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

Diagnosis: Chest Pain
Treatment: Inpatient Hospital Admission
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

The patient us an adult female that was hospitalized for chest pain. In the emergency department, her initial blood pressure was elevated to 188/97. Her past medical history is remarkable for morbid obesity, hypertension, smoking, alcohol abuse, 
hypercholesterolemia, asthma, depression, and arthritis. She became chest pain-free while in the emergency department and blood pressure was 164/75, followed by 128/65. Oxygen saturation was 100% (percent) on room air. Chest film was negative. Chest computed tomographic angiography (CTA) was negative for pulmonary embolism (PE) or aortic dissection. Troponin was negative. Low-density lipoprotein (LDL) was 107. Electrocardiogram showed sinus rhythm and no evolving changes such as acute myocardial infarct (AMI). Nuclear stress test was negative. The requested coverage for Inpatient Hospital Admission was denied based on the patient's policy, and the patient is appealing the decision.

The requested health service was not medically necessary.

Based on the peer-reviewed medical literature, including the Milliman Care Guidelines (MCG) criteria for Chest Pain, #M-89, criteria for inpatient admission are not met, including hemodynamic instability, respiratory distress, pulmonary edema, angina with acute coronary syndrome, chest pain that is indicative of a serious cardiac condition like pulmonary embolism or aortic dissection, acute myocardial infarction, pneumonia, hypertension requiring inpatient hospitalization, or any other medical condition, symptom, or finding for which inpatient hospitalization is considered appropriate. In this particular case, there was no clinical decline or inadequate response to treatment that required an inpatient hospital stay. The care the patient received for nonspecific chest pain with hypertensive urgency is routinely provided safely and effectively at a lower level of care. 
Therefore, based on the submitted information and the current the published medical literature, the requested health service is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Loss
Treatment: Bone-Anchored Hearing Aid (L8692 x 1)
The insurer denied: Bone-Anchored Hearing Aid (L8692 x 1)
The denial is overturned.

The patient is a school aged female with a history of a profound sensorineural hearing loss (SNHL) on the right. There is normal hearing on the left. Computed tomography (CT) reports show an absent right cochlea. The provider is requesting coverage of an ADHEAR BAHA L8692. The request was previously denied, and the provider is appealing the denial.

The requested health service is medically necessary.

There is a history of a profound sensorineural hearing loss on the 
right. There is normal hearing on the left. Computed tomography reports show an absent right cochlea. With the patient's condition not amenable to a hearing aid or cochlear implant due to anatomy and level of hearing loss, the placement of a bone anchored hearing aid (BAHA) type device would be supported by scientific literature and United States Food and Drug Administration (FDA) guidelines. Therefore, the L8692 would be confirmed as medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary Embolism (PE)
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

The patient is an elderly female with hypertension and diabetes. The patient presented to emergency room (ER) with left lower extremity deep vein thrombosis (DVT). The patient was found to have pulmonary embolism in the emergency room. The patient was admitted to the hospital. The patient was started on a heparin drip. The acute hospital admission was denied due to lack of medical necessity. This denial is being appealed.

The requested health service was not medically necessary.

The patient was diagnosed with deep vein thrombosis (DVT) / pulmonary embolism (PE). At the time of admission, the patient was hemodynamically stable. The patient was not in any distress. The patient's oxygen levels were above 92% (percent) on room air. The patient did not have any limitations to ambulation. The patient was started on a heparin drip and was monitored on telemetry. The patient continued to receive heparin drip until transitioned to oral anticoagulation. The acute hospitalization was not medically necessary since the patient did not receive any treatment that could not have been provided safely and effectively at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: acute kidney injury
Treatment: inpatient stay
the insurer denied the inpatient stay
the health plan's determination is overturned. 

The patient is a male who presented to the hospital for evaluation of his kidneys. He states that he has been experiencing bilateral lower extremity swelling and scrotal swelling for the past 1-2 weeks. He was seen in the emergency room earlier today and found to have a creatinine of 4.72, he was recommended to stay but signed out against medical advice at that time. He did receive 80 milligrams (mg) of lasix in the emergency room earlier which slightly helped his swelling. His vitals showed a blood pressure of 181 over 110 (181/110), a pulse of 106, a respiratory rate of 18, a room air pulse oximetry of 96 percent (%) and he was afebrile. He was not in acute distress and he had bilateral lower extremity swelling. A renal ultrasound did not show hydronephrosis.

