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

Diagnosis: Contact with and exposure to other viral communicable diseases
Treatment: Polymerase Chain Reaction Testing (0202U-59-91)
The insurer denied the polymerase chain reaction testing (0202U-59-91).
The denial is upheld.

This patient is a male with a diagnosis of contact with and exposure to other viral communicable diseases.  He is appealing denial of coverage of polymerase chain reaction testing, respiratory panel testing (0202U-59-91).  The test was denied due to lack of signs/symptoms of COVID-19 (coronavirus).  The patient notes these tests were performed to test for COVID-19.  The panel was positive for COVID-19 on the first two dates.  The test was negative on the third date.

No, the proposed treatment was not medically necessary.

Polymerase chain reaction (PCR) Respiratory Panel Testing may be medically necessary for individuals who are at high risk for complications of respiratory viral infection, such as the immunocompromised.  The diagnosis indicates this patient was exposed to a communicable virus.  There is no documentation that the patient is immunocompromised or at high risk for complications of a respiratory infection.  Therefore, the proposed polymerase chain reaction testing, respiratory panel testing (0202U-59-91), was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease

Treatment: Repatha SureClick

The insurer is denied coverage for Repatha SureClick.

The denial is upheld. 

This male patient has a history of coronary artery disease (CAD), hyperlipidemia, anxiety, psoriasis, sleep apnea, testicular hypofunction, impotence, lower extremity edema and macrocytosis.  

This patient had a normal myocardial perfusion study and a preserved left ventricular ejection fraction (LVEF). Coronary calcium score was less than 300. His ten-year risk of a cardiovascular event is 2.5% (percent). (Reference 1) On maximally tolerated high intensity statin treatment (atorvastatin 40mg (milligrams) daily) and Ezetimibe, total cholesterol was 169 low density liproprotein (LDL) cholesterol was 104 mg/dl (milligrams per deciliter) Current American Heart Association and American College of Cardiology guidelines recommend statin therapy as well as ezetimibe in this setting but not Evolovumab. (Reference 2,3,4).  The addition of Evolocumab would be indicated if the patient had evidence of clinical atherosclerotic cardiovascular disease and a ten-year risk of greater than or equal to 7.5% (Reference 1-4).  In conclusion, treatment with Repatha/evolocumab is not medically necessary.

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

The carrier's denial of coverage for the Repatha SureClick is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Intractable nausea and vomiting. 
Treatment: Hospital admission. 

The insurer denied coverage for hospital admission. 

The denial is overturned. 

This case involves an adult male who presented to the Emergency Department (ED) complaining of nausea and vomiting. The submitted documentation does indicate that he has had 3 prior ED visits within a month, prior to presentation due to similar complaints. He was previously found to have colitis and given Flagyl for treatment. The documentation indicated he has a past medical history of diabetes as well as anxiety. He had a blood pressure of 143/100 on physical examination with a temperature of 99.6. Oxygen saturation was 100% (percent). The documentation indicated he was given multiple doses of Zofran as well as famotidine, Haldol, and Ativan without improvement in symptoms. The recommendation was made for laboratory studies and additional diagnostic studies. A computed tomography (CT) scan with contrast did not reveal any active colitis. The patient did admit to smoking marijuana daily. The physician indicated the patient had intractable nausea and vomiting which was possibly cannabis hyperemesis. It was recommended he be admitted to medicine for further treatment. He was recommended to continue treatment with intravenous (IV) fluids. Laboratory studies did reveal a blood glucose of 312. The official CT scan revealed no evidence of a mechanical bowel obstruction or acute inflammatory bowel disease. The documentation indicated he was admitted and underwent an endoscopy. The study revealed mild gastritis. He continued to be treated with IV medications and his symptoms continued to improve. He did not have any further significant adverse events while hospitalized and was discharged. 

The patient presented to the ED with intractable vomiting and unable to keep food down. This was his 4th ED presentation, and he has failed outpatient therapy. While the vitals in the ED or lab findings do not indicate an acute illness, the fact that he was unable to keep oral intake down without vomiting and that he failed outpatient management necessitated inpatient admission and gastroenterology consultation. A premature discharge would have likely resulted in a repeat ED presentation. 

