Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned

The patient is a male with relapsed neuroblastoma. He was treated with standard of care therapy at diagnosis followed by appropriate salvage therapy. The provider is requesting approval of binemetinib therapy due to the patient's tumor having a NRAS mutation identified on molecular testing through Foundation One.

The health plan's determination is overturned. 

The proposed treatment with Mektovi is likely to be more beneficial than any standard treatment for this patient's life threatening disease.
Unfortunately, there are no standard treatments, nor any therapies thought to be curable for relapsed neuroblastoma. Treatment with MEK inhibitors, including binemetinib, has been beneficial in other malignancies. This is most commonly seen in melanoma, and there is extensive data showing clinical benefit for MEK inhibitors in melanoma with RAS pathway alterations. Unfortunately, this patient will most definitely succumb to his disease quickly without further therapy and there are no options outside of potentially an early phase trial. Should the drug be effective, it could be lifesaving or prolonging. If not, the treatment duration will be short-lived.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bilateral ATK amputations
Issue under review: Personal care aide 75 hours/week

Determination:
The Personal care aide 75 hours/week is medically necessary.

The patient is an elderly male with a history of bilateral above the knee amputations. For these reasons, he requires assistance with the majority of his activities of daily living (ADLs). Recent documentation from the patient's Primary Care Provider indicates that the patient requires frequent assistance with bed mobility, transfers and ambulation. For these reasons, the currently approved health of NY - Personal Care Aide Level II Basic per 15 minutes, 65 hrs/week is insufficient to meet the patient's needs. Hence, the proposed treatment of an increase in NY - Personal Care Aide Level II Basic per 15 minutes to 75 hours/week is deemed medically necessary to offer increased ADL assistance.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Pharmacy/Prescription Drugs

The patient is a man with hypertension and hyperlipidemia. In the past, he has been treated with amlodipine 2.5-5 milligrams (mg) daily, clonidine 0.1 mg twice daily, valsartan/HCTZ 160/25 mg daily, valsartan 320 mg daily, lisinopril/HCTZ 20/12.5 mg daily and labetalol 200 mg daily, with suboptimal blood pressure control. His blood pressure has been well controlled on Edarbyclor (azilsartan/chlorthalidone) 40/25 mg since 2017. Coverage for Edarbyclor is at issue.

The health plan's determination is upheld. Edarbyclor 40mg-25mg Tablet is not medically necessary for this patient. The formulary alternatives to Edarbyclor (azilsartan/chlorthalidone) include telmisaran, irbesartan, candesartan, olmesartan, losartan, and eprosartan, all of which would be taken in addition to chlorthalidone. It does not appear from the limited records provided that the patient has tried an ARB other than azilsartan in combination with chlorthalidone. While he has taken HCTZ (a diuretic like chlorthalidone) in combination with other medications, chlorthalidone has been shown to be a more potent antihypertensive agent than HCTZ. Thus, it has not been shown that a combination of one of the formulary ARBs along with chlorthalidone would result in ineffective blood pressure control for this man. It has not been demonstrated that a combination of one of the formulary ARBs along with chlorthalidone would result in ineffective blood pressure control for this man.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with a past medical history of hypertension, congestive heart failure, coronary artery disease, aortic stenosis, atrial fibrillation and hypothyroidism who had been assigned 6 hours/day, 3 days a week to total 18 hours per week of personal care assistant (PCA) services. The patient is wheelchair bound. Because of her medical conditions, the patient has episodes of lightheadedness and syncope. The patient had extensive evaluation of lightheadedness and syncope with her cardiologist with medication adjustment but her symptoms persisted. There was a request for increased hours and the patient had assessment tool performed. Following this assessment, the patient had an increase in the PCA hours to 6 hours/day, 5 days/week to total 30 hours per week. There was an appeal to increase the PCA service hours to 8 hours/day, 7 days/week to total 56 hours per week.  The patient's primary care provider (PCP) provided a letter requesting an increase in PCA hours to 40 hours per week and and increase to CDPAS hours to 30 hours per week. The patient's cardiologist wrote a letter requesting and increased in PCS and Consumer Directed Personal Assistance Services (CDPAS) due to her medical conditions. The patient's daughter provided a letter to the health plan  citing discrepancies in the  assessment tool. At issue is the medical necessity of 56 hours per week of personal care aide services.
The health plan's determination is overturned. The 56 hours per week of aide services are medically necessary. The patient has complications from her chronic cardiac conditions of atrial fibrillation, congestive heart failure, hypertension and aortic stenosis that make her prone to episodes of lightheadedness and syncope. Because of her risk of syncope the patient is wheelchair bound and requires total assistance with walking, dressing lower extremity (LE), transferring with toileting and toilet use. According to her cardiologist and PCP, it is medically necessary for her to have and an increase in PCA services (as noted above). The requested services are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Respiratory System
Home Health Care

