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

Diagnosis: Down syndrome
Treatment: codes 97112 therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities; 97530 therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes: 97110, therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
The insurer denied coverage for codes 97112, 97530 and 97110
The denial is upheld.

The patient is a child with a diagnosis of Down syndrome. The occupational therapy (OT) notes at the time of service were inadequate and do not support medical necessity. The OT treatment notes are hand written, poorly legible and provide insufficient objective clinical information to support the medical necessity of the provided therapy for the treatment dates under review. There is no concurrent comprehensive initial evaluation, plan of care or specific treatment goals. The therapy treatment notes fail to provide evidence of significant improvement to support the medical necessity of continuing a structured outpatient therapy program. Quantitative measures of improvement (e.g., balance, motor strength, functional ability) are not specifically documented. The medical records at the time of treatment do not provide clinical evidence that the treatment was restorative. The lack of documented improvement is consistent with maintenance treatment and does not support the medical necessity of OT for the dates under review.  
	
Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations. All decisions are evidence-based.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, OT services were not medically necessary. 
 
The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.

The insurer's denial of coverage for the codes 97112 therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities; 97530 therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes: 97110, therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.
Treatment: Inpatient Hospital Admission.
The insurer denied: Inpatient Hospital Admission.
The denial is upheld.

The patient is an adult female with history of hypothyroidism and breast cancer. She was seen at an outside hospital with perforated appendicitis. She was tachycardic on admission, but her blood pressure was normal. Her WBC (white blood count) was 8. She underwent laparoscopic appendectomy with area of perforation. She was admitted and discharged two days later.

The Inpatient Hospital Admission was not medically necessary.

The patient had perforated appendicitis. Post-operatively, she had tachycardia. The patient's tachycardia improved, she tolerated a diet and was discharged home. Per the MCG (Milliman Care Guidelines) guidelines, for patients with localized perforation, the goal length of stay is ambulatory status and in two days. This patient did not have any major medical co-morbidities that needed inpatient admission. The patient also tolerated diet one day afterwards and was discharged. Given the records, the patient's inpatient admission is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Vitilgo
Treatment: Opzelura
The insurer denied Opzelura.
The determination is upheld

This is a male patient with vitiligo. His genitalia and trunk are affected. He has tried and failed topical pimecrolimus. The prescriber is a dermatologist. The medication under review is Opzelura.

The formulary drug tacrolimus would not be ineffective, would not be as effective as the non-formulary drug Opzelura, and would not have adverse effects.
There is no documentation provided that the patient has tried and failed the conventional therapies for vilitigo, such as the calcineurin inhibitor topical tacrolimus (1). Lee et al writes "In this meta-analysis of 46 studies including 1499 patients, topical calcineurin inhibitor monotherapy produced an at least mild response in 55.0%(percent) of the patients, at least moderate response in 38.5 percent (%), and a marked response in 18.1% after a median treatment duration of 3 months. ...Topical calcineurin inhibitors appear to have significant therapeutic effects on vitiligo and it seems that their use should be encouraged in patients with vitiligo" (2). Seneschal writes in "Efficacy and Safety of Tacrolimus 0.1% for the Treatment of Facial Vitiligo: A Multicenter Randomized, Double-Blinded, Vehicle-Controlled Study" that "Results. A total of 42 patients were included. Therapeutic success was achieved in 65% of tacrolimus-treated patients versus 0% of vehicle-treated patients at week 24 (probability [P] less than [<] 0.0001). Only 40% of relapse was observed at 48 weeks. Conclusions and Relevance: Twice-daily tacrolimus 0.1% ointment showed superior efficacy to that of the vehicle through the 24 weeks of intervention and 24 weeks of follow-up in adult patients with facial vitiligo" (3). Calcineurin inhibitors such as tacrolimus ointment are a first-line treatment for vitiligo and should be tried and failed prior to initiating Opzelura (1-4).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: dementia, congestive heart failure, atrial fibrillation.

Treatment for patient care assistance (PCA) services 2-12-hour split shift, 7 days a week.

The insurer denied coverage for patient care assistance (PCA) services 2-12-hour split shift, 7 days a week.

The denial is overturned.