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

The insurer's denial of coverage for the hospital admission is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class three malocclusion. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female.  The case is a request to review the medical necessity of an acute inpatient admission for a female adult patient who underwent orthognathic surgery followed by a postoperative admission in an intensive care unit (ICU) overnight stay. 

Yes, the proposed treatment was medically necessary. 

The patient underwent elective reconstructive orthognathic surgery involving osteotomies of the upper and lower jaw.  She was admitted to the intensive care unit (ICU) postoperatively overnight for acute pain management via patient controlled analgesia (PCA), airway evaluation and control, and continuous airway and ventilation management involving the use of pulse oximetry and arterial blood gases. It is noted that the patient was maintained in intermaxillary fixation as a condition of her skeletal fixation, thereby making it imperative that her oropharyngeal and nasopharyngeal airways remain patent.  These surgical cases experience extreme amounts of postoperative edema that can occlude a patent airway in a matter of hours both from postsurgical edema and/or postoperative hemorrhage.  Heavy secretions and mucus can also cause acute airway issues. Loss of airway control is the number one because of severe postoperative morbidity in these patients.  Discharging these patients to the floor prematurely is both negligent and dangerous until clinical parameters and guidelines are clearly satisfied. If such patients experience airway emergencies, with their jaws wired shut, a hospital surgical floor is not the appropriate venue to manage a compromised airway and/or possible emergent intubation and/or tracheostomy procedure.  The surgical intensive care unit (ICU) is the appropriate setting for such postoperative patients who have undergone such significant maxillofacial region reconstruction. The American Association of Oral and Maxillofacial Surgeons Parameters of Care consider postoperative transfer to the intensive care unit as a standard of care for such patients until the following parameters have been fully addressed and satisfied: Patients must be assessed for and cleared in the following areas: hemostasis, emesis control, airway patency and pulmonary toilet, pain control, adequacy of oral fluid and oral intake, ability to manage activities of daily living (ADLs), all prior to discharge. An admission is required for orthognathic surgery on both jaws, and approval is advised.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: BRCA (gene mutation)

Treatment: in vitro fertilization (IVF)

The insurer is denied coverage for in vitro fertilization (IVF).

The denial is upheld. 

This female patient has a history of BRCA (gene mutation).

BRCA mutations in women confer a high risk for breast and ovarian cancers. The recognition of the role of BRCA1 and BRCA2 mutations in some women has led to the involvement of preimplantation genetic diagnosis (PGD), recently renamed preimplantation genetic testing for monogenic disorder (PGT-M), whereby embryos are created by in-vitro fertilization (IVF) and cell(s) are removed and genetically analyzed for specific disease-related mutations.

The clinical data from well-conducted randomized controlled or cohort trials in the 
prevailing peer-reviewed published medical literature is inadequate to conclude that PGD 
testing is an effective diagnostic tool in this clinical scenario. There is a lack of adequate studies in which the transmission of BRCA2 has been prevented. The available data involve few cases where PGD was done but in the majority of cases reported no confirmatory testing when the baby was born nor is there long term follow up studies suggesting a decrease in neoplasia in those offspring. 

The prevailing peer-reviewed published medical literature is inadequate to conclude that PGD  testing prior to IVF has a beneficial effect on clinical outcomes of patients with BRCA gene mutation.

Note that of the cases reported in the scientific literature, some women developed breast cancer after treatment. In other words, there are risks involved with undergoing IVF in this population and maternal safety of IVF(PGD) in female carriers needs further evaluation.

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

The carrier's denial of coverage for the in vitro fertilization (IVF)  is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, morbid obesity, nonhealing
ulcers
Treatment: Personal Care Services (Level 2), 8 Hours Per Day, 7 Days Per Week for a Total of 56 Hours Per Week
The insurer denied the Personal Care Services (Level 2), 8 Hours Per Day, 7 Days Per Week for a Total of 56 Hours Per Week
The denial is overturned. 

The patient is a female with a history of diabetes mellitus, hypertension, lymphedema, morbid obesity and gastroesophageal reflux disease (GERD). Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An appeal review has been requested for potential approval of 56 hours/week of personal assistance services to offer increased activity of daily (ADL) support.

