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

Central Nervous System
Home health care

Diagnosis: Parkinson's
Treatment: home health care
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift), Total Amount of 168 Hours per Week.
The health plan's determination is overturned. 

The patient is a female with medical history notable for Parkinson's disease, bed bound status, and incontinence of bladder and bowel. The patient and her care team requested Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift), Total Amount of 168 Hours per Week.

The requested health service of Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift), Total Amount of 168 Hours per Week is medically necessary for this patient.

The patient has advanced dementia, Parkinson's disease, and is fully incontinent of both bowel and bladder. She is unable to direct her own care. She requires frequent diaper changes throughout the day and night. She requires frequent position changes secondary to bradykinesia which is associated with Parkinson's disease. Her conditions are expected to be continuous and unscheduled throughout the day and night. A night-time live-in personal care aide would not be able to receive sufficient rest, as she requires frequent diaper changes in turning and repositioning at night. She has been receiving informal support from her son, but he is no longer able to continue to provide this for her. Therefore, the requested increase to 24 hour split shift care for a total of 168 hours per week is medically necessary for the patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease
Treatment: Personal Care Services (PCS) 24 hours/day, 7 days/week (split shift)
The insurer denied: PCS 24 hours/day, 7 days/week (split shift)
The denial is overturned.

The patient is an elderly male. He has a relevant medical history of Parkinson's disease and recent hospitalization after a fall. Denial of personal care services (PCS) 24 hours/day, 7 days/week (split shift) is being appealed. The health plan approved PCS 7 hours/day, 4 days/week and 6 hours/day, 3 days/week.

The patient's Uniform Assessment System (UAS) evaluation completed 2 months ago shows he needs assistance with all ADLs (activities of daily living). He has bladder incontinence. He has frequent incontinence.

Appeal statements report that the patient does not have accommodations for live-in, and that his mobility and strength have decreased. He needs assistance with all ADLs. He cannot move his extremities for proper alignment and comfort.

A letter from the patient's provider reports that the patient has advanced Parkinson's disease. He has significant limitations in mobility. His on-periods last no more than 2 hours. He has frequent falls and is unable to transfer without assistance. He needs assistance with ADLs. He has no informal support.

The requested health service is medically necessary.

Live-in 24-hour personal care workers provide one-on-one care for individuals with stable chronic conditions that need daily assistance with ADLs, including toileting, walking, transfers, turning/positioning, and feeding. Continuous or split shift PCS is uninterrupted care, by more than one personal care aide, for more than 16 hours in a calendar day for an individual that needs assistance with toileting, walking, transferring, turning, or positioning; the frequency of care would be unlikely to give the aide five hours daily of uninterrupted sleep during the aide's shift. Denial of PCS 24 hours/day, 7 days/week (split shift) is being appealed. The health plan approved PCS 7 hours/day, 4 days/week and 6 hours/day, 3 days/week.

This patient has advanced Parkinson's disease with frequent falls. He was recently hospitalized after a fall. He has no informal support. UAS evaluation completed 2 months ago showed the patient requires assistance with all ADLs. He is incontinent of bladder. The appeal statements support the patient is dependent with all ADLs and requires frequent assistance with transfers and turning/repositioning. Due to the patient's lower extremity weakness and as a result of the patient's Parkinson's, he has prolonged periods of immobility resulting in inability to position himself. These periods are unpredictable and can occur during day and nighttime, resulting in need for frequent assistance with transfers and repositioning/turning. This patient has continuous needs that will not give the aide five hours daily of uninterrupted sleep during the aide's shift. The currently approved PCS is insufficient to meet this patient's needs for assistance with ADLs. The requested increase to 24 hours/day, 7 days/week (split shift) is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Open wounds, purulent drainage over implantable cardioverter defibrillator (ICD) pulse generator pocket
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient who presented to the emergency department (ED) complaining of open wounds with purulent drainage over his implantable cardioverter defibrillator (ICD) pulse generator pocket. Portions of the ICD system were visible in the wounds. He had first noticed the wounds and device erosion approximately one month prior; the wounds had been draining for approximately one week. His medical history was remarkable for nonischemic cardiomyopathy, heart failure with reduced ejection fraction, diabetes, chronic kidney disease, hypertension, hyperlipidemia and longstanding persistent atrial fibrillation.There were two large open wounds over the ICD pulse generator pocket; the ICD pulse generator and the proximal portion of one of the leads were visible. A chest x-ray showed cardiomegaly and pulmonary venous congestion; four ICD leads were visible, one of which was fractured. The patient was treated with intravenous antibiotics and was admitted to the hospital. He was transferred to another institution under the care of the physician who had previously implanted his ICD. The medical necessity for an inpatient admission is at issue.
Based on the documentation provided, an inpatient level of care was not medically necessary.
This patient presented with infection and erosion of his implantable cardioverter defibrillator. He was afebrile and hemodynamically stable, without evidence of systemic inflammatory response syndrome or sepsis. Treatment in this situation involves removal of the pulse generator and lead extraction, with a prolonged course of antibiotics. While admission for intravenous antibiotics pending transfer to another facility was appropriate, the patient did not require an inpatient level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Obesity.
Treatment: Wegovy.
The insurer denied Wegovy.
The determination is overturned.