 
This is an elderly patient with congestive heart failure, atrial fibrillation and dementia.  The insurer approved PCA live-in services, 7 days/week and the request is for patient care assistance (PCA) services 2-12 hour split shift, 7 days a week, which is under review.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is "Minimally impaired."  However, she is totally dependent for bathing, personal hygiene, dressing, locomotion, ambulation and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel.  Extensive assistance is needed for bed mobility and eating.  Instrumental activities of daily living (IADL) also range from total dependence to extensive assistance.  She has had several falls in the past resulting in rib fracture and hospitalization.   She has a healing decubitus ulcer. The patient's medical condition: essentially total dependence for most of her IADL and activities of daily living (ADL) tasks are at a level or unpredictable as to require the requested PCA services 24 hours/day, 7 days/week (split shift).  Based on the records reviewed, the currently approved live-in PCA is unlikely capable of providing for the patient's functional needs while having the ability to consistently obtain uninterrupted 5 hours of sleep. The patient is at particularly high risk for additional falls, severe hemorrhage and sustaining multiple fractures due to her balance deficits and anti-coagulation for atrial fibrillation. Bed repositioning approximately every 2 hours is also necessary to prevent further decubitus ulcers. The patient's health and safety are more appropriately provided and maintained at home with the requested PCA services 24 hours/day, 7 days/week split shift.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for additional patient care assistance (PCA) services 2-12-hour split shift, 7 days a week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis.
Treatment is an inpatient admission.
The insurer denied an inpatient admission.
The insurer's denial is overturned. 

This is an adolescent with a history of type 1 diabetes. The patient presented to the emergency room (ER) with complaints of chest tightness and difficulty breathing. The patient is noncompliant with the home insulin regimen. The blood glucose level was 573. The patient was admitted to the Pediatric Intensive Care Unit (PICU) with diabetic ketoacidosis (DKA). The patient was started on intravenous (IV) fluids and IV insulin. The patient's condition improved after treatment, and he was discharged.

Hospitalization for DKA is universally medically necessary. Patients with diabetes and diabetic ketoacidosis (DKA) initially generally require ICU (intensive care unit) level care until they are converted to subcutaneous insulin and have closed their anion gaps and have no other conditions requiring ICU level care.  Most hospitals admit patients with DKA to the ICU due to rules regarding level of service with every 1-hour blood draws and nursing rules. The patient was admitted for treatment of diabetic ketoacidosis. The patient had hyperglycemia, ketosis, and acidosis after malfunction of the insulin pump. The patient was treated for diabetic ketoacidosis with an insulin infusion. The request for acute inpatient hospitalization is consistent with generally accepted standards of medical practice and is therefore medically necessary.

The hospital admission is considered medically necessary for this patient.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for the hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Appendicitis.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.


This patient presented to the emergency department with right lower quadrant pain. The patient had some associated nausea and vomiting. His vital signs were within normal limits. He had tenderness at McBurney's point on abdominal exam. The white blood cell count (WBC) was 16.8. A computed tomography (CT) scan of the abdomen and pelvis demonstrated findings concerning for acute appendicitis. The patient was hospitalized and underwent a laparoscopic appendectomy later that day. The surgery was without complications. The patient seen on postoperative day number 0. He was doing well and was started on regular diet. He was discharged home on postoperative day number (#) 1
At issue is the medical necessity of an inpatient stay.

Inpatient medical stay was not medically necessary. The patient could have been safely managed at a lower level of care.
The patient easily met discharge status criteria, did not experience complicated appendicitis and did not have clinically active comorbidities. The patient was hospitalized and underwent a laparoscopic appendectomy later that day. The surgery was without complications. The patient did not experience complications of wound dehiscence, wound infection, or enterocutaneous fistula and he did not experience an ileus. The patient did not experience postoperative bleeding or complications or conditions such as anemia, arrhythmia, electrolyte disorder, fever, gastrointestinal (GI) bleed, hyperglycemia or complicated diabetes control, mental status change, psychiatric disorders, respiratory insufficiency, urinary complications, thrombotic complications or wound and skin care complications. There is no evidence that a complicating event occurred before, during, or after the procedure that required a higher level of care. There is no documentation that the treating team identified conditions or problems specific to the patient that would have required inpatient care. The patient did not have significant dehydration, hemodynamic instability, severe pain requiring frequent or high doses of narcotics, signs of intestinal obstruction, peritonitis, or bacteremia. The provided documentation does not support the medical necessity of inpatient level of care.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Blood test to measure level of the drug infliximab, Remicade and body's reaction to the drug (antibodies) 
The insurer denied Blood test to measure level of the drug infliximab, Remicade and body's reaction to the drug (antibodies) 
The determination is overturned.