The inpatient admission was medically necessary in this case based on the documentation provided. The patient presented with severe acute kidney injury with a serum creatinine of 4.73 which continued to rise over 5 during his hospital stay. He required an inpatient admission to ensure that he didn't develop life-threatening complications of kidney injury including severe electrolyte disorders, cardiac arrhythmias, respiratory distress, uremic pericarditis, uremic encephalopathy and uremic bleeding. It was only after he was closely monitored in a hospital setting to be certain that he would not require emergent dialysis that it was safe and appropriate to continue work up as an outpatient. Admission to a lower level of care would not have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: otitis media
treatment: Ciprofloxacin/Dexamethasone Otic Suspension
The insurer denied Ciprofloxacin/Dexamethasone Otic Suspension
The health plan's determination is upheld. 

The patient is a young female with a history of a "painful ear infection" likely secondary to frequent pool water exposure. The patient was seen and was diagnosed with otitis media. The patient was noted to have right ear pain with palpation of the tragus, ear canal erythema, and tympanic membrane bulging. Based on the history and examination, she was prescribed ciprofloxacin/Dexamethasone otic suspension.

Ciprofloxacin/Dexamethasone Otic Suspension is not medically necessary.
The patient was diagnosed with otitis media in addition to having an external ear infection. Although ciprofloxacin/Dexamethasone otic suspension is an appropriate treatment, first line treatments for the otitis external could have adequately managed the ear infection. There is no documentation that the patient tried/failed the plan's formulary alternative treatments such as ofloxacin drops or neomycin-polymyxin-hc otic. If the patient did have a bulging ear drum (suggesting otitis media) in addition to the swollen ear canal, an oral antibiotic would have also appropriate along with the topical drops.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Arthritis, obesity and urinary incontinence

Treatment: Personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week

The insurer denied coverage for personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week

The denial is overturned

 
The participant is an adult with a history of arthritis, obesity and urinary incontinence. The patient lives downstairs from her son who is supportive and involved in her care.  She has access to a personal emergency response system, hospital bed, shower chair, grab bars, walker, incontinent supplies to manage toileting needs.  A few months ago, the Plan increased personal care services to 5 hours a day 7 days a week: 35 hours a week due to significant changes in status.

A letter from Vinod Gulati, MD noted that the patient is very unsteady on her feet, and she has fallen numerous times.  She is bedridden and needs close attention, help with activities of daily living (ADLs), bills, food shopping, meals and administer medication.  The patient has requested 8 hours/day 56 hours a week to help for better caregiving and to insure safety.

A letter was submitted by the participant's son, noting that the participant remains in bed 24/7 and needs help with all activities of daily living.  She is a fall risk and falls 50% of the time with attempts to walk.  She needs help with cleaning and meal prep, medication management, personal hygiene, organizing mail and business affairs.  The son also noted that he and his wife work out of the home and the patient needs 8 hours of personal care assistance. 

Based on the Uniform Assessment System (UAS) - The patient has frequent bowel/bladder incontinence. Extensive assistance is needed for walking and locomotion and transfer to the toilet. Maximal assist is needed for bathing. The patient is independent/set-up help only for personal hygiene and upper body dressing. Limited assistance is needed for lower body dressing and bed mobility. The patient is also documented to ambulate with a walker as the caregiver supports the patient under the arm.

An allotment of time separate and apart from the personal care tasks authorized is not permitted for safety monitoring according to New York State Department of Health regulations.

The patient is diagnosed with a history of arthritis, obesity, frequent urinary and bowel incontinence. The patient lives downstairs from her son who is supportive and involved in her care. Also noted is the absence of family support while at work.  Patient has had numerous falls and needs support to ambulate. As such, personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week is medically necessary.  

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for personal care aide (PCA) level 2: 8 hours per day - 7 days per week - a total of 56 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Stelara 90 milligrams (mg) every 4 weeks
The insurer denied Stelara 90 milligrams (mg) every 4 weeks.
The determination is overturned.