The patient is being prescribed Wegovy auto-injectors for the diagnosis of obesity. Coverage for this medication was denied by the health plan.
The patient is currently being treated with the requested medication; she has titrated up to the 1 milligram (mg) per week dose, and the prescriber is requesting an increase to 1.7 milligrams (mg). This medication is not being requested in conjunction with any other weight loss treatments. The patient's current body mass index (BMI) is 34.14 The patient's other medical conditions include polycystic ovary syndrome (PCOS), migraines, irritable bowel syndrome, hyperlipidemia, bipolar disorder, asthma, and anxiety.
The health plan denied coverage for the requested medication. Medications for weight reduction are among the general exclusions from coverage under the terms of the health plan. Because it is not a covered benefit, there were no formulary alternatives available to the patient. At issue is whether the non-formulary drug being denied is clinically appropriate for the patient's condition.

The patient is being treated for obesity. Weight loss is recommended for patients with obesity as it has been associated with favorable health and metabolic outcomes. The requested medication, Wegovy, is an appropriate treatment for the patient's diagnosis of obesity. It is Food and Drug Administration (FDA) approved as a pharmacologic agent to promote weight loss as part of a comprehensive weight loss plan.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Asthma, Wheezing
Treatment: Inpatient Hospital Stay
The insurer denied the Inpatient Hospital Stay.
The determination is overturned.

The patient is a male child born prematurely at with a medical history significant for chronic lung disease, asthma, history of multiple emergency department (ED) visits and Pediatric Intensive Care Unit (PICU) admissions including intubation, on preventive medications, who was taken to the emergency department (ED) via Emergency Medical Services (EMS) with a two-day history of a non-productive cough, runny nose, nasal congestion, and one-day history of wheezing treated with two cycles of nebulized albuterol. 
A chest x-ray was obtained and was unremarkable by formal read.  He was given a normal saline bolus and magnesium as well as DuoNeb and Decadron. Upon re-evaluation, he remained tachypneic. He was admitted for further care of a viral respiratory infection and acute asthma exacerbation. Admission orders included continuous cardiorespiratory monitoring, regular pediatric diet, maintenance intravenous (IV) fluids, nebulized albuterol every three hours, and oral corticosteroids.
Following admission, he demonstrated increased distress prompting transfer to the PICU where he was treated with albuterol every two hours. By hospital day three, he was able to transition to treatments every three hours. A pulmonary consultation was obtained, affirming his home medication regimen. They also reviewed correct technique for medication administration. Outpatient follow-up was recommended. He was subsequently deemed stable for discharge home. At issue is the medical necessity of an inpatient stay.

The requested inpatient hospital admission was medically necessary and appropriate for this child.
This young child born prematurely with chronic lung disease and asthma presented with increased work of breathing in the setting of a viral respiratory illness. He had history of multiple visits to the ED, PICU admissions, and an episode requiring intubation. He initially responded to aggressive management in the ED enough to be admitted to the general pediatric ward. His symptoms continued to worsen, requiring transfer to the PICU for ongoing care and more frequent breathing treatments. He remained on albuterol every two hours from the day of admission until the third hospital day. This level of care is most consistent with acute inpatient management.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: ADHD (attention deficit hyperactivity disorder). 
Treatment: Concerta [methylphenidate ER (extended release) Osmotic Release]. 
The insurer denied the Concerta (methylphenidate ER Osmotic Release). 
The denial is upheld. 

