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

Diagnosis: osteoarthritis and oxygen-dependent lung disease
Treatment: Personal Care Aide Level II, Live-in, 7 Days/Week
The insurer denied the Personal Care Aide Level II, Live-in, 7 Days/Week
The denial is overturned

The patient is a male. His diagnoses include osteoarthritis and oxygen-dependent lung disease. He is in hospice due to multi organ failure. Reduction of Personal Care Aide Level II, live-in, 7 days per week to personal care aide 42 hours per week is being appealed. The services were reduced because the patient was receiving shared services as mutual with his spouse, who is no longer receiving services. The patient has been receiving informal support that is ending due to employment responsibilities. The Plan states the patient does not qualify for the proposed level of care. The patient's daughter states additional hours are needed due to chronic illnesses.

There are several appeal statements provided. They recommend continuous assistance because the patient is dependent with all ADLs (activities of daily living). They note that the patient's conditions have deteriorated and he is now wheelchair-bound. He has had several falls requires assistance with transfers.

Yes, the Personal Care Aide Level II, Live-in, 7 Days/Week is medically necessary.
Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Reduction of Personal Care Aide Level II, live-in, 7 days per week to personal care aide 42 hours per week is being appealed.

This patient has multiple chronic medical conditions and is in hospice care due to multi-organ failure. The hours were reduced after the death of his wife with whom he shared services. The appeal statements show that the patient's condition is deteriorating. He is wheelchair bound and requires assistance with all ADLs (activities of daily living) and has bladder incontinence. His family has provided informal support but is unable to continue due to inability to continue working from home. Based on this patient's loss of informal support and dependence on assistance with all ADLs (activities of daily living), the approved PCA (personal care aide) 42 hours per week in inadequate to meet the patient's needs for assistance with ADLs (activities of daily living) and personal care. The proposed PCA (personal care aide) live-in, 7 days per week is medically necessary.

No, the health plan did not act reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma
Treatment: Asmanex HFA, Pre-service
The insurer denied the Asmanex HFA, Pre-service
The denial is upheld

The patient is a female with a history of allergic asthma and her physician is requesting approval for Asmanex, which is a formulary exception. 
The requested drug Asmanex is not on the plan's formulary. According to the plan, the formulary exception criteria require that in order to cover a drug not on the formulary, there must be documented prior trials with all formulary alternatives including: Arnuity Ellipta, Flovent Diskus, Flovent HFA, Pulmicort Flexhaler, Qvar Redihaler.

No.
There is no documentation to support that there should be a formulary exception in this case. The reason the physician submitted indicates that the reason the drug was requested was that the patient was on this drug in the past. There are no prior trials with the plan's listed formulary alternatives. There are no literature or studies to show that the formulary alternatives are inferior than the requested drug. Therefore, the health plan should not cover the proposed treatment.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular. 
Treatment: Home Health Care. 
The insurer denied Consumer Directed Personal Assistance Services. 7 days per week, 24 hours per day continuous care by more than one person. 
The denial is overturned.

The patient is a female with past medical history of central pontine myelinolysis, type II neuropathy, bedbound status, coronary artery disease, diabetes mellitus type 2, bipolar disorder, hypertension, nephrolithiasis, hyperlipidemia, incontinence of stool, and incontinence of bladder who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services 12 hours/day x 7 days/week to total 84 hours/week based on assessment tool performed  assessing the patient at total assistance with tasks of meal preparation, ordinary housework, managing finances, stairs, shopping, transportation, equipment management, and locomotion while maximum assistance with tasks of managing medication, phone use, bathing, personal hygiene, dressing upper/lower body, toilet use, bed mobility, and eating. The tasks of walking and transfer toilet did not occur during assessment. The subject under review is the medical necessity for CDPAP services 7 days per week 24 hours a day continuous by more than one person.

The requested service is medically necessary for this patient. 
The patient is noted to have a degenerative brain condition with documented decline in physical and mental functioning since hospitalization. The patient is noted to require assistance with all activities of daily living (ADLs)/Instrumental activities of daily living (IADLs). The patient has unpredictable and unscheduled care needs that span a continuum of time and the insurer has failed to document a plan to meet these unpredictable and unscheduled care needs especially in the overnight hours. There is documentation that the patient has skin breakdown with the necessity for turning and repositioning as well as changing soiled diapers every 2 to 3.5 hours. Patient's overnight care needs would not allow a CDPAP aide to obtain at least 5 hours of uninterrupted sleep. Furthermore, there is no definite documentation that the patient's new apartment would be able to accommodate a CDPAP aide, live-in. The patient's care needs cannot be met solely with medical supplies and adaptive equipment. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs and IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 24 hours/day, 7 days/week, continuous by more than one person are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cough, Diarrhea, Muscle Aches, Fever and Headache
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a female with a history including asthma. She presented to the ED (emergency department) complaining of cough productive of green sputum, headache, diarrhea, and muscle aches.

