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

Diagnosis: Muscle weakness, osteoarthritis, legally blind.
Treatment: Personal Care Assistance (PCA) Services of 12 hours per day, 7 days per week for a total of 84 hours per week.

The insurer denied coverage for PCA Services of 12 hours per day, 7 days per week for a total of 84 hours per week.  The denial is overturned. 

This is a male patient with a past medical history of congestive heart failure, chronic obstructive pulmonary disease, respiratory failure with hypoxemia, type 2 diabetes mellitus, hypertension, benign prostatic hyperplasia, and legally blind. Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and his daughter were present on the call. The patient lives alone in a 3 bedroom multi-level private house with about 4 steps to enter the home. The patient's daughter has been temporarily staying at the patient's home to assist with his needs, but she goes to work before the personal care aide comes to assist. The patient's son is also supportive. The patient needs assistance with activities of daily living and instrumental activities of daily living due to muscle weakness, osteoarthritis and being legally blind. An increase in personal care assistance (PCA) services from 10 hours per day, 7 days per week to 12 hours per day, 7 days per week for a total of 84 hours per week was requested.

The patient has multiple co-morbidities. He is legally blind and has cognitive impairment. He also has extensive functional limitations. He has informal caregivers who cannot commit to being able to provide coverage for his needs 14 hours/day. Due to impaired cognition, blindness, need for nasal oxygen, physical limitations and need for unscheduled toileting, the insurer's denial is overturned.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. This reviewer disagrees with the plan's interpretation of the patient's needs.

The insurer's denial of coverage for the requested Personal Care Assistance (PCA) Services of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Psoriasis Vulgaris.

Treatment: Ilumya.

The insurer denied coverage for Ilumya.

The denial is upheld. 

This is a male patient with a history of psoriasis. The patient is reported to have tried and failed aggressive topical therapy including Duobrii, clobetasol, triamcinolone, Halog ointment and Olux. Approval for Ilumya is requested.

Ilumya is not medically necessary for the patient's condition, Psoriasis Vulgaris.  There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Ilumya for this patient's condition above reasonable alternatives as an accepted standard of practice.  

There are no comparative, controlled head-to-head studies showing that Ilumya has a superior efficacy or safety profile to all the formulary alternatives such as phototherapy, methotrexate, or Humira.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient (1,2,6).   Within the peer-reviewed literature, Racz et al. writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks" (3).  Mehta et al. writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments...NB-UVB [Narrow-band ultraviolet B] effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile." (4)

There are no head-to-head studies which conclusively show that Ilumya would provide a greater safety or efficacy than formulary alternatives.  The provided medical notes do not provide any evidence of an absolute contraindication for the use of those available.  As such, the decision to deny Ilumya at this time is upheld.  The health plan acted reasonably with sound medical judgement and in the best interest of the patient.

The insurer's denial of coverage for Ilumya is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory. 
Treatment: Inpatient Hospital. 
The insurer denied inpatient stay. 
The denial is upheld. 

The patient is a male with a past medical history significant for peptic ulcer disease, gastrointestinal bleeding, iron deficiency anemia, chronic back pain, and COVID-19 infection who presented to the emergency department after he had a syncopal episode at home. Reportedly, he developed heartburn after eating his dinner. After walking upstairs, he started to feel dizzy and lightheaded. He splashed water on his face, and then passed out. The patient reported that he hit his head on the wall.

The patient was admitted to the hospital for evaluation of the syncopal episode and possible gastrointestinal bleeding.
In the hospital, the patient was seen by a gastroenterologist who noted that the patient took nonsteroidal anti-inflammatory drugs (NSAIDS) for his chronic back pain.
It was reported that the patient had anemia in the past. Specifically, it was mentioned that he had severe anemia one year before his presentation when he was diagnosed with peptic ulcer disease.
Because of the concern for possible gastrointestinal bleeding, the patient underwent esophagogastroduodenoscopy (EGD) that demonstrated irregular Z-line with salmon-colored mucosa. Biopsies were obtained. The patient had normal-appearing gastric and duodenal mucosa with no evidence of active bleeding.
In the hospital, the patient was checked for signs of orthostatic hypotension, but this was negative.
His diet was gradually advanced. The patient remained in normal sinus rhythm.
His vital signs remained stable. Therefore, he was discharged from the hospital on the next day after the day of admission. The patient was advised to abstain from nonsteroidal anti-inflammatory drugs.
The subject under review is the medical necessity for the inpatient stay.

