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

Diagnosis: Lack of Coordination
Treatment Occupational Therapy (OT)
The insurer denied the Occupational Therapy.
The determination is upheld.

The patient has a diagnosis of an unspecified lack of coordination. There is no underlying medical diagnosis provided in the documentation.
Available records include policy plans, appeal request from patient's father, OT notes, OT initial evaluation, bills. At issue is the medical necessity of occupational therapy.
The OT visits are not medically necessary for this patient. The occupational therapist (OT) Rose Santos-Martinez documented in  the most recent note available, that the patient displayed avoidance behaviors when walking tandem on an elevated surface, due to decreased vestibular modulation.  He completed 3 trials of eye-hand coordination tasks with noted ability to complete 5 consecutive catches, requiring minimal (min) verbal and visual cues for redirection of attention.  In the oldest OT progress note the OT began with documenting that the patient engaged in a therapeutic gross and visual motor activity that challenged his eye hand coordination, visual attention, and attention to task though the activity is not specified.  This note also documents that the patient worked with a small ball to practice his ball skills in order to improve bilateral coordination, eye hand coordination, and visual attention and that manipulating a smaller ball increased the difficulty of the task. Clinical and industry guidelines for skilled OT require documentation of broadly accepted objective impairment measures, description of impact on activities of daily living and these are absent from these progress notes. To establish medical necessity, progress made by patient towards long and short term goals must be documented. The occupational therapy notes provided lack documentation of these components which are necessary to establish medical necessity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Trauma/injury.
Treatment:  Inpatient admission.

The health plan denied the inpatient admission.  The denial is upheld.

The health plan's determination of medical necessity is upheld in whole. The inpatient hospital stay was not medically necessary. 

This patient presented to the emergency department (ED) with c/o mechanical fall associated with right foot pain.  The patient did not have structural heart disease, Hematocrit (HCT) < 30, shortness of breath (SOB), hypotension or history of sudden cardiac death, history of dilated cardiomyopathy, aortic stenosis, hypertrophic cardiomyopathy (HCM), left ventricular outflow disease, pre-excitation syndrome, Brugada syndrome, QT interval abnormalities or conduction blocks.  The patient did not have subarachnoid hemorrhage, pulmonary embolism, acute gastrointestinal (GI) bleed, malignant arrhythmia, sustained bradycardia, supraventricular tachycardia (SVT) or ventricular tachycardia (VT), confirmed acute coronary syndrome (ACS), evidence of heart failure, cerebrovascular accident (CVA), shock, coma, major trauma or cardiac arrest, or exertional syncope.  In addition, while the patient did have bilateral foot drop, this was noted to be a chronic/baseline problem and was thus not a new-onset problem.  The patient was diagnosed with a mechanical fall and treated with clinical monitoring and physical therapy.  Overall, this patient received no interventions that could not have been safely treated at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Infectious Disease: Viral Infection
Inpatient hospital

The patient is a male with history of hypertension who presented to the emergency Department with complaints of diarrhea, nausea, fever, and cough. The patient reports that he had returned from a trip. He had developed diarrhea near the end of his trip in Thailand, and had presented to urgent care where he received intravenous (IV) fluids Tylenol and Zofran . His temperature at home was noted to be 103. Vital signs were: T (temperature) 102.5, blood pressure 139 over 92, heart rate 90-112, respiratory rate 20, and oxygen saturation's 97-99% on room air (RA). He was admitted to the hospital. 

The health plan's determination is overturned. The inpatient admission was medically necessary. He presented with 3/4 SIRS criteria and ultimately sepsis due to a viral infection. His admission was notable for fevers and leukopenia and ultimately the patient developed significant neutropenia. He warranted an infectious work up and monitoring of his ANC to ensure did not drop below 500 and for hematology evaluation for consideration of therapies such as G-CSF (2). He warranted ID evaluation and continued assessment for diagnostic and treatment recommendations for fever in a traveler with neutropenia. A lower level of care would have a high risk of morbidity and mortality if the patient had not shown clinical improvement. He was discharged once he had evidence of bone marrow recovery. The inpatient admission was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Problems
Treatment: Orthodontic Procedure 

The patient has maxillary and mandibular crowding and several unerupted permanent teeth. The orthodontist mentioned in the diagnosis that #7 and #10, and possibly other teeth, are impacted. The patient was treatment planned for 30-36 months of comprehensive orthodontics. 