The patient was positive for COVID.  Her vital signs were as follows: Temperature 99.1, pulse 98, respiration rate 18, blood pressure 116/78, oxygen saturation 99% RA (room air). Her exam was unremarkable. Her chest x-ray revealed NAD (no active disease). Her EKG (electrocardiogram) revealed NSR (normal sinus rhythm). Her labs were remarkable for abnormal WBC (white blood count) of 3.9.

The patient was admitted with COVID pneumonia.  Plan of care included IV (intravenous) antibiotics.

On day two, the patient's vital signs were stable, and the patient was afebrile. The plan was to continue antibiotics.

On day three, ID (infectious diseases) consult recommended Regeneron and 5 days of antibiotics.  The patient's venous pH was 7.35.

On day six, Regeneron infusion was ordered.

No, the inpatient admission  was not medically necessary.
This patient was admitted with COVID pneumonia. Coverage for admission was denied due to failure to meet InterQual Acute Adult, Infection, COVID-19 criteria. Evaluation showed the patient was hemodynamically stable and afebrile. The patient did not have tachypnea. The patient had normal oxygenation. The patient did not have altered mental status. Chest x-ray was normal. Electrolytes and renal function were unremarkable. She did not have active comorbid conditions. The patient had not failed a lesser level of care. The patient remained clinically stable during hospital stay.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rapid heartbeat
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld.

This patient is a male for which an inpatient level hospitalization is under review. There was no past medical history. The patient presented with a rapid heartbeat. A heart rate was elevated. The blood pressure was mildly elevated. The oxygen saturation was normal. He was in no apparent distress. A D-Dimer was negative. Electrolytes were normal. He was diagnosed with rapid atrial fibrillation. He was not high risk for stroke. He was started on an amiodarone infusion and administered an oral beta blocker. He converted to sinus rhythm. He was started on oral amiodarone and anticoagulant.

No, the proposed inpatient admission was not medically necessary.
This patient presented with atrial fibrillation with ultimately successful cardioversion . There was no myocardial infarct (MI), acute coronary syndrome, congestive heart failure (CHF), hemodynamic instability, need for prolonged intravenous medication, cerebral vascular accident (CVA), altered mental status, respiratory distress, recent thromboemboli, severe underlying structural heart disease, need for acute anticoagulation, introduction of high risk antiarrhythmic medication requiring in hospital monitoring, need for ongoing oxygen support, severe electrolyte abnormality, or a recurrent unstable arrhythmia. In the setting of this case an acute inpatient level hospitalization, compared to a lower level of care, has not been established as standard of care towards improved cardiac outcomes. It is therefore considered not medically necessary in this case.

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Tooth Agenesis 
Treatment: Implants for teeth #3, #7, #8, #9, #10, #14, #18, #19, #20, #30 and #31 

The insurer denied coverage for implants for teeth #3, #7, #8, #9, #10, #14, #18, #19, #20, #30 and #31. 

The denial is upheld. 

Based on review of the submitted documentation which includes copy of panoramic radiograph, dental treatment note, in addition to insurer correspondence, it appears that this patient presented for dental evaluation and treatment and discussion regarding prosthetic rehabilitation for the maxilla and mandible. The dentist recommended endosteal implants in areas as enumerated above. The dentist is requesting implants over removable partial dentures presumably due to the patient's reported dysphagia and nausea. The insurer has denied the services stating that in their estimation endosteal implants are not the only appropriate treatment, and implant services are only covered when there is a documented medical condition that will be alleviated by the implants. The insurer states that the medical records received do not demonstrate such a condition and therefore the endosteal implants and related services are considered not medically necessary, considered elective and therefore no benefit is available. 

Upon review of the objective documentation which primarily consists of the panoramic radiograph, the patient exhibits oligodontia in both the maxilla and mandible. As regards endosteal implant placement, although implants are an acceptable treatment restore edentulous spaces, an accepted standard of care in dentistry is not exclusively endosteal implants. Alternative appropriate treatment would include conventional removable dentures. Further, the documentation provided does not support, justify, or substantiate the requested treatment. Therefore, as removable dentures remain a standard of care in general dental practice, and the medical documentation does not indicate a specific limitation precluding use of partial dentures aside from self-reported difficulty, the endosteal implants are considered elective and not medically necessary. 