The health plan's determination is upheld.

The inpatient stay was not medically necessary.
The San Francisco Syncope Rule is a risk stratification tool. It predicts risk for serious outcomes at 7 days in patients presenting with syncope or near-syncope. Based on the calculations, this patient received zero points. This means that the patient belonged to a low-risk group for serious outcomes. Therefore, the workup could have been performed at a lower level of care status.
Having said that, clinical judgment should always prevail, and in this particular situation, the patient had heme positive stools, anemia, and orthostatic changes. Admission for monitoring was justified, but this could have been appropriately carried out at lower level of care.

In this particular case, the patient had no evidence of active gastrointestinal bleeding based on the EGD. Furthermore, only one syncopal episode was reported. There was no evidence of recurrent syncopal or near syncopal episodes.
During the hospital stay, this patient remained in stable clinical condition. His hospitalization was short.
Therefore, neither the severity of the patient's condition nor the complexity of the services provided justified admission at the acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cognitive and physical impairment. 

Treatment: Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week. 

The insurer denied coverage for PCW Services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week. 

The denial is overturned. 

This is a female patient with a past medical history of coronary artery disease, hypertension, congestive heart failure, type 2 diabetes mellitus, coronavirus disease 2019 (COVID-19) associated pneumonia, urinary tract infections, pressure ulcers, anemia, constipation, insomnia, incontinence, vertigo, osteoarthritis, impaired balance, as well as a history of falls.  Per the telephonic New York State Department of Health's Uniform Assessment System (UAS-NY), the patient, her daughter, her Personal Care Worker and a nurse providing wound care, were present on the call.  The patient lives alone in a private home, and she is bed bound.  Her activities of daily living status notes overall self-sufficiency decline. 

The patient's needs are: Total dependence/Maximal assistance for all functions, Cognition: There is severe impairment, Continence: There is frequent urinary and bowel incontinence, Wound: Stage III right buttock skin breakdown. 

An increase to personal care worker (PCW) services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week is being requested. 

The patient is dependent for all activities of daily living (ADLS). Comparison of Uniform Assessment System (UAS) reports shows that she has deteriorated.  She has severe dementia and bowel and bladder incontinence.  She has a history of pressure sores and currently has a stage III sore.  Activity Log does not note turning and positioning, but this should be done.  Incontinence needs to be promptly handled, either with assistance to the bathroom if possible or clean-up of her and bed thereafter.  The provision of diapers and alternate pressure beds is not by itself adequate for prevention of pressure sores.  As noted in "Preventing pressure ulcers" changing diapers regularly and positioning are also necessary. Given her degree of cognitive and physical impairment and presence of sores with incontinence, the plan's determination is overturned. 

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

The insurer's denial of coverage for the requested Personal Care Worker (PCW) Services of 7 days per week, 24 hours per day, continuous care by more than 1 person, for a total of 168 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis Vulgaris

Treatment: Skyrizi

The insurer denied coverage for Skyrizi

The denial is upheld

Skyrizi is not medically necessary for the patient's condition, Psoriasis Vulgaris.  There is no medical and scientific literature and/or evidence based clinical practice guidelines that strongly support the administration of Skyrizi for this patient's condition above reasonable alternatives as an accepted standard of practice in the U.S. 

There are no comparative, controlled head-to-head studies showing that skyrizi has a superior efficacy or safety profile to all the formulary alternatives such as phototherapy, methotrexate, or humira.  According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature alternative effective treatments for the management of psoriasis are available and appropriate for this patient.(1,2,6)   Within the peer-reviewed literature, Racz et al writes "Phototherapy is a standard treatment option for psoriasis, generally applied if topical treatment modalities fail or are contraindicated...Phototherapy may lead to the clearance of psoriasis in 5 to 8 weeks." (3)  Mehta et al writes "Ultraviolet (UV) B phototherapy is most appropriate for patients with >10 % affected body surface area who have not responded to topical treatments...NB [narrowband]-UVB effective treatment options for psoriasis...Long-term data on NB-UVB indicate that it has a good safety profile."(4)

Additionally, West et al 2016 conducted a review of ELEVEN comparative, controlled studies that passed a Cochrane risk of bias analysis.(5)  They concluded that methotrexate achieved significant improvement in reducing psoriasis plaques.  Methotrexate is a preferred treatment.  Thus, methotrexate is an effective first-line treatment for the management of psoriasis.(5)

Lanna et al.(7) discuss the safety and efficacy of humira in the treatment of psoriasis vulgaris.  

