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

Diagnosis: Chronic Obstructive Pulmonary Disease (COPD), diabetes, heart failure and dementia.

Treatment: Personal Care Services (PCA) services 24 hours per day, 7 days per week, split shift, for a total of 168 hours per week.

The insurer denied coverage for PCA services 24 hours per day, 7 days per week, split shift, for a total of 168 hours per week.

The denial overturned

This is a geriatric patient with multiple medical problems that include COPD, diabetes, heart failure and dementia. The patient lives with daughter in a private residence. The insurer approved PCA services 12 hours per day, 7 days per week (84 hours per week) and the request is for 24 hours per day, 7 days per week, split shift, which is currently under review. 

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills were described as severely impaired-never or rarely makes decisions. Patient is totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL); tasks include meal preparation, ordinary housework, and shopping. Patient is also totally dependent for bathing, lower body dressing and toilet use. Maximal assistance is needed for personal hygiene, upper body dressing, locomotion, ambulation, and toilet transfer. Extensive assistance is needed for bed mobility and eating. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. The patient is severely and cognitively impaired, requiring maximal assist. Patient's clinical condition, impairments and limited functional ability support the medical necessity of the requested PCA services. Based on the records reviewed, the patient's health and safety are more appropriately provided and maintained at home with the requested PCA services 24 hours per day, 7 days per week split shift.

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. 

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 PCA services 24 hours per day, 7 days per week, split shift, for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Congestive heart failure, atrial fibrillation, and osteoarthritis.
Treatment:  Personal Care Aide (PCA) Level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (Split-Shift) for a total of 168 hours per week

The insurer denied coverage for PCA Level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (Split-Shift) for a total of 168 hours per week.  The denial is overturned. 

This is a geriatric patient with multiple medical problems, including congestive heart failure, atrial fibrillation, and osteoarthritis. The patient lives alone in a 1-bedroom apartment. The insurer approved PCA services 12 hours per day, 7 days per week and the request is for 24 hours per day, 7 days per week, Split-Shift, which is currently under review. 

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent. However, patient is totally dependent to maximal assistance for performing Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient is also totally dependent for bathing, personal hygiene, locomotion, ambulation, and toilet transfer. Maximal assistance is needed for bed mobility, dressing and toilet use. The patient is frequently incontinent of bowel and bladder. The patient's IADL/ Activities of Daily Living (ADL) status and overall self-sufficiency have declined and deteriorated, respectively over the prior 90 days. The patient's functional ability is also documented as declined compared to a prior UAS report. The patient's clinical condition, limited functional ability and total dependence for mobility support the medical necessity of the requested PCA services 24 hours per day, 7 days per week, split shift. 

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. 

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 PCA Level 2: 12 hours per day- 7 days per week; 12 hours per day- 7 days per week (Split-Shift) for a total of 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Hearing loss.
Treatment:  Cochlear implant system in the right ear.

The insurer denied coverage for cochlear implant system in the right ear.  The denial is overturned.

The patient is a young adult with progressive hearing loss in the right ear. This progressed to a profound hearing loss in the right ear. The patient underwent a right tympanoplasty, which found soft tissue around incus body (biopsied and sent), incudostapedial (IS) joint divided and was ossified. This was essentially mobilized after division. A magnetic resonance imaging (MRI) found normal VIII nerves right and left.

The Food and Drug Administration (FDA) has approved cochlear implantation for unilateral hearing loss (UHL)/single sided deafness (SSD) in adults and children. The peer reviewed literature has shown the efficacy of cochlear implantation for UHL/SSD in adults. [1-4] The patient fulfilled the criteria for implantation, in that the MRI found the VIII nerve on the right side to be normal. There appears to be no reason to delay implantation after establishing the unilateral loss. 

The cochlear implant in the right ear is considered medically necessary for this patient in order for the patient to have optimal hearing for school, social and economic success. [1-4] The loss of hearing in one ear results in degradation of aural communication which is disadvantageous to the patient in all interactions. The cochlea will greatly ameliorate that so as to allow for the patient to achieve their potential. 

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 a cochlear implant system in the right ear (codes 69930 and L8614) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Venous stasis ulcer

Treatment: Durable medical equipment: topical oxygen wound therapy (TOWT) a total of 16 units

The insurer denied coverage for durable medical equipment: TOWT a total of 16 units.

The denial is upheld.

Topical hyperbaric oxygen (HBO) is not a proven treatment for the patient's condition and thus not medically necessary. The Undersea and Hyperbaric Medical Society has issued a Position Statement regarding Topical HBO. The following is quoted from their Position Statement:

Therefore, the policy of the Undersea and Hyperbaric Medical Society in regard to topical oxygen is stated as follows:

1) Topical oxygen should not be termed hyperbaric oxygen since doing so either intentionally or unintentionally suggests that topical oxygen treatment is equivalent or even identical to hyperbaric oxygen. Published documents reporting experience with topical oxygen should clearly state that topical oxygen not hyperbaric oxygen is being employed. 2) Mechanisms of action or clinical study results for hyperbaric oxygen cannot and should not be co-opted to support topical oxygen since hyperbaric oxygen therapy and topical oxygen have different routes and probably efficiencies of entry into the wound and their physiology and biochemistry are necessarily different. 3) The application of topical oxygen cannot be recommended outside of a clinical trial at this time based on the volume and quality of scientific supporting evidence available, nor does the Society recommend third party payor reimbursement. 4) Before topical oxygen can be recommended as therapy for non-healing wounds, its application should be subjected to the same intense scientific scrutiny to which systemic hyperbaric oxygen has been held.