The patient is a female with past medical history of dementia, oxygen dependent chronic obstructive pulmonary disease (COPD), depression, legal blindness in one eye, osteoporosis, incontinence and chronic low back pain. She had consumer directed personal care aide services 6 hours/day, 7 days/week to a total of 42 hours per week.  The patient's neurologist supported increased level of support due to worsening of her dementia and the need for additional personal care hours.
The patient had an assessment tool and the assessment remained the same compared to the prior assessment except for a change in locomotion from extensive to total assistance. The patient's daughter provided a letter stating the patient was not able to bath herself with extensive assistance as stated in the most recent assessment. The patient required total assistance according to her daughter. The most recent assessment noted the patient needed extensive assistance with toilet transfer but according to the daughter the patient required total assistance. Physical therapy (PT) was recommended but the patient declined; according to the daughter's letter  the patient did have PT and a social work assessment in the summer. The personal care aides leave at 3 pm and the patient's husband is not able to provide the level of care to meet her needs. The patient also fell out of her hospital bed twice in the last year. The primary care physician (PCP) office note documented that the patient was bedridden and rapidly declining and could not get to the commode or bathe herself. The PCP requested an increase in personal care aide service hours.

The health plan's determination is overturned.

Yes, the patient had updated assessment tool done but medical record documentation from her PCP indicates significantly worse functioning with activities of daily living (ADLs) then reflected on that assessment. Her neurologist indicated that her condition would worsen and has worsened over the last 6 months. The patient has personal care aides that leave at 3 pm and her elderly husband is not able to manage her increased needs. The patient's daughter further indicated the specific needs and discrepancy with the most recent assessment tool.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain; Diarrhea
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an adult male, status post previous abdominal surgery. He presented with abdominal pain for one week with vomiting and diarrhea. His pain was described as 6/10. 

The patient's initial evaluation demonstrated tenderness in the abdomen with no guarding or rebound. Initial labs were significant for a white count of 10.6 and a lactic acidosis of 2.8, improved with fluids. CT scan showed small bowel obstruction with a transition point. 

The patient was admitted to the hospital for IV fluids and nasogastric tube. On the first hospital day (HD), the patient began passing gas and having bowel movements. Vital signs and heart rate were normal. Abdominal exam was significant for a soft nontender nondistended abdomen. Gastrografin challenge demonstrated contrast in the rectum. All symptoms resolved with conservative treatment, and the patient was deemed stable for discharge later that day, Hospital day #1.

The patient initially presented with severe dehydration and signs and symptoms consistent with a small bowel obstruction. Quick resolution of all symptoms was readily apparent upon initiation of conservative therapy. The patient's bowel function returned quickly with passage of flatus and bowel movements. A surgical abdomen was ruled out immediately.

Small bowel obstruction (SBO) occurs when the normal flow of intestinal contents is interrupted. The management of bowel obstruction depends upon the etiology, severity, and location of the obstruction. The goals of initial management are to relieve discomfort and restore normal fluid volume and electrolytes. Bowel compromise (ischemia, necrosis, or perforation) and a surgically correctable cause of SBO (e.g., incarcerated hernia) require immediate surgical exploration; other patients may be candidates for a trial of nonoperative management. Although 60 to 85 percent of adhesion-related SBOs resolve without surgery, it is difficult to predict a priori which patients will fail nonoperative management. Non-adhesion-related SBO is usually secondary to another intra-abdominal process (e.g., inflammation, infection), targeted treatment of which will lead to the resolution of SBO symptoms.

The patient needed to be treated for conservative therapy for his small bowel obstruction. However, resolution was rapid. His diet was advanced. He was discharged home in stable condition. This patient could have than managed safely and effectively in the outpatient setting.
Appeal type: Medical necessity
Decision: Upheld

Substance Abuse/Addiction
Inpatient hospital

The patient is a man who was admitted to the hospital with heroin overdose. He was confused, but able to answer questions. Vital signs showed blood pressure 113/91, heart rate 87, respiratory rate seven, oxygen saturation 97%, and temperature 98.2 Fahrenheit. On physical examination, heart was regular, breath sounds were normal, abdomen was soft and nontender with positive bowel sounds, and no neurologic deficit was noted. Labs showed white blood cell (WBC) 9.2, hemoglobin 12.9, platelets 227, sodium 141, potassium 4.4, creatinine 1.0, Glucose 81, aspartate aminotransferase (AST) 163, and alanine aminotransferase (ALT) 90. The patient was admitted for a heroin overdose.