As such, the health care plan acted reasonably in denying Skyrizi for this patient as numerous alternative options exist in the treatment of the patient's condition.  The provided medical notes do not provide any evidence of an absolute contraindication for the use of available therapies or unique clinical situation which would specifically warrant Skyrizi. The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for Skyrizi to treat psoriasis is upheld. Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Symptomatic Varicose Veins

Treatment: Procedure code 36465, sclerotherapy to treat varicose veins

The insurer denied coverage for procedure code 36465, sclerotherapy to treat varicose veins

The denial is overturned

This case involves a male who has a history of extensive symptomatic varicose veins. The submitted documentation indicated the patient had evidence of venous reflux bilaterally. The physician detailed the patient was also noted on diagnostic ultrasound and physical exam to have type III varicosities. The patient has had conservative treatment that includes weight control with exercise, elevation and utilizing gradient to support stockings. The physician indicated the patient has many perforators and if left untreated the patient was at risk for a venous ulcer. The documentation does include a history and physical and certificate of medical necessity indicating the patient had physical evidence of stage II venous insufficiency based on edema as well as skin irritation and hyperpigmentation. The recommendation was for the patient to undergo venous ultrasound mapping followed by bilateral rescue endovenous chemical ablation.

The denial of coverage for the procedure (CPT code 36465) for symptomatic perforator reflux should be overturned as this is not a cosmetic procedure, but a medically necessary procedure. The patient has recurrent symptoms, failure of conservative management, and ultrasound proven perforator reflux noted.

The patient previously tried conservative management with elevation and compression stockings, but failed that approach. Ultrasound guided (USG) venous reflux study indicated bilateral great saphenous vein (GSV), anterior accessory saphenous vein (AASV) and small saphenous vein (SSV) reflux and thus he underwent thermal ablation of the bilateral GSV, AASV, and left SSV.

He was then continued on conservative management and was encouraged to have exercise and weight loss therapies. He continued to have symptoms and follow-up indicated CEAP (Clinical-Etiological-Anatomical-Pathophysiological) class 4 clinical exam with lipodermatosclerosis and edema and pain. Repeat venous reflux study indicated bilateral medial calf reflux in the perforator veins.

Thus, due to continued symptoms and failure of continued conservative management, and evidence of perforator reflux, the procedure of perforator ablation with thermal or non-thermal ablation is medically indicated and should be approved.

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

The insurer's denial of coverage for the procedure code 36465, sclerotherapy to treat varicose veins is reversed. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of breath.  
Treatment: Inpatient hospital admission.  

The insurer denied coverage for the inpatient hospital admission.  

The denial is upheld.  

This is a male patient with a history of chronic obstructive pulmonary disease (COPD)/ asthma, and neurofibromatosis.  The patient presented to the Emergency Department (ED) with a complaint of shortness of breath (SOB).  The patient also complained of some cough with productive green sputum.  At presentation, vital signs (V/S) were temperature (T) 96, respiratory rate (RR) 24, heart rate (HR) 116, blood pressure (BP) 143/95 and oxygen (O2) saturations 96 %.  The patient was alert and oriented x3 (A X OX 3).  The patient was in some respiratory distress.  The patient had some wheezing on exam.  The patient was treated with Prednisone, Nebulizers, Magnesium and intravenous (IV) fluids. 

Initial labs: white blood cell (WBC) count 12.9, hemoglobin (Hb) 17.3, blood urea nitrogen (BUN)/ Creatinine were within normal limits (WNL).  Electrolytes were WNL.  Venous blood gas (VBG) was 7.4/39/57/24. 

Chest x-ray showed no acute infiltrates; some linear atelectasis. 

The patient was improving after treatment in the ED.  T was 97.6, RR 18, HR 104, and BP 142/91.  The patient was symptomatically better. 