The patient is an adult male diagnosed with attention deficit hyperactivity disorder (ADHD), inattentive type. The patient has been prescribed Brand Concerta (methylphenidate extended release) to address the symptoms of ADHD (attention deficit hyperactivity disorder). The physician correspondence indicates that the patient has failed a trial with amphetamine-dextroamphetamine extended-release formulation. There is no co-occurring substance use disorder or other co-morbid conditions mentioned in this case, and no report of significant general medical issues. The health plan has denied coverage for Brand Concerta based on plan guidelines that require treatment failure or contraindications for use of formulary alternatives that includes the generic formulation of Concerta, as well as dextroamphetamine-amphetamine mixed salts extended release; dextroamphetamine extended release; Vyvanse; and Azstarys. Note: the generic formulation of Concerta is methylphenidate extended-release. The denial determination references that plan's Certificate of Coverage and Prescription Drug Coverage.
The patient's clinician has requested approval for the Brand Concerta with the submitted prior authorization questionnaire indicating that formulary alternatives are contraindicated in this case. The appeal does not indicate that the patient has tried or failed treatment with the generic formulation of Concerta (methylphenidate extended-release tablet) and has not had a failed a trial due to lack or efficacy or adverse effects with other available generic alternatives other than dextroamphetamine-amphetamine mixed salts extended-release formulation which was tried and failed due to lack of effect. 

The health plan should not cover the formulary exception for Concerta. 

The formulary contains multiple agents that have proven to be effective in treating ADHD (attention deficit hyperactivity disorder). Formulary alternatives potentially include dextroamphetamine-amphetamine mixed salts extended-release formulation, dextroamphetamine extended-release formulation, Vyvanse, Azstarys, and the generic formulation of Concerta, methylphenidate extended-release. Other than dextroamphetamine-amphetamine mixed salts, the alternative formulary agents would be reasonably expected to be as effective as the requested non-formulary drug Concerta, and would pose no greater risk for adverse effects for this patient. 
Clinical guidelines for the management of ADHD (attention deficit hyperactivity disorder) consistently recommend pharmacologic treatment and medications covered under the plan. Thus, per the New York State instruction for this review and in keeping with prevailing standards of care for the treatment of the condition diagnosed in this case, the health plan has reasonably denied coverage for the formulary exception for Brand Concerta.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Chronic Gastritis/Duodenitis

Treatment: 30 feeding therapy visits

The insurer denied coverage for 30 feeding therapy visits.

The denial is modified.

The patient is a child born prematurely with a past medical history of chronic gastritis/duodenitis, food refusal, autistic spectrum disorder, global developmental delay, lactose intolerance, oral sensory issues and feeding difficulties requiring dependency on gastrostomy tube feeding. The patient is currently able to tolerate 50% (percent) of goal intake of Pediasure with the rest delivered via gravity feed via the gastrostomy tube (GT). The patient can self-feed high calorie liquids only but requires coaching/prompting. 

To address these needs, the patient was admitted to the feeding program virtually x (times) 30 visits. The patient's care was transitioned to twice weekly virtual sessions.

The patient showed progress with both the short and long-term goals established by the multidisciplinary feeding team with most goals attained by the discharge date. An additional 10 follow-up sessions were approved to ensure continued progress at home. 

Weight before, during and after the feeding therapies were documented as follows: 28.304 kilograms, 30.209 kilograms and 28.213 kilograms (home scale).

The insurer has denied coverage for additional 30 Feeding Therapy visits citing Centene Clinical Policy: Pediatric Oral Function Therapy CP.MP.188 criteria but approved 10 additional sessions.

The treating team is appealing for the full 30 visits.

The questions for review are the appropriateness of the denial and whether feeding therapy is medically necessary for this patient.

This patient's failure to thrive is certainly related to many of the above factors. It would be expected that with a structured feeding program, the patient would expand the variety of foods that they will accept and be able to take adequate intake to achieve a reduced dependence on GT feeds. In fact, the patient had progressed sufficiently during their time receiving therapy.

This child has documented weight loss since completing the more frequent feeding program visits (albeit on a different scale). This is somewhat surprising since the patient's total calorie intake should be achieved using their GT feeds to supplement any oral intake. The patient's diagnosis of autistic spectrum disorder and sensory/behavioral issues are playing a part in their marginal oral nutritional progress. The request for additional feeding therapy visits to reach the goals outlined by the feeding team is warranted and reasonable. However, starting with 20 additional feeding therapy visits is both medically necessary and in the best interest of the patient. 

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 medical necessity for 30 feeding therapy visits is not substantiated. However, 20 additional feeding therapy visits are both medically necessary and in the best interest of the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hemiplegia and hemiparesis following cerebral infarction. 
Treatment: Increase in Consumer Directed Personal Assistance Program (CDPAP) services to a split shift, for a total amount of 168 hours per week. 
The insurer denied coverage for increase in Consumer Directed Personal Assistance Program (CDPAP) services to a split shift, for a total amount of 168 hours per week. 
The denial is upheld. 