In 2021, Hayes (1) rates topical oxygen therapy for chronic wound healing as D2. A D rating indicates that the technology is experimental and investigational and is not supported by the majority of the medical community.

Overall, current evidence supporting topical HBO for any condition is limited and consists of small, low-quality studies that support the categorization of topical oxygen therapy as experimental and investigational. A search using Pubmed with the terms "venous stasis ulcer" AND "topical oxygen" returned one pilot study for patients with pressure ulcer involving 18 patients. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. The medical necessity for durable medical equipment: topical oxygen wound therapy (TOWT) a total of 16 units is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Vitiligo
Treatment: Opzelura (1.5% cream, dispense 60 g, topically, 1 dose 2 times a day, for 6 months)
The insurer denied the Opzelura (1.5% cream, dispense 60 g, topically, 1 dose 2 times a day, for 6 months).
The denial is upheld.

The patient is a male with vitiligo. His scalp and penis are affected. He has failed tacrolimus, hydrocortisone, and Excimer. The subject under review is the medical necessity for Opzelura.

The health plan's determination is upheld.

The requested treatment with Opzelura is not medically necessary for this patient based on the current evidence-based literature. There is no documentation provided that the patient had a poor response to one topical calcineurin inhibitor applied for at least 12 weeks, or that the patient has a contraindication or intolerance.

Lee et al. writes "In this meta-analysis of 46 studies including 1499 patients, topical calcineurin inhibitor monotherapy produced an at least mild response in 55.0% of the patients, at least moderate response in 38.5%, and a marked response in 18.1% after a median treatment duration of 3 months. ...Topical calcineurin inhibitors appear to have significant therapeutic effects on vitiligo and it seems that their use should be encouraged in patients with vitiligo" (2). Based on the standard of care, calcineurin inhibitors are a first-line treatment for vitiligo and should be tried and failed prior to initiating treatment with Opzelura. Therefore, Opzelura is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alzheimer's dementia

Treatment: Personal Care Aide (PCA): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week 

The insurer denied coverage for PCA: 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week

The denial is modified

This is an elderly patient with progressive Alzheimer's dementia. The patient lives with his spouse in a 2-bedroom apartment. The insurer approved PCA 4.5 hours/day, 7 days/week (31.5 hours/week). He is requesting 24 hours/day,7 days/week (split shift).  

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately Impaired- Decisions consistently poor or unsafe; cues/supervision required at all times." The patient requires extensive assistance for bathing, personal hygiene, and lower body dressing. Limited assistance is needed for upper body dressing and toilet transfer. He is occasionally incontinent of bladder and continent of bowel. Supervision is needed for eating; toilet use and ambulation. The patient is independent with bed mobility. His functional ability has declined compared to the prior UAS report, particularly for cognition, bathing, and hygiene and lower body dressing. The insurer's PCA increase from 4 to 4.5 hours/week is inadequate to meet his functional needs. However, the patient's condition and functional decline are not at a level or unpredictable as to require the requested PCA services 24 hours/day, 7 days/week (split shift). Safety monitoring under personal care services does not include monitoring an individual (e.g., dementia) when no other Level I or Level II personal care services task is being provided. Based on the records reviewed, the patient's health and safety would be more appropriately provided and maintained at home by increasing PCA services to 12 hours/day, 7 days/week (total 84 hours/week).

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.  

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 
 
The insurer's denial of coverage for personal care aide (PCA): 12 hours per day - 7 days per week; 12 hours per day - 7 days per week (split shift) - for a total of 168 hours per week is modified as noted above. Medical necessity is not substantiated for 12 hour per day 7 days a week (split shifts) for total of 168 hours weekly. However, 12 hours per day 7 days a week is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Asthma
Treatment: Dulera
The insurer denied the Dulera.
The determination is overturned.

This is a female patient with a medical diagnosis of asthma who is currently well controlled on Dulera. The patient has previously tried and failed Advair Diskus, Breo Ellipta and Symbicort. The provider is requesting the continuation of Dulera as the patient's asthma has been controlled with its use. At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug, Dulera, or would have adverse effects.

The patient has previously tried and failed Advair Diskus, Breo Ellipta and Symbicort and they would not be as effective as the non-formulary drug, Dulera.

Per the clinical documentation, the patient has a diagnosis of asthma and is currently well controlled on Dulera. The patient has previously tried and failed Advair Diskus, Breo Ellipta and Symbicort. The provider is requesting the continuation of Dulera as the patient's asthma has been controlled with its use. There are studies that show that maintaining medication in the treatment of asthma has positive outcome and changing medications may be detrimental to asthma control.

