteroscopy is an ambulatory procedure by the standard of care. This procedure is typically performed in an outpatient setting. The patient is typically discharged after an appropriate length of postoperative observation. 
The patient underwent this outpatient procedure as an ambulatory outpatient procedure within the hospital footprint. She was admitted as an outpatient on the outpatient service, underwent an uncomplicated procedure and was discharged as an outpatient on the same day. Therefore, the patient meets the standard of care, and the procedure was medically necessary. 

The Health Plan denied coverage for the procedure in an outpatient hospital setting on the basis that it did not meet their guidelines, which state, "A planned procedure performed in a hospital outpatient department is considered medically necessary if there is an inability to access an ambulatory surgical center for the procedure due to ANY one of the following:...There is no geographically accessible ambulatory surgical center at which the individual's physician has privileges..." According to the provided documentation, the patient's gynecologist did not have privileges at a geographically accessible ambulatory surgical center. Therefore, according to the Health Plan guidelines the procedure was medically necessary. Therefore, the patient meets medical necessity by both the standard of care and Health Plan guidelines.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left knee arthritis
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

This patient with a history of left knee arthritis refractory to medications, physical therapy, and steroid injections who had a total knee replacement. She rehabilitated on the orthopedic unit. She received physical therapy, pain control, and pulmonary toilet. She was discharged to a rehabilitation unit. The patient required treatment for sleep apnea and fluid boluses secondary to hypotension. The hypotension delayed the onset of physical therapy. The patient required clearance from physical therapy prior to discharge to skilled facility. At issue is the medical necessity of an inpatient stay.

The  admission was medically necessary and appropriate for inpatient level of care. The patient underwent a total knee replacement which is a lengthy and surgically intensive procedure associated with numerous potential intraoperative and post-operative complications. Potential complications include, but are not limited to delayed neurovascular compromise, severe swelling, hypotension secondary to fluid imbalance, hematoma, post-operative confusion, post- operative anemia, and urinary retention. The patient required close evaluation and management by multiple interdisciplinary teams including orthopedics, general medicine and physical therapy services. Coordination of care in such situations is quite complex and often requires hospital stay, particularly with arthroplasty procedures. The level of intensity of the post-operative treatment is quite high and the hypotension delayed physical therapy. Adequate physical therapy and management of hypotension made it critical to monitor the client closely so as to avoid dizziness, mental status changes, orthostatic-induced disfunction and perhaps a fall which could compromise the results of the surgical procedure. Therefore, the admission was medically necessary and within the standard of care.
Per the MCG Inpatient and Surgical Care 21st Edition Hip and Knee Arthroplasty Section, requirements for admission include one or more of the following:
1) Need for intensive inpatient care of a specific disease
2) Anesthesia, surgical, or general medical complications (such as hypotension and sleep apnea)
3) High post-anesthetic risk
4) Intractable pain, nausea, or vomiting
The client met items 1 and 2 above, hence the admission is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic neck patch
Treatment: Formulary exception for Lidocaine 5% EX PTCH
The insurer denied the Formulary exception for Lidocaine 5% EX PTCH.
The denial is overturned. 

The patient is a female with a diagnosis of chronic neck pain who has been prescribed Lidocaine patches.  

Yes, the health plan should cover the formulary exception for Lidocaine 5% EX PTCH.

The patient is a female with chronic neck pain who has been taking lidocaine patches. This is a continuation of therapy. The patient has tried and failed numerous alternatives including physical therapy (PT), acupuncture, and nerve blocks. The patient is already on opiates, which are not without risk. The patient cannot take non-steroidal anti-inflammaotry drugs (NSAIDs) due to peptic ulcer disease (PUD), and has previously taken opiates.  This is a continuation of therapy, and the patient has done well with this medication.  

The formulary alternatives have not been studied in randomized controlled trials (RCT) for the treatment of low back, neck, or myofascial pain.  The alternatives have not been compared to 5% lidocaine patch in the literature. Synera is only approved for local analgesia prior to venous access. 

This is a continuation of therapy, and the patient has done well with this medication.  By discontinuing it, the potential for escalating opiates or other more invasive methods become likely.  

Given the above, the requested Lidocaine patches are medically necessary.