The patient has stricturing Crohn's disease. He has failed 6-mercaptopurine, Remicade, and Humira. He has had improvement and symptoms on Stelara. Magnetic resonance enterography showed a terminal ileum stricture 10 centimeters (cm) in length with active inflammation and proximal dilation, decreased but present active inflammation in the transverse colon, and new marked dilation of the sigmoid colon and rectum likely due to anal stricture. The coverage is requested for Stelara 90 milligrams (mg) every 4 weeks for the treatment of Crohn's disease, which is under review for medical necessity.
The use of Stelara 90 mg every 4 weeks is medically necessary for the treatment of this patient's Crohn's disease. 
In this case, the patient had initial response to Stelara, with good control of disease symptoms, but has had significant objective evidence of active disease (including terminal ileum inflammation with stricture, colonic inflammation, and anal stricture with proximal dilation). American College of Gastroenterology guidelines for the treatment of Crohn's disease state that patients with active disease should have their medication dose adjusted in order to attempt to optimize therapy (Lichtenstein, et al). A relationship between the Stelara level and inflammatory markers has been shown; Stelara levels have been shown to correlate with "clinical and histologic efficacy and markers of inflammation" (Restellini, et al; Battat, et al). Continued use of Stelara every 8 weeks or discontinuation of Stelara (even if an alternative is attempted immediately) may result in loss of disease control, with complications such as stricture, fistula, bowel obstruction, flare, hospitalization, need for surgery, or other complications in this patient with stricturing disease.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteoarthritis, gastric cancer. 
Treatment: Consumer directed personal assistance program (CDPAP): 7 hours per day - 7 days per week - for a total of 49 hours per week. 
The insurer denied coverage for CDPAP: 7 hours per day - 7 days per week - for a total of 49 hours per week. 
The denial is upheld. 

This case involves an adult patient with a subject for review for the denial of coverage for consumer directed personal assistance program (CDPAP): 7 hours per day - 7 days per week - a total of 49 hours per week. 

In this case, the patient lives with their spouse, son and son's family. The member is alert and oriented x2, reported being forgetful at times and needing reminders for medical appointments and medications. The patient is able to express their needs and able to self-direct their care and call for help in case of an emergency. The patient's son reports the patient is confused in new situations and is not able to go out or find their way back home if they go out on their own, needing supervision at those times. The patient has a diagnosis of osteoarthritis (OA) and stomach cancer causing debility, weakness, pain, unsteady gait, and inability to stand on their feet for long. 

According to the assessment, the patient required maximal assistance with meal preparation, managing medications, shopping, bathing, dressing lower body, and toilet use. The patient is totally dependent for ordinary housework. The patient needs extensive assistance with managing finances, personal hygiene, dressing upper body, walking, locomotion, and transfer toilet. Furthermore, the member needs setup help with phone use, limited assistance with bed mobility. In addition, the patient uses an assistive device for walking. Per the Client Task Sheet, the patient needs 5.5 hours per day and 27.5 hours per week. The assessment done showed that the member needed 5.5 hours per day and 38.5 hours per week is needed. 

The approved CDPAP: 9 hours per day - 3 days per week; 8 hours per day - 1 day per week - for a total of 35 hours per week is sufficient to meet the needs of the member to perform their activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The hours can be managed flexibly to perform the activities and remain safe. In addition, the member's daughter-in-law lives with member and assists member as needed with ADLs and IADLs during non-CDPAP hours. The member's daughter also helps the member with ADLs and IADLs as needed during non-CDPAP hours. As such, the denial of coverage for consumer directed personal assistance program (CDPAP): 7 hours per day - 7 days per week - a total of 49 hours per week is upheld and not medically necessary. 

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 consumer directed personal assistance program (CDPAP): 7 hours per day - 7 days per week - a total of 49 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder.
Treatment: Braces and monthly visits (x12).
The insurer denied Braces and monthly visits (x12).
The determination is overturned.

The patient is a male with a Class II malocclusion with protrusive maxillary incisors. He has a 6 millimeter (mm) overjet and a 4 mm deep bite. He has moderate maxillary and mandibular crowding. He is treatment planned for 30-36 months of orthodontics with extraction of 5, 12, 21 and 28 to correct this malocclusion. At issue is the medical necessity of braces and monthly visits (x12).

There is strong medical evidence that that early correction of patients with prominent maxillary front teeth can reduce the risk of incisal trauma. (1) Evidence shows orthodontic treatment will reduce the chances of damage to the maxillary incisors and the associated costs and morbidity of repairing these teeth. Additionally, overjets of 6 plus (+) millimeters (mm) are shown to negatively affect the oral health quality of life of patients. (2) For these reasons, treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Comprehensive Dental Treatment

Treatment: Outpatient dental procedure with anesthesia (41899 x 32)

The insurer denied coverage for outpatient dental procedure with anesthesia (41899 x 32)

The denial is upheld

Upon review of these submitted documentation which includes undated occlusal, bitewing and periapical radiographs, anticipated treatment plan, treatment progress notes, and narrative letter of support from the pediatric dentist, in addition to insurer correspondence and clinical guidelines, it appears that this pediatric patient presented for comprehensive dental treatment. Based on the progress notes, this patient was able to undergo dental treatment in the outpatient setting in the past; however, due to the extensive dental treatment now necessary, the pediatric dentist recommended dental treatment under general anesthesia as per the letter. The insurer states that the records do not indicate the patient received approval from the dental insurer for the requested procedures and are basing their denial on their guidelines for dental anesthesia and facility services. The pediatric dentist is appealing the denial.