Bjermer, in his editorial in Respiration, states "Switching may be associated with a poor inhalation technique, reduced disease control and quality of life, increased use of other treatments and health care resources, and a greater chance of unsuccessful treatment... It is recommended that patients with stable disease remain on their current device." In addition, the patient is currently stabilized on the requested medication and a change in therapy may cause a potential destabilization of her asthma control and/or require extensive management and resources that have been previously utilized. The Dulera is needed to prevent an illness (asthma exacerbations) and prevent endangering this patient's life, is being given at the right places and at the right levels of care for the treatment of members' health conditions, is consistent with health care practice guidelines and standards that are endorsed by professional health care or government agencies, is consistent with the diagnosis of the conditions, it is not more intrusive or restrictive than needed to give a good balance of safety, effectiveness and efficiency and it is not mainly for the ease of the doctor or member. In addition, the patient has tried and failed three of the available formularies. Therefore, at this time the Dulera is indicated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Diabetes Mellitus
Treatment: Formulary exception for Humalog Kwikpen
The insurer denied the formulary exception for Humalog Kwikpen.
The denial is overturned.

The patient is an adult female with latent autoimmune diabetes of the adult on t:slim X2 insulin pump with insulin resistance. The request for Humalog Kwikpen 200 U/mL (units per milliliter) is under review. The prior request was denied coverage by the health plan, as the patient has not tried and failed Fiasp and Novolog or demonstrated contraindication or intolerance to these alternatives.

The health plan should cover the formulary exception for Humalog Kwikpen.

This request is for Humalog 200 U/mL for the treatment of diabetes mellitus. This patient is on an insulin pump and has high insulin requirements. The use of concentrated insulin is supported by the American Diabetes Association clinical guidelines in the setting of insulin resistance, such as this patient. Humalog 200 U/mL has been shown to be safe and effective when administered via insulin pump and improved post-prandial glucose control [1]. Advantages with using concentrated insulins in pumps include higher maximum bolus, higher maximum basal rate, and less frequent infusion set change/reservoir refills. Without Humalog 200 U/mL, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. The available formulary alternatives are not appropriate in this case as they are not available in a U-200 formulation. Therefore, yes, the health plan should cover the formulary exception.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Meningitis
Treatment: Inpatient stay 
The insurer denied coverage for the inpatient stay
The denial is overturned.

Patient is an adult with a past medical history of tick exposure who presented to the emergency department with complaints of fever, headaches, nausea, and vomiting.

Vitals on presentation included: Temperature 38.6 degrees Centigrade, Blood Pressure 119/70, Pulse 86, Respiratory Rate 18, oxygen (O2) saturation 96% on room air. Laboratory values were notable for the following: white blood cell count (WBC) 17.2, Hemoglobin-13.9, Hematocrit-41.6, glucose-112, creatinine-1.61. Cerebrospinal fluid (CSF) showed: WBC-69 (64% neutrophils).

Patient was empirically started on intravenous antibiotics (vancomycin, ceftriaxone, acyclovir) for possible meningitis. CSF showed elevated WBC with lymphocyte predominance. Additional studies to test for central nervous system (CNS) Lyme disease were sent. Chest x-ray was negative. Head computed tomography (CT) scan showed no abnormalities. Infectious Diseases consulted and adjusted antibiotic therapy. Patient improved clinically, remained afebrile, hemodynamically stable. He was discharged to continue management as an outpatient.

According to medical records, patient presented with complaints of severe headaches (10 out of 10). He was febrile to 38.6 degrees Centigrade, laboratory results showed elevated WBC (17.2), acute renal insufficiency (creatinine-1.61), and lumbar puncture showed WBC with lymphocytic predominance. Based on above abnormal findings and severity of symptoms, hospital admission was medically necessary for empiric treatment and additional diagnostic evaluation.  

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular lesion.

Treatment: destruction of cutaneous vascular proliferative lesions (port wine stain) (Code 17108).

The insurer denied coverage for destruction of cutaneous vascular proliferative lesions (port wine stain) (Code 17108).

The denial is overturned.

The patient had a large port wine stain located on her arm, shoulder, and chest. The vascular lesion has increased in size with risk of bleeding. The lesion was treated with pulsed dye laser therapy. The request is for approval of pulsed dye laser therapy for treatment of the port wine stain.

Based on the standard of care, the use of pulsed dye laser would be considered medically necessary in the treatment of the patient's large port wine stain. The vascular proliferation covers a large part of the body with risk of bleeding. No reliable alternative therapies are available for the treatment of port wine stains, other than pulsed dye laser therapy. Current Procedural Terminology (CPT) code 17108 is for the laser destruction of vascular lesions, which would be an accurate and appropriate description of the procedure performed. In this clinical scenario the use of pulsed dye laser to treat the port wine stain would be within the standard of care and considered medically necessary.  

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 destruction of cutaneous vascular proliferative lesions (port wine stain) (Code 17108) is substantiated.