The health plan's determination is upheld. The patient was hemodynamically stable and did present with heroin overdose, but had no other significant abnormalities requiring inpatient care. Liver enzymes were elevated but there was no evidence of liver dysfunction. He was also evaluated by psychiatry and was found to not have acute suicidal or homicidal ideation, although he was diagnosed with antisocial personality disorder. A patient with this presentation is typically managed with a referral for treatment of opioid dependence disorder and possibly referred to an addiction/dependence program or initiated on methadone or Suboxone, but this type of patient does not otherwise require acute inpatient level of care in the setting of an uncomplicated presentation.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's disease; dementia
Issue under review: Increase in personal care aide hours

Determination:
The Increase in personal care aide hours is medically necessary.

The patient is an elderly male with a complex medical history including Parkinson's Disease complicated by advancing dementia; prostate cancer with urinary retention requiring Foley catheter; congestive heart failure; atrial fibrillation; hypertension; Type II diabetes; with multiple open venous ulcer.  Recently, the patient has experienced increasing confusion leading to worsening cognitive abilities and in general declining medical conditions.  Additionally, the patient has experienced worsening of his generalized health resulting in increased confusion at bedtime with worsening safety decisions; skin breakdown requiring every two (Q2) hour turning; progressive restlessness and periods of agitation requiring 24/7 supervision.  The patient has multiple nocturnal falls secondary to poor safety decision making paired with poor balance and generalized weakness leading to multiple falls.

Based on recommendations made by the patient's treating physicians, the patient has experienced significant progressive debility with worsening mobility associated with multiple areas of skin breakdown requiring Q2 hour rotations.  Additionally, the patient is no longer capable to do the following:  
1) maximum assist required with all activities of daily living 24/7
2) high risk for falls and in fact patient has experienced multiple recent falls
3) venous leg ulcers are present and require continuous 24/7 supervision of care to prevent development of new ulcers
4) sun downing, patient with worsening confusion after bedtime throughout the night resulting in multiple falls caused by poor decision making and lack of supervision
5) unable to make needs known
6) declining medical conditions
7) unable to understand circumstances under which he should call 911
8) progressive pain with increasing generalized disability to the point that he no longer is able to utilize wheelchair and walker without continuous supervision.

Therefore, based on the above, the Increase PCA services is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Substance abuse
Inpatient Substance abuse

The patient received inpatient substance abuse level of care. The patient was reported to have had an opioid withdrawal score of 15 and alcohol withdrawal score of 9 at the time of admission. Patient was reported to be drinking a half pint of liquor and a six pack of beer per day as well as using 20 bags of heroin daily. Diagnoses were opioid dependence with withdrawal, cocaine dependence, nicotine dependence, and alcohol dependence with withdrawal.
The patient had a history of a detoxification admission the month prior for 45 days. There were medical/surgical hospital admissions in the past  for a stab wound to the rib/shoulder, and for a cut with a blade to the right arm. The patient also had inpatient detoxification for five days earlier in the year. The patient denied having been on medication assisted treatment for substance use disorders in the past. The patient denied any history of mental illness or psychiatric hospitalizations or suicide attempts.
Patient was started on a methadone taper for opioid withdrawal and a Librium taper for alcohol withdrawal. These were preplanned tapers rather than symptom driven withdrawal management. Clinical documentation does not indicate any severe manifestations of withdraw from either opioids or alcohol. The health plan's determination of medical necessity is upheld in whole. The patient did not require immediate hospitalization for a life-threatening medical condition or severe psychiatric crisis. Alcohol was the substance with the greatest potential to cause harm to self or others. The patient clearly met criteria for alcohol use disorder as well as opioid use disorder and cocaine use disorder. The patient did not have full remission from a substance use disorder. The patient was using a substance with risk of medical complications from withdrawal. The patient did not have any serious psychiatric or medical symptoms that required 24 hour inpatient medical management. Risk of withdrawal was not limited to opioids. The patient did not require 24 hour medical oversight. Based on  the Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Level of Care, Stabilization Services in a Residential Setting is the recommendation. The patient could have been safely and effectively treated in a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malpositioned Teeth
Treatment: Dental/Orthodontic Procedure

The patient in question is a male with a Class I malocclusion and anterior crossbite of tooth #11. There is mild spacing on both arches. The maxillary and mandibular incisors are excessively protrusive. His treatment planned is for 18-24 months of orthodontics to correct his malocclusion. This is the subject of this review. 