This is a female patient with Crohn's disease. She started Remicade with 6-Mercaptopurine. She noted fecal incontinence after Remicade infusions; Imodium was recommended, and a lab test was ordered to assess for Remicade level and anti-Remicade antibodies. She had testing for Remicade level and anti-Remicade antibody levels. She presented on Remicade 5 milligrams per kilogram (mg/kg) every 8 weeks, with some fatigue, but no further loose bowel movements after infusions, and no abdominal pain, bleeding, fever, or unintentional weight loss. At issue is the whether the requested testing is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The use of Remicade drug level and anti-Remicade antibody level testing has demonstrated safety and efficacy. The patient was on Remicade (infliximab) at the standard dose for the treatment of Crohn's disease, and had symptoms consistent with uncontrolled disease (diarrhea with incontinence) [1]. In this case, Remicade level and anti-Remicade antibody level were checked after the patient had these findings. According to the American Gastroenterological Association (AGA) Guideline on Therapeutic Drug Monitoring in Inflammatory Bowel Disease, "In adults with active inflammatory bowel disease treated with anti-tumor necrosis factor agents, the AGA suggests reactive therapeutic drug monitoring to guide treatment changes" [2]. The guidelines states that "Based on the currently available evidence, the panel suggests target trough concentrations of 5 milligrams per milliliter (mg/mL) for infliximab" [2]. According to the AGA Clinical Care Pathway guidelines for the treatment of Crohn's disease, drug concentration and anti-drug antibody levels should be checked if there is a loss of response to an anti- tumor necrosis factor (TNF) medication such as Remicade, with a subsequent change in management (switch within drug class, assess for inflammation, or increase dose) [3]. American College of Gastroenterology guidelines for the management of Crohn's disease also recommend drug level testing, stating "If active Crohn's disease is documented, then assessment of biologic drug levels and antidrug antibodies (therapeutic drug monitoring) should be considered... recent guideline has suggested minimal "therapeutic" target trough levels" [4]. Current medical literature concurs [5]. For these reasons, the request for testing of Remicade drug level and anti-Remicade antibody level is likely to be more beneficial than any standard treatment or treatments for the insured's Crohn's disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Crohn's disease
Treatment: Blood test to measure level of the drug infliximab, Remicade and body's reaction to the drug (antibodies) 
The insurer denied Blood test to measure level of the drug infliximab, Remicade and body's reaction to the drug (antibodies) 
The determination is overturned.

This is a female patient diagnosed with terminal ileal Crohn's disease on a computed tomography (CT) scan. She had a normal magnetic resonance elastography (MRE) after diagnosis. She was placed on budesonide initially with good response. She started infliximab. She had a colonoscopy with mild ileal ulcerations, no colonic involvement (after infliximab level checked). She was also on 6-Mercaptopurine (MP) but somewhat non-compliant. She was doing very well (no abdominal pain or diarrhea) on infliximab with no side effects.

The patient's provider ordered an infliximab drug level. At issue is whether this is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Infliximab drug level and antibody testing can be performed on a reactive or proactive manner. Reactive means testing is done as a response to a patient who is experiencing a clinical deterioration while on infliximab. Results can help direct the clinician as to whether to increase the dose of the drug or possibly switch drug classes.

Proactive testing, as was done in this case, is performed when the patient is well. One is looking to determine if infliximab is under- or over-dosed and future infusion doses can be adjusted accordingly. There is now significant data from randomized trials to support a benefit in this approach. A recent Delphi study, interviewing topic experts (after exhaustive review of the medical literature) agreed that this approach is better than standard clinical management without drug level testing.[1]
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension

Treatment: Request for Formulary Exception for Nebivolol to treat hypertension

The insurer denied Formulary Exception for Nebivolol 

The denial is upheld.