 The health plan's determination of medical necessity is upheld. Orthodontic treatment is not medically necessary for the patient at this time. This patient is in the process of losing the remaining primary teeth as they are replaced with permanent teeth. There are not excellent guidelines specifically for impacted lateral incisors, but can apply the risk factors for impacted canines in patients over 10 years of age. 1) If there is asymmetry in palpation or a pronounced difference in eruption of canines between the left and right side. (The patient does not have this, as shown in the panoramic radiograph.) 2) The canines cannot be palpated, and occlusal development is advanced (occlusal development is not advanced - there are many primary teeth remaining and the second molars are far from eruption.) 3) The lateral incisor is proclined and tipped distally (Photographic evidence submitted for review does not indicate proclined lateral incisors.)
Appeal type: Medical necessity
Decision: Upheld

This is a patient who presented to the emergency room (ER) for the evaluation of abdominal pain and large volume hematochezia. The abdominal pain began several hours prior to admission. It was primarily epigastric in location and awoke him from sleep. He had a total of 7-8 bowel movements (BMs). He was described on admission as in no acute distress and had a normal abdominal exam without palpation tenderness. His initial hemoglobin (hgb) was 13.2. He did not have an elevated white blood cell count. He had no lactic acidosis. A computed tomography (CT) scan demonstrated thickening of the left colon possibly indicating underlying colitis. The patient was placed on intravenous (IV) antibiotics. He was discharged the following day.

The health plan's determination is upheld. The patient appeared well on initial evaluation in the ER. In addition, his abdominal exam was unremarkable. His hemoglobin was in the normal range. There was no leukocytosis, acidosis, or evidence of significant dehydration. The CT scan findings were non-specific and not necessarily indicative of a significant intra-abdominal process and may have been due to the lack of oral contrast. Therefore, an acute inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Deep venous thrombosis.
Treatment:  Inpatient admission.

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

This case involves then a male patient who presented to the Emergency Department (ED) with complaints of swelling to the lower extremity.  The patient's past medical history was significant for cardiovascular accident (CVA).  The patient reported that he noticed swelling that morning prior to ED arrival.  The patient reported that he had recently discontinued taking Xarelto, approximately several months ago.  The patient's examination revealed left lower thigh swelling with no tenderness to palpation, warmth or redness.  The recommendation was made for laboratory diagnostic studies.  The patient's duplex to the left lower extremity revealed an acute thrombus to the left common femoral vein.  The patient was given Lovenox and was admitted for inpatient management of deep venous thrombosis (DVT).  The patient's laboratory studies revealed an elevated white blood cell count of 15.45.  The patient was also treated with medications, which included hydrocodone as well as me thocarbamol.  The patient's electrocardiogram (EKG) revealed sinus arrhythmia with a possible lateral myocardial infarction.  The patient continued with treatment and denied any further significant adverse events.  The following day the patient was discharged given medical stability.

In review, this patient with past medical history of Lupus, cardiovascular accident (CVA), and history of deep venous thrombosis (DVT) had been noncompliant with his anti-coagulation medication for about several months.  As a result, the patient presented with clinical signs and symptoms consistent with deep venous thrombosis.  The patient reported acute left thigh pain on hospital presentation.  However, based on the medical documentation, the patient did not exhibit any associated signs/symptoms of complicated DVT, such as leg edema, phlegmasia, mottling or motor/sensory changes to the affected (left) leg.  In addition, the patient did not exhibit any associated symptoms of pulmonary embolism, such as dyspnea, shortness of breath, and/or elevated D-dimer.

Thus, as this was an uncomplicated deep venous thrombosis (DVT) due to medical noncompliance without other associated symptoms, it was prudent to re-start the anticoagulation, and discharge the patient from the Emergency Department.  Literature review does not support that inpatient admission was medically necessary for this patient. 

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

Based on the above, the medical necessity for the inpatient admission is not substantiated.  The insurer's denial should be upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 diabetes with hyperglycemia
Issue under review: Formulary exception for Kombiglyze XR 
The insurer denied the Formulary exception for Kombiglyze XR.
The denial is overturned. 

Yes, the health plan should cover the Formulary exception for Kombiglyze XR (saxagliptin-metformin ER).

This patient is a male with type II diabetes. He has previously been successful on Kombiglyze XR. He has tried and failed Jentadueto XR due to gastrointestinal adverse effects. His A1C (glycated hemoglobin) was 6.2%. The request for Kombiglyze XR is under review. 