The health plan's determination is overturned. The braces are medically necessary. The patient has significant maxillary anterior spacing with tooth #11 in crossbite. This tooth has a high risk for restorative problems in the future due to its traumatic occlusion with the mandibular teeth. Studies have shown that even the untreated dentition shows increased anterior irregularity with time, which will make treating this occlusion at a later time more difficult. Tooth #22 already has slight recession, and further movement of #22 will likely lead to the need for future for periodontal grafting on this tooth. Orthodontic treatment now will likely prevent the need for future periodontal and restorative procedures. For these reasons, the orthodontic treatment is medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

The patient is a male diagnosed with opioid use disorder. The patient was prescribed brand Suboxone (buprenorphine/naloxone) Film Strips as maintenance medication assisted treatment of the opioid use disorder. The patient has taken Suboxone Film Strips in order to maintain abstinence and support his ongoing recovery from opioid use disorder. The patient has a past history of poly-substance use with opioids as drugs of choice including heroin and prescription opioids/opiates, as well as past use of benzodiazepines, MDMA (Ecstasy), Molly, and cocaine. He is a social drinker with minimal use of alcohol and tobacco dependent. He has no co-occurring psychiatric disorders but does have chronic insomnia treated with clonidine at bedtime. There are no current general medical or psychiatric diagnoses or conditions noted in this case. 

Generic formulation of buprenorphine-naloxone film strips have been tried more recently due to a change in his health plan coverage with adverse effects including chills, hot flashes, a feeling of opioid withdrawal (post-acute withdrawal symptoms) and inability to function well. The patient was also prescribed Zubsolv and failed to respond to this formulation of buprenorphine/naloxone.

 The patient was switched back to the brand Suboxone Film Strips with tolerability and a satisfactory clinical response as before. Again, the generic formulation of Suboxone Film Strips has consistently resulted in adverse effects including hot and cold flashes, insomnia/sleep disturbance, chills, and feeling unwell. The health plan's determination is overturned. In considering whether the formulary drug Zubsolv will be or has been ineffective, would not be as effective as the non-formulary drug Suboxone, or would have adverse effects; the patient in this case has had a trial of Zubsolv and has failed to benefit from the formulary alternative, Zubsolv, in this case-as noted in the clinical summary.

In this case, Brand Suboxone Film Strips have consistently resulted in more effective control of craving and withdrawal symptoms with tolerability and lack of adverse effects. Moreover, the patient has been compliant with the treatment plan while taking the Brand Suboxone Film Strips with a satisfactory response and clinical course including involvement in counseling with clinically appropriate monitoring. The patient's physician has requested that the patient continue to have coverage for the brand formulation of buprenorphine/naloxone in view of a satisfactory clinical response, and adverse effects occurring with the generic formulation, and failure in the past to respond to the formulary alternative, Zubsolv.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Overbite
Treatment: Braces
The Braces are medically necessary.

The patient has a deep, impinging overbite with severe soft tissue damage to his palate. This is an 'automatic qualifier' according to the handicapping index scale. The patient needs orthodontic treatment to correct this.
Appeal type: Medical necessity
Decision: Overturned

Dental Problems/Dental
Orthodontic Procedure

The patient presented with a fracture of tooth #31. A crown is being requested at this time.
The health plan's determination is overturned in whole.
The requested health service/treatment of Crown - Porcelain Fused to High Noble Metal, Tooth # 31 is medically necessary.
The submitted intra-oral photographs show tooth #31 with a large fractured distal marginal ridge. The existing occlusal filling extends far into the lingual groove, leaving minimal tooth structure remaining on the lingual surface. Because there is little tooth structure remaining on the lingual surface and distal marginal ridge is fractured, fixing the fracture with a filling will cause the distolingual cusp to fracture off.
Because tooth #31 has an extensive fracture on the distal marginal ridge and the distolingual cusp is weakened, the patient crown on tooth #31 is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Toxic encephalopathy, weakness, pressure ulcer
Treatment:  Continued Skilled Nursing Facility 
The Continued SNF stay is not medically necessary.

The patient is a female with history of toxic encephalopathy secondary to sepsis with generalized weakness, debility, deconditioning and developing lymphedema lower extremities and stage III sacral pressure ulcer.

The patient has relevant past medical history of multiple sclerosis, hypertension, chronic pain, Anemia, Acute Kidney Insufficiency, GERD (gastroesophageal reflux disease), etc.

Prior to admission, the patient was living alone in a private residence and independent with activities, and the plan is to discharge her to live alone in a private residence.

The patient had been in need of maximum-assistance to totally dependent in all ADLs (activities of daily living), and later she required moderate assistance with all ADLs.


The patient has not shown further tangible improvement in SNF.  She required moderate assistance with all ADLs.  The plan is to discharge to a private residence. 

Generally, patients in similar circumstances have the option of continuing at a lower level of care.

As stated above, the proposed continued stay in SNF was not medically necessary.  Withholding the continued stay in SNF in whole or in part is not reasonably expected to affect the patient's health adversely.  The patient will be better in a lower level of care to meet her continued rehabilitation needs.