This is an adult patient with a history of hypertension. The patient is treated with Irbesartan and Amlodipine. A letter is submitted by the patient's provider stating that the American Heart Association (AHA) Task force on clinical practice guidelines in hypertension has deemed formulary medications contraindicated including Carvedilol, Metoprolol, Propranolol, and Atenolol. The basis of this contraindication is the absence of specific cardiac morbidities. In fact, as discussed in Table 18 of reference 1, the comment refers to not using them as "first line agents". This does not apply in this patient already on 2 different drugs. 

The formulary drugs are not likely to cause an adverse reaction. The formulary drugs would be just as effective as Nebivolol in controlling the patient's blood pressure. This patient should be treated with Propranolol or Atenolol. The AHA guidelines do not state that these medications are contraindicated for treating hypertension. (Reference 1) Any of the formulary medications should be effective in treating hypertension. (Reference 2) In conclusion the formulary medications should be utilized in this case.

The formulary drugs are not expected to cause adverse effects. The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication. The formulary drug is not expected to be ineffective. The non formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of Request for Formulary Exception for Nebivolol to treat hypertension is upheld.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dementia, hypothyroid, osteoarthritis, anemia

Treatment: Consumer directed personal assistance services (CDPAS) 7 days per week, 24 hours per day, 168 hours per week services

The insurer denied coverage for CDPAS 7 days per week, 24 hours per day, 168 hours per week services

The denial is modified

This is a geriatric patient with chronic medical problems including dementia, hypothyroid, osteoarthritis and anemia. The patient lives alone in a private residence. The insurer approved CDPAS 4 hours per day, 7 days per week for a total of 28 hours per week and the request is for CDPAS 24 hours per day, 7 days per week for a total of 168 hours per week. 

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognition was described as "minimally impaired." The patient is totally dependent for much of the Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient requires extensive assistance for bathing and lower body dressing. Otherwise only limited assistance is needed for personal hygiene, upper body dressing, locomotion, ambulation, eating and toilet transfer and use. The patient is occasionally incontinent of bladder and continent of bowel. The patient is independent with bed mobility. There have been no falls over the prior 90 days. When compared to the previous UAS report, the patient's functional ability has only modestly declined. The patient's condition and functional needs are not at a level or unpredictable as to require the requested CDPAS 24 hours/day, 7 days/week. Based on the records reviewed, the patient's health and safety can be more appropriately provided and maintained at home with an increased CDPAS 8 hours/day, 7 days/week for a total of 56 hours/week. This physician would agree that the patient may require additional monitoring. However, safety monitoring under Personal Care Services (PCS) does not include monitoring an individual (with dementia) when no other Level I or Level II personal care services tasks are being provided. 

The healthcare plan did not act reasonably, with sound medical judgment or in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based. 

From a physical medicine and rehabilitation perspective, CDPAS, 24 hours/day (continuous care by more than 1 person) is not medically necessary. However, increasing CDPAS to 8 hours/day, 7 days/week (total 56 hours/week) is medically necessary. 

Based on the above, the insurer's denial must be modified. The health care plan acted reasonably in part. The medical necessity for CDPAS 7 days per week, 24 hours per day, 168 hours per week services is not substantiated. However, CDPAS of 8 hours/day, 7 days/week (total 56 hours/week) is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Gastroesophageal reflux disease
Treatment: Formulary exception for Dexilant
The insurer denied the formulary exception for Dexilant.
The denial is overturned.

The patient is an adult female with chronic gastroesophageal reflux disease (GERD) and cough related to GERD. She has failed pantoprazole, omeprazole and esomeprazole and has done well on Dexilant for the past 6 years. The physician (MD) is requesting continuation of Dexilant.

The health plan should cover the proposed formulary exception for Dexilant.

The patient has GERD with extra-esophageal manifestations of cough. The patient has already failed multiple formulary preferred agents to treat GERD and is doing well on Dexilant. Changing Dexilant to another generic proton pump inhibitor would be associated with an increased risk for recurrent GERD and recurrent cough, and therefore, continued use of Dexilant is clinically appropriate, accepted standard of medical care, and medically necessary.

This patient has failed pantoprazole, omeprazole, and esomeprazole and has done well on Dexilant for the past 6 years. As the patient has failed three preferred formulary alternatives, the health plan should cover the requested Dexilant.