Yes, the proposed 56 hours per week of Personal Care Services (Level 2) is deemed medically necessary.
The patient is a female with a history of diabetes mellitus, hypertension, lymphedema, morbid obesity and gastroesophageal reflux disease (GERD). Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs). An assessment of the patient's functionality and ability to perform activities of daily living (ADLs) was completed and revealed the need for a range of extensive assistance, maximal assistance and total dependence for tasks including managing equipment, transportation and ordinary housework. Another assessment was completed five months later and does not indicate a decline in functioning. However, a letter from the provider documents an extensive history of chronic medical conditions including morbid obesity, diabetic polyneuropathy, nonhealing ulcers and partial paralysis due to a severe burn suffered as a child as well as severe lumbar degenerative disc disease, which have all left the patient unable to perform activities of daily living (ADLs) without assistance. These conditions are corroborated by office visits. There is also a letter from the patient's advocate indicating that she has difficulty leaving the home unless it is intermittent and for a short duration, and noting that the patient has scheduled and unscheduled needs that require an increase in personal care services. A reduced schedule would leave her alone, unassisted for numerous hours a day. This is problematic as she requires assistance with meal preparation, toileting, showering/bathing, transferring to a commode and throughout the apartment. The current plan approved 42 hours are insufficient to meet the patient's needs. 

Hence, provision of 56 hours per week of personal care services can reasonably be expected to be beneficial for the patient and withholding these services, in whole or in part, can reasonably be expected to affect the patient's health adversely. For these reasons, the proposed treatment of 56 hours per week of personal care services is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: breast cancer, bone cancer, depression, shortness of breath, dizziness, abnormalities of gait and mobility

Treatment PCW (personal care worker) services 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week

The insurer denied coverage for PCW services 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week

The denial is overturned

The patient is female with a medical history of breast cancer, bone cancer, depression, shortness of breath, dizziness, abnormalities of gait and mobility, pleural effusion, and generalized muscle weakness. Per the Uniform Assessment System (UAS) - New York Comprehensive Community Health Assessment Report, the patient lives alone. Her cognitive skills are severely impaired and are noted to have declined. The patient is frequently incontinent of bladder and bowels, maximal to total dependence is needed for activities of daily living (ADLs) and her overall self-sufficiency is noted to have deteriorated. She has been approved for 24-hour live-in services personal care worker (PCW) services. Split-shift services are requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 

(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.

The patient is dependent for all functions and is incontinent of bladder and bowel. She is unable to care for her toileting needs, and bed mobility is impaired. The need for 24-hour care is not questioned; at issue is whether a live-in aide can provide adequate coverage and get the required sleep. She has already had skin breakdown, and the daughter notes that a live-in aide has already quit due to not getting sleep. The provision of diapers and other durable medical equipment (DME) for incontinence is important but is not by itself adequate for prevention of pressure sores. As noted in "Preventing pressure ulcers" changing diapers regularly and positioning are also necessary. (6)

Given the above circumstances the request for split-shift is approved. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The insurer's denial of coverage for personal care worker (PCW) services 7 days per week, 24 hours per day; continuous care by more than 1 person; 168 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Sleep Disorder.
Treatment:  Hetlioz 20mg, Pre-service.
The insurer denied the  Hetlioz 20mg, Pre-service.

The denial is overturned.

The patient is a male.  Office note noted insomnia, delayed sleep phase syndrome, snoring, migraine, and epilepsy. His vitals and exam were normal. He has a past history of type I diabetes and bipolar. 

Yes, the proposed treatment is medically necessary.
The patient was diagnosed with non-24-hour sleep-wake disorder and has started this medication. This has greatly improved the patient's sleep duration and quality. It was thought that this circadian rhythm disorder was induced by epilepsy. The patient is responding well to treatment. This disorder has been well described in sighted patients. Based on the current literature below, this medication is medically necessary and beneficial for the patient in question.

The patient is greatly benefiting from the medication and it is being used with its appropriate indication to treat the patient's disorder.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Complex regional pain syndrome (CRPS) and neuralgia, lower extremities.

Treatment dorsal root ganglion stimulator, code 63650.

The insurer denied coverage for dorsal root ganglion stimulator, code 63650.