Uphold denial of coverage for dental implants as not medically necessary, as an appropriate alternative standard of care treatment would be conventional removable dentures and the medical documentation provided does not substantiate a limitation that would preclude the patient using removable partial dentures. Therefore, as other acceptable alternative treatments are appropriate and the documentation provided does not support the recommended treatment this renders the endosteal implants and associated services not medically necessary. The health plan has acted reasonably, with sound medical judgment, and in the best interest of the patient. 

Based on the above, the medical necessity for the implants for teeth # (number) 3, #7, #8, #9, #10, #14, #18, #19, #20, #30 and #31 is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scalp Laceration (deep cut or tear from a gunshot wound).
Treatment: Inpatient admission.

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

Scalp Laceration (deep cut or tear from a gunshot wound) that grazed the scalp but did not penetrate the skull. There was no loss of consciousness or changes in mental status.

No, the acute inpatient stay was not medically necessary.

As per the submitted medical records: Acute Admission was denied and Observation Care could be approved.

As per the MCG (Milliman Clinical Guidelines) National Criteria for Trauma:
Hospital admission is indicated when patient with significant multiple trauma requires inpatient care for 1 or more of the following:  1) Major surgical and postprocedural care, or 2) Nonoperative care of significant injury.  Neither Criteria was met.

This patient was struck in the right parietal frontal area with no other injuries, including no loss of consciousness or change in mental status.  A CT (Computed tomography) scan showed laceration in the area without penetration of the skull or brain injury. It was concluded that while being shot can be psychologically traumatic: This all could have been managed as Trauma Observation Care for really only neurological monitoring was needed which again did not need an acute Observation Care. The need for Neurologic Monitoring can be an accepted indication for overnight Observation Care.

Yes, the health plan did act reasonably, with sound medical judgment and in the best interest of the patient in order to provide safe, effective, and efficient medical care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse/Addiction. 
Treatment: 9 units of inpatient detoxification treatment. 

The insurer denied 9 units of inpatient detoxification treatment. The denial is overturned.

The patient is a male who was admitted on following an emergency department evaluation and medical screening with referral for acute inpatient level services for detoxification and withdrawal management of severe alcohol use disorder and comorbid cannabis use disorder. The patient was using up to two pints of vodka daily together with intermittent use of marijuana. He had a longstanding history of alcohol use beginning as a young boy with progression of the disease and escalating use of alcohol following the death of his wife five years prior to admission with complicated conjugal bereavement and multiple psychosocial stressors.

The health plan's determination is overturned in whole.

Yes, the requested health service/treatment of 9 units of inpatient detoxification treatment is medically necessary for this patient; the requested health service/treatment, admission and continued Medically Supervised Inpatient Detoxification, Withdrawal Management, and Stabilization Services for the entire stay through discharge, is medically necessary and was warranted.

The proposed inpatient services and detoxification treatment and withdrawal management for severe alcohol use disorder and other services noted in the clinical summary could not have been safely and effectively provided at a lower level of care. The inpatient treatment of this patient's substance use disorders did require the admission and the continued structure of an inpatient level setting and 24-hour monitoring in view of the severity of the alcohol use disorder, and the presentation with moderately severe withdrawal symptoms that persisted together with intense craving and high risk for an against medical advice (AMA) discharge. Withdrawal symptoms were managed with tapering dosages of benzodiazepine/Valium requiring monitoring, as well as comfort medications and vitamin replacement therapy. The patient's treatment for bipolar disorder and seizure prophylaxis was provided with appropriate monitoring consistent with the appeal and with New York State Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3 Criteria. Thus, the patient did require a safe and effective detoxification with withdrawal management during the time frame under review, as it was reasonable that the patient would have been unable to abstain from the substances of abuse if detoxification and treatment were to be attempted at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rapid Atrial Fibrillation

Treatment: Full hospital admission

The insurer denied coverage for full hospital admission.

The denial is upheld.

The patient was brought to the Emergency Department (ED) by Emergency Medical Services (EMS) with complaint of sudden onset of midsternal chest pain, palpitations and shortness of breath while at rest. He reported being more stressed given the recent death of his brother who died from massive myocardial infarction (MI). EMS administered IV (intravenous) fluids, oxygen, Nitro 0.04 mg (milligrams) x (times) 2, and aspirin (ASA) 325 mg. The patient's past history included hypertension, hyperlipidemia, atrial fibrillation with prior ablation (3.5 years earlier), multiple cardioversions, and obesity. An echocardiogram was said to be unremarkable. Outpatient medications included enteric-coated aspirin, amlodipine, olmesartan, atorvastatin, pantoprazole, diclofenac, and glucosamine. 