This patient has tried and failed Jentadueto XR due to gastrointestinal adverse effects. It is not appropriate for this patient to try Jentadueto given he has tried and failed Jentadueto XR. This patient has been successful on Kombiglyze XR. Use of Kombiglyze XR in this clinical situation for the treatment of type II diabetes is consistent with the Kombiglyze XR prescribing information and the American Diabetes Association clinical guidelines [1]. Without Kombiglyze XR, this patient is at risk for hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. Therefore, yes, the health plan should cover the proposed Formulary exception for Kombiglyze XR (saxagliptin-metformin ER).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: s/p Surgery (laparoscopic left nephrectomy)
Issue under review: Inpatient admission
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male was admitted through the ER with a 9 cm left renal tumor on.  The admission history notes that patient stated that "My doctor sent me in here because I have a tumor on my left kidney and I need surgery tomorrow."  He has a history of hypertension.

He was treated with a laparoscopic left radical nephrectomy.  The surgery was uncomplicated.  He had an epidural pain catheter.  He was sent to the surgical unit.

The patient was discharged to home.

No, the inpatient admission is not "medically necessary".

The admission through the ER did not require an acute inpatient level of care.  The patient had no acute findings.  He presented for next day, planned surgery.  He was medically stable.

The surgery was uncomplicated.  Although a major surgery, he was able to be discharged home the next day.  He did not have complicated comorbid conditions.  He did not have hemodynamic instability, sepsis, uncontrolled pain, impaired GI function or complications.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Idiopathic short stature (ISS).

Treatment: Nutropin AQ Nuspin

The insurer denied coverage for Nutropin AQ Nuspin. The denial is upheld

This patient is a female diagnosed with idiopathic short stature (ISS). The patient had experienced a rapid advancement of bone age. The patient's height velocity over the past several months had decelerated from 8 cm/year to less than 3 cm/year.

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 auxological, biochemical and sometimes radiological findings. The auxological 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 SDS below the mean; 2) height more than 1.5 SDS below the mid parental height; 3) height more than 2 SDS below the mean and a height velocity over 1 year more than 1 SDS below the mean for chronological age, or a decrease in height SDS of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SDS below the mean over 1 year or more than 1.5 SDS sustained over 2 years. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml. In this case, the patient did not meet the biochemical criteria. Growth hormone stimulation testing was not reported.

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines [4-9]. 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." In this case, the patient did not have a pretreatment height less than or equal to -2.25 SD. The patient therefore did not meet idiopathic short stature criteria. 

Thus, given that this patient did not meet the clinical diagnoses of growth hormone deficiency or idiopathic short stature, growth hormone therapy with Nutropin is not considered medically necessary for this patient. The request does not meet any nationally accepted criteria for use of growth hormone. The request is therefore not medically necessary.

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

Based on the above, the medical necessity for Nutropin AQ Nuspin is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Respiratory System
Durable Medical Equipment (DME) (including Wearable Defibrillators)

Diagnosis: Bronchiectasis
Treatment: Chest Shaking Vest 
The insurer denied the Chest Shaking Vest. The health plan's determination is upheld. 

The patient is a female with a medical history of right upper/middle lobe, left upper lobe including the Lingula focal bronchiectasis with a chronic cough secondary to gastroesophageal reflux disease and hyperactive airway. She has a history of mycobacterium avium complex (MAC) infection status post treatment. Per the physician's notes, there is no documentation of trying or failing other airway clearance therapies. The attending physician is requesting a high frequency chest wall oscillation system (HFCWO) for airway clearance.

The Chest Shaking Vest is not medically necessary for this patient. Most recently HFCWO was evaluated for non-cystic fibrosis diffuse bronchiectasis and it was found that HFCWO provides an improvement both in pulmonary function and quality of life related parameters in patients with bronchiectasis with increased secretions. However, they state that studies are needed to establish the effectiveness of the different airways clearance devices and techniques for long-term home use. The patient does not have a documented failure of standard treatments to adequately mobilize retained secretions (eg. Acapella valve, PEP valve). Per the most recent physician note from late 2019, the patient's cough was determined to be secondary to gastroesophageal reflux disease and hyperactive airway, not bronchiectasis. Therefore, without a diagnosis of diffuse bronchiectasis and trying, failing or having a contraindication to alternative clearance therapies, the E0483RR - Chest Shaking Vest is not medically necessary for this patient.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Hypertrophic obstructive cardiomyopathy

Treatment: Formulary Exception for Norpace CR (disopyramide)

The insurer denied coverage for Formulary Exception for Norpace CR (disopyramide). The denial is reversed.