The patient was noted to have some elevated WBC - likely from steroids. 
The patient was on steroids, bronchodilator (BD) via Nebulizers, Montelukast.  Levaquin was added. The plan was to switch to oral (PO) steroids and switch to PO Azithromycin.  The patient's arterial blood gases (ABG) were 97%.  The patient was to be followed up by his Pulmonology after discharge. 

This patient did not need acute inpatient hospitalization.  He could have been placed in Observation status while diagnostic testing and treatment were initiated.  The patient could have been in Observation for up to 48 hours.  The patient was not hypoxic after treatment in the emergency department. There was no pneumonia (PNA) on chest x-ray (CXR).  There was no CO2 (carbon dioxide) retention.  The patient was wheezing minimally.  He was speaking full sentences and tolerating oral intake (PO).  This patient was stable to be switched to PO medications after a period of observation and subsequently discharged home with outpatient follow-up.  The prior denial is upheld.  The health plan acted reasonably with sound medical judgment in the best interest of the patient.  

The insurer's denial of coverage for the inpatient hospital admission is upheld.  Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bipolar disorder.
Treatment: 6 units of continued inpatient mental health treatment.

The insurer denied coverage for 6 units of continued inpatient mental health treatment.  
The denial is overturned. 

This is a female patient with a history of bipolar disorder, diabetes, hypertension, hyperlipidemia, and hypothyroidism. She was admitted to the hospital due to psychotic symptoms including paranoid delusional thinking, religious preoccupation, disorganized thinking and speech, threatening statements including saying it is all going to end today, restlessness, perseverative speech, grandiosity, and she reportedly was brought in by police. She reportedly had past inpatient psychiatric hospitalizations. She reportedly took Seroquel, Clonazepam, and Trazodone, and then Lithium and Gabapentin. She continued to have reported psychotic symptoms until discharge.
  
The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Bipolar Disorders reports that the least restrictive level of care for safe and effective treatment is appropriate and also that patients with severe agitation, aggression, psychotic symptoms, suicidal or homicidal plan or intent or attempts, manic episodes, severe major depressive episodes, or inability to adequately care for basic self-care needs are in need of hospital treatment. In this case this patient had continued reports of psychotic symptoms during the denial period and had manic symptoms also and was still considered not at baseline and not able to care for her basic needs while still presenting with these symptoms. 

She continued with psychotic and manic symptoms requiring psychiatric hospitalization during the denial period. She also had medications added including Lithium and Gabapentin in addition to Seroquel, Clonazepam and Trazodone. She also had medical issues including low blood glucose. She lacked support and was reportedly homeless after her mother's death. Prior to admission she was unable to function in the community or care for basic needs, so she was considered still in need of psychiatric hospital treatment while reporting psychotic and manic symptoms.  

It did not appear that the health care plan acted reasonably or in the best interests of the patient.

The insurer's denial of coverage for 6 units of continued inpatient mental health treatment is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic lower back pain.
Treatment: Pain management/radiofrequency ablation for non-facet joint nerves.

The insurer denied coverage for pain management/radiofrequency ablation for non-facet joint nerves.  The denial is upheld. 

This is a female patient who has a history of spinal stenosis and multiple disc herniations. She presented to the pain management physician's office for the evaluation of chronic lower back pain. 

The patient has an 8-year history of lower back pain. The left side hurts more than the right, and pain is rated at a level of 10 out of 10. The patient has received partial relief with medication, heat, ice, and prior injections. She is taking Meloxicam twice a day (BID). Magnetic resonance imaging (MRI) of the lumbar spine (L) revealed L3/4 disc herniation and central spinal stenosis. There were L4/5, L2/3, and L1/2 disc bulges. There was L2/3 left neural foraminal disc herniation and thoracic (T) 9/10 and T10/11 small disc herniations. An MRI revealed Modic changes to L3 and L4. The physician recommended the Intracept procedure to L3 and L4 to treat chronic lower back pain.

The publications to date have been company sponsored and had methodology flaws. UpToDate (3) has evaluated this procedure and concluded that it is still investigational. There are other evidence-based interventions available to this patient. 

The health plan acted reasonably with sound medical judgment in the best interest of the patient. 

The insurer's denial of coverage for pain management/radiofrequency ablation for non-facet joint nerves is upheld.  Medical Necessity is not substantiated.