The denial is upheld

This adult male has complex regional pain syndrome (CRPS) and neuralgia of the lower extremities. He has a history of thoracic spine fusion. He has bilateral severe foot pain. He has been given pain medications and had placement of a spinal cord stimulator (SCS) but continues to have 10 out of 10 foot pain and hypersensitivity. His physician has recommended a dorsal root ganglion stimulator.

The unique issue here is that he already has a functioning SCS that is not providing pain relief, and this is another approach to stimulation. The literature supporting dorsal root ganglion (DRG) stimulation (1) was conducted in patients who have not had a prior trial with a SCS. While stimulator naive patients have had better outcomes with DRG stimulation, there are no data on patients that have failed SCS and then went onto a DRG trial. Data to date is limited to case reports (2,3). A trial of DRG stimulation after failed SCS would be considered experimental/ investigational.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. A dorsal root ganglion stimulator is not considered medically necessary for this patient.

The insurer's denial of coverage for dorsal root ganglion stimulator, code 63650 is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD).
Treatment: Vyvanse (lisdexamfetamine).
The insurer denied the Vyvanse (lisdexamfetamine).
The denial is overturned.

The patient is an adult female, who has been diagnosed with attention deficit hyperactivity disorder (ADHD).  No comorbid psychiatric disorders are reported, but the patient is also prescribed fluoxetine and lamotrigine, according to pharmacy records.

The patient has been prescribed Vyvanse and the patient's prescribing clinician, a psychiatrist, is requesting coverage treatment with Vyvanse for the treatment of ADHD (attention deficit hyperactivity disorder).  The patient was previously treated with formulary alternatives, with adverse reactions, to Concerta, Ritalin LA, Metadate CD (extended release capsule) and Focalin XR (extended release) while living in the United Kingdom, as well as prior treatment with Adderall and Strattera, according to pharmacy records.

The insurer denied coverage of Vyvanse indicating that Vyvanse is non-formulary. The insurer requires that formulary drugs must be tried and failed before authorization is granted for a coverage exception for Vyvanse.   The insurer's formulary alternatives include Concerta, Ritalin LA (extended release capsule), Metadate CD (extended release capsule) and Focalin XR (extended release).

The prescribing physician indicates that formulary alternatives have been tried and failed due to adverse effects. 

Yes, the requested Vyvanse is medically necessary for this patient.

The insurer's requirement for treatment failure with a formulary alternative is met in this case.  This patient has failed all formulary alternatives due to adverse effects.  Thus, the formulary drugs would be ineffective and not likely to be as effective as the requested treatment with Vyvanse.  As such, the requested Vyvanse is in the patient's best interest and is prescribed with sound medical judgment.  The use of Vyvanse in this case scenario is consistent with prevailing standards of medical practice, the FDA (United States Food and Drug Administration) indicated use for the treatment of ADHD (attention deficit hyperactivity disorder), is clinically appropriate and indicated; and consistent with nationally recognized scientific evidence and prevailing medical standards and clinical guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis, muscle weakness, asthma, and chronic venous insufficiency ulcer of leg. 
Treatment: Long Term Custodial Care Services. 

The insurer denied the Long Term Custodial Care Services. 
The denial is upheld. 

This patient is a male with diagnoses of cellulitis, muscle weakness, asthma, and chronic venous insufficiency ulcer of leg.  The patient is a appealing denial of ongoing long term custodial care.  The request was denied because the patient does not require assistance for activities of daily living (ADLs) such as dressing and bathing.  The prior review extended coverage to allow the patient time to coordinate discharge.  The medical records show that the patient is noted to be a long term resident.  Clinical notes show the patient is clinically stable.  He is able to direct self care.  He is able to transfer to/from bed and toilet independently with assistive device.  He is able to ambulate 15 feet and he uses a wheelchair.  He is receiving daily Kerlex dressings. 

No, the proposed health service is not medically necessary. 

Custodial care is care primarily for the purpose of assisting a patient in activities of daily living (ADLs) or in meeting personal rather than medical needs, and which is not specific treatment for an illness or injury.  The patient is clinically stable.  He does not require complex wound care.  He is able to direct his care.  His functional status shows he is able to transfer and ambulate independently.  The patient is able to care for himself.  The proposed Long Term Custodial Care Services are not medically necessary.