In the ED, blood pressure was 116/109, heart rate varied from 100-150 beats per minute (bpm) and respiratory rate was 20/min. Electrocardiogram (EKG) noted atrial fibrillation with rapid ventricular response at 143 bpm, incomplete right bundle branch block, and ST (interval on EKG) depression V3-V6 (precordial leads). Chest X-Ray was unremarkable. Treatment included Cardizem 20 mg IV bolus, IV normal saline (NS) 500 ml (milliliter) bolus and Cardizem 30 mg IV bolus followed by Cardizem drip. 

The patient was admitted formally to telemetry in Atrial Fibrillation with rapid ventricular response (RVR) (120's-130's). Cardizem drip was continued. Recommendations included aspirin (ASA) 81 milligrams (mg) QD [daily], Sotalol 80 mg q [every] 12h [hour] and cardioversion. A DCCV [Direct Current cardioversion] with 200 J [joules]x1 was performed with conversion to sinus rhythm. Post-procedure EKG showed sinus rhythm. He was discharged on Betapace 80 mg BID [twice daily].  

The health care plan acted reasonably, with sound medical judgment, and in the best interest of the patient. The inpatient stay was not medically necessary. The patient had rapid atrial fibrillation which required urgent treatment. The patient did require prolonged treatment including a cardizem drip. Further, it was reasonable to perform a cardioversion. As such, the patient needed to be in a monitored setting for some time but this could have been performed in observation status with the idea that conversion of the atrial fibrillation would occur within a short period, i.e. (that is) less than 24 hours. The patient was hemodynamically stable so there was no reason that full inpatient admission was medically necessary.

As noted above, prolonged care and monitoring were necessary for this patient but these approaches could have been performed on an observation status and full admission was not medically necessary.

Based on the above, the medical necessity for the full hospital admission is not substantiated. The insurer's denial is upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic Low back Pain. 
Treatment: 22899, unlisted procedure, spine. 

The insurer denied coverage for 22899, unlisted procedure, spine.  The denial is upheld. 

This patient has chronic low back pain. She had a laminectomy at L(lumbar)2-L3. She has tried Chiropractic care, Physical therapy, Home Exercise, Epidural Steroid Injections, and Medial Branch Blocks. She has tried medication management with Flexeril, Sertraline, Aspirin, Gabapentin, Oxycodone and Lidocaine patches. Her Magnetic resonance imaging (MRI) shows Modic Type 1 changes at L3-L4.  The request is for radiofrequency ablation (RFA) of the Basivertebral nerves at L3 and L4. 

Fischgrund and colleagues (1) published a double-blind, sham controlled RCT [randomized control trial] evaluating the Intracept system and RFA of the Basivertebral nerve for the treatment of chronic low back pain. A total of 225 participants with chronic (>= 6 months) isolated lumbar pain who had not responded to at least 6 months of non-operative management were randomized to either a sham (n=78) or treatment (n=147) intervention. In the active treatment group, the RF probe was activated and the temperature at the tip was maintained at 85 Celsius for 15 minutes. The duration of the session in the sham group was the same but the RF treatment was only simulated. Study participants had a minimum Owestry disability index (ODI) of 30 points (on 100-point scale) and a minimum VAS [visual analog scale] of 4 cm (centimeters) (10 cm scale). The primary efficacy endpoint was the comparative change in ODI from baseline to 3 months. Both intention-to-treat (ITT) and per protocol (PP) analysis were pre-planned. A total of 19 of 147 (13% [percent]) participants in the treatment group were excluded from the PP analysis; 16 for a targeting failure, 1 for procedural failure and 2 for protocol non-compliance. One participant in the sham group was excluded from the PP analysis and this was for protocol non-compliance. 

In sum, The Intracept procedure publications to date have been company sponsored and had methodology flaws.  There is no published data on long term complication rates.  UpToDate (3) has evaluated this procedure and concluded that it is still unproven.  There are other evidence- based interventions available to this patient.  This procedure is unlikely to be more beneficial than the standard approaches. The increased risks over other standard procedures have yet to be determined. 

The carrier's denial of 22899, unlisted procedure, spine should be upheld.