Upon review of the submitted documentation, it does appear that the patient requires comprehensive and extensive dental treatment. However, the current procedural terminology (CPT) code 41899 submitted and at issue in the review, is a medical code that refers to surgical procedures on the dentoalveolar structures. This is an unspecified code and does not necessarily equate to the dental services that are scheduled to be provided by the pediatric dentist. Further, there is no specific anesthesia code requested in the provided documentation. Given the inadequate documentation provided for review, in addition, because of the unspecified medical code used in attempt to justify dental services, the denial is upheld. The documentation cannot support or substantiate the recommended treatment.

Uphold denial as the documentation provided does not support, substantiate or justify the recommended treatment; further, although it is implied that the dental treatment would be performed under general anesthesia no anesthesia codes are submitted for review.

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 dental surgery (41899 x 32) is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type 1 Diabetes Mellitus
Treatment: Afrezza
The insurer denied Afrezza.
The determination is upheld.

This is a male patient with diabetes mellitus type 1. The request is for Afrezza . Per a prior authorization form, the medication is medically necessary for management of type 1 diabetes.  Per a provider appeal, the patient had trial and failure of injectable insulins Humalog and Novolog. Fiasp contains the same ingredient as Novolog and would not offer additional benefit. Novolin is inferior to rapid acting insulins. Per an office note, the patient has diabetic ketoacidosis (DKA) in the setting of dexamethasone use. He is currently on Toujeo and Novolog as needed which the patient takes 1-2 times weekly if his glucose is over 200 and does not count carbohydrates (carbs). His diabetes is controlled, the provider recommends to continue the current regimen but may need to move to multiple daily insulin, but to give Omnipod and inhaled insulins a try. His A1c was 7.9 percent (%). At issue is whether the formulary drugs (Fiasp, Novolin R.Novolog) will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The formulary drugs Fiasp, Novolog would not be ineffective or have more adverse effects. Novolin R generally is less preferred to rapid acting insulins above due to slower onset and potentially higher hypoglycemia risk. This is a type 1 diabetes patients with A1c above goal (designated as 6.5-7% by the American Diabetes Association (ADA) and American Association of Clinical Endocrinologists (AACE) diabetic guidelines). This uncontrolled A1c does not indicate the patient has tried and failed formulary rapid acting insulins - but rather that this patient is not using mutliple daily injections (such as bolusing before meals) as is the standard of care for type 1 diabetes patients. In pharmacodynamic trials maximum serum insulin concentrations were reached by 15 minutes (min) in Afrezza (versus 30 minutes in insulin lispro), however, of note, Afrezza reaching peak concentrations faster did not result in faster onset of activity than lispro (Food and Drug Administration (FDA) label). The half life for Afrezza is 39 minutes, whereas for Humalog the half life is 50 minutes. However, despite faster onset and shorter half life for Afrezza, there is lack of convincing evidence showing randomized control data supporting that Afrezza is superior to Humalog for prevention of hyper or hypoglycemia. In an open label randomized trial between Novolog and Afrezza of type 1 diabetes patients, Afrezza was noninferior to Novolog in change in A1c and may result in a slightly lower hypoglycemia event rate than aspart patients (9.8 versus (vs) 14.0 events/patient-month), however, this result has not been replicated in more trials. It is appropriate to try plan preferred rapid acting insulins first.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: rule out stroke
Treatment: inpatient stay
The insurer denied the inpatient stay
The health plan's determination is upheld. 

This case involves a man admitted to the hospital with bilateral lower extremity weakness. The patient reported a history of stroke seven years before this event and a motor vehicle accident two months before this admission. The patient described episodes of whole-body numbness, lasting for an unknown period of time. The emergency department (ED) evaluation showed an National Institute of Health (NIH) stroke score of 3. The patient was noted to have left facial numbness and left body numbness. 

The inpatient hospital admission was not medically necessary. The patient underwent a stroke work-up, which was negative. Head computed tomography (CT) brain magnetic resonance imaging (MRI) failed to demonstrate a new stroke. The patient's symptoms appeared chronic and recalcitrant from an old stroke. There was no evidence of seizure activity. There was no intracranial bleeding. There were no intracranial tumors. Hemodynamics throughout the hospital stay were stable. The documentation failed to demonstrate an acute medical diagnosis requiring inpatient treatment, which could not be otherwise managed in an observation setting. A lower level of care was appropriate.