This patient is a female with hypertrophic obstructive cardiomyopathy. Norpace CR (disopyramide) is requested. The patient has been on Norpace name-brand for several years. When the prescription was last filled, the patient was given the generic disopyramide. Since starting it, the patient has been having worsening symptoms. The insurer has denied coverage for Norpace CR (disopyramide). In their Final Adverse Determination letter, they write that the plan approves Norpace CR when the drug is being used for an FDA-approved or compendia supported indication. The formulary alternative is disopyramide. Per an appeal letter from the patient's doctor, the patient has a rare condition or disease for which there is no standard treatment.

Immediate release disopyramide dosing is four times daily dosing which would expose the patient to drops in the therapeutic drug level. Brand-name Norpace CR is longer acting and has no generic. Norpace CR is appropriate for treatment of hypertrophic obstructive cardiomyopathy. The patient has been on brand-name Norpace for several years with an appropriate control of clinical symptoms (dyspnea). When this was changed to generic disopyramide, the formulary option, the medication did not control the patient's symptoms. This is a rare condition with a niche use of this drug for treatment, and therefore there are no other alternatives which would be appropriate in this clinical instance. Moreover, given the long-term control of symptoms on this medication, it would be inappropriate to switch to another medication or the generic version of disopyramide. Therefore the requested drug Norpace CR is more effective than the formulary drug.

Based on the above, the insurer's denial of Formulary Exception for Norpace CR (disopyramide) is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Kidney disease
Treatment: Consumer Directed Personal Care Assistance: 70 Hours per Week 
The insurer denied the Consumer Directed Personal Care Assistance: 70 Hours per Week. 
The health plan's determination is upheld. 

The patient is a female with a past medical history significant for anemia, chronic kidney disease, hypertension, dyslipidemia and gait abnormalities. She currently goes to hemodialysis 3 times a week.
The patient is requesting consumer directed personal assistant (CDPA) service hours of 70 hours per week. She was approved for 37 hours a week. She was previously receiving 70 hours a week. This appeal is to restore the 70 hours a week.

The NY Consumer Directed Personal Care Assistance: 70 Hours per Week is not medically necessary.
The MCO (managed care organization) does not need to provide CDPA hours when the patient is at dialysis since there are no specific activities of daily living (ADLs) being performed at this time. The patient is at dialysis 3 times a week. The allotted 37 hours/week are sufficient to meet the patient's needs.
According to the health plan's in-home nursing assessments, safety monitoring should not be authorized in absence of an activity of daily living need. Safety monitoring can only be authorized to be performed during delivery time of a level 2 task, a task that helps assist with an ADL. The patient was evaluated using Senior whole health tasking tool. This noted that 37 hours a week were needed to support her in daily care needs. 70 hours are in excess of the patient's actual needs. When a CDPA accompanies a member to dialysis appointments, the CDPA is for safety monitoring and to act as a medical facilitator. However, the aid is not performing any services at that time which would assist in ADLs or Instrumental activities of daily living (IADLs).
The 37 hours a week are sufficient to meet the patient's medical needs for ADLs and IADLs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Central nervous system/Neuromuscular disorder/chronic pain 
Treatment: Surgical services 
The insurer denied re-trial of SCS. 
The denial is upheld in whole 


The patient is a female with chronic pelvic pain. The history is significant for a trial of spinal cord stimulator (SCS). The details of the trial are not reported in the files submitted for review. The patient presented with complaints of ongoing pelvic pain. The record suggests lead migration during a trial of SCS.
No, the proposed re-trial of SCS is not considered medically necessary for this patient. Treatments tried to date have included medications and multiple interventional pain procedures. In short, the patient struggles with chronic pelvic pain. An extensive review of relevant peer-reviewed medical literature for the condition in question reveals the following: A case-series report of SCS for the treatment of pelvic pain concludes "It appears that SCS may have a significant therapeutic potential for treatment of visceral pelvic pain" [1].
The Neuromodulation Appropriateness Consensus Committee (NACC) of the International Neuromodulation Society (INS) states (in-part) "Randomized controlled studies support the efficacy of spinal cord stimulation in treating failed back surgery syndrome and complex regional pain syndrome. Similar studies of neurostimulation for peripheral neuropathic pain, postamputation pain, postherpetic neuralgia, and other causes of nerve injury are needed. International guidelines recommend spinal cord stimulation to treat refractory angina; other indications, such as congestive heart failure, are being investigated" [2].
Reliable evidence shows that the consensus among qualified objective experts regarding the inherent nature of SCS (conventional and high-frequency) for the treatment of chronic pelvic pain is that further clinical studies, clinical outcomes research, or clinical trials are necessary to determine its safety, efficacy and anticipated outcomes as compared with the standard means of treatment or diagnosis of the condition in question.