 This case involves an elderly male under review for the coverage of Consumer Directed Personal Assistance Program (CDPAP) services to a split shift, for a total amount of 168 hours per week. 

This case involves an elderly male with significant history of Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side with motor deficits, gait, and balance problems. The patient's doctors stated that since the stroke the patient has left sided weakness. In the recent Uniform Assessment System (UAS) comprehensive assessment was noted that the patient is totally dependent on housework, he requires maximal assistance in meal preparation, managing finances, managing medications, phone use, and shopping. The patient requires maximal assistance in all his activities of daily living (ADL) such as bathing, personal hygiene, upper/lower body dressing, locomotion, toilet transfer, toileting and requires limited assistance/physical guidance in eating. The patient's providers are recommending for 24hours/day x 7days/week of Consumer Directed Personal Assistance Program (CDPAP) services to a split shift, for total of 168 hours per week. Based on the UAS-NY (New York) assessment current approved CDPAP hours are sufficient to meet the member's needs. The patient has been attended to for 13 hours/day. The patient lives with his son who is very supportive and involved in the member's care with ADLs/instrumental activities of daily living (IADLs) and doctor appointments. The patient has a Personal Emergency Response System (PERS) that he can use in case of an emergency. The patient is currently receiving Consumer Directed Personal Assistance Program (CDPAP) services of Live-in per diem, 7 days per week (13 hours/day) for a total of 91 hours/week. The son can help the member when the caregiver is not present. The clinical information submitted for review has not established the necessity for the requested services of 24 hours/day x7 days/week (split shift). 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for an increase in Consumer Directed Personal Assistance Program (CDPAP) services to a split shift, for a total amount of 168 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Scheduled heart valve repair procedure
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld.

This patient is an adult female with elective admission for mitral valvuloplasty for mitral stenosis. Comorbidities include human immunodeficiency virus (HIV), cerebral vascular accident (CVA), pulmonary emboli on blood thinners, seizure disorder, tricuspid regurgitation, and symptomatic mitral stenosis. The mitral valvuloplasty was uncomplicated. The patient was observed overnight and discharged the next day. Admission was denied as not medically necessary.

The requested health service was not medically necessary.

Determination of level of care is primarily dependent on the actual care a patient receives and whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. In this case, the elective procedure was uncomplicated, and the patient was admitted for observation. She was asymptomatic and hemodynamically stable throughout. No added intervention was necessary. The letter of appeal was carefully considered, but it offered no evidence to support inpatient level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. Tests showed absence of ischemia. While there is always a potential for an adverse event, one did not happen, and no actual treatment was added. Milliman criteria requirements were not fulfilled as this was an elective percutaneous procedure that did not require any therapy that could not be safely performed in a lower level of care. All testing and therapy would be appropriate, safe, and guidelines-consistent to be in a lower level of care. Thus, inpatient level of care was not medically necessary. The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Obesity and pre-diabetes.

Treatment: Wegovy 2.4 mg/0.75 ml, pen injectors.

The insurer denied coverage for Wegovy 2.4 mg/0.75 ml, pen injectors.

The denial is upheld.

This is a patient diagnosed with obesity. This request is for Wegovy. As per the visit note, the patient had pre-diabetes with a hemoglobin A1C of 5.4%, dyslipidemia, obstructive sleep apnea (OSA), and hypertension (HTN). The patient is on Ozempic 2 milligrams (mg) weekly. The patient is noticing with Ozempic some stomach cramps and loose stools. 

The patient's starting weight was 293 pounds (lbs.). On subsequent visits, the patient's weights and body mass index (BMI) were: 262.4 lbs., BMI 33.7; 262.8 lbs., BMI 33.7; and most recently, 258 lbs., BMI 33.1. 

Semaglutide is a glucagon-like peptide 1 receptor (GLP1R) agonist that is approved by Food and Drug Administration (FDA) in treating type II diabetes and obesity. Recent studies published in major peer-reviewed medical journals have shown safety and efficacy of semaglutide for the treatment of obesity. This medication is now available for treating obesity in the form of Wegovy. The standard of care based on multiple societal guidelines requires that the patient participate in lifestyle modification. It also requires that the patient has a BMI of 30 or greater or a BMI of 27 or greater with comorbidities such as hypertension and hyperlipidemia. 

The patient had a BMI of 33.1 recently; however, there is no documentation of participation in lifestyle modifications. 

Based on the above, the insurer's denial must be upheld. The health care plan acted reasonably and with sound medical judgment and in the patient's best interest. The medical necessity for Wegovy 2.4 milligrams (mg)/0.75 milliliters (ml), pen injectors services is not substantiated.