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

Diagnosis:  Atrial fibrillation with rapid ventricular response 

Treatment:  Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.  The denial was upheld.

This patient is a female with a past medical history notable for arrhythmia, diabetes, and morbid obesity.  She presented to the Emergency Room with complaints of palpitations.  She was found to have atrial fibrillation with rapid ventricular response with a heart rate of 122.  Other vital signs were unremarkable.  An electrocardiogram revealed atrial fibrillation with a heart rate of 140 beats per minute.  The D-dimer was elevated.  The patient was admitted with new onset atrial fibrillation.  The plan was to obtain labs, administer intravenous Cardizem for rate control, start 5 milligrams of Eliquis twice a day, obtain a transthoracic echocardiogram, and obtain a computed tomography angiography.  She was admitted for intravenous (IV) rate control, started on oral anticoagulation, underwent echocardiography, and was seen by cardiology.  Cardiology recommended anticoagulation, considering apixaban, checking serial cardiac enzymes, doing serial electrocardiograms, checking thyroid function tests, checking the D-dimer, continuing hydrochlorothiazide, and holding amlodipine if diltiazem is used.  Echocardiography showed a normal ejection fraction of 60-65%.  Cardiology recommended outpatient stress testing.  The patient was discharged home.

The patient presented with atrial fibrillation.  The remainder of the cardiac workup was unremarkable, including an unremarkable cardiac troponin.  The patient remained clinically and hemodynamically stable.  Inpatient admission was not medically necessary for this patient.  In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.  Inpatient admission criteria were not met.  Although the patient had a new onset symptoms, medical necessity criteria were not met for any other additional extenuating circumstances. 

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

Based on the above, the medical necessity for the inpatient hospital admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Shoulder Problem/Pain
Physical Therapy

The patient is a female with the complainant of left lateral rib and shoulder pain. Initial clinical impression was suggestive of thoracic outlet syndrome on the left. The patient was evaluated for left shoulder pain. The patient describes a two-month history of pain in the left side of the ribs that is now moved to the left shoulder blade and has been present for 3 to 4 months. Recommendation is for PT (physical therapy) treatment frequency two times a week for 12 weeks.

The health plan's determination is overturned. The requested Physical Therapy Services: Three (3) Units of CPT 97140 was medically necessary for this patient. The patient was being treated for left-sided neck and shoulder pain related to either cervical radiculopathy or possible thoracic outlet syndrome. Soft tissue mobilization of the cervical spine was utilized to treat this patient's pain symptoms. Soft tissue mobilization as part of manual therapy is a technique used to facilitate soft tissue elongation, pain reduction and improvements in functional range of motion, thereby diminishing pain. Soft tissue mobilization is a hands-on technique utilized by physical therapists and chiropractic providers (among others), which is frequently part of a conservative approach to cervical and periscapular pain syndromes. The use of soft tissue mobilization along with therapeutic exercise and modalities was both medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease (CAD), heart failure, non-rheumatic mitral valve disease
 
Treatment: Consumer Directed Personal Assistant Services (CDPAS) 40 hours per week

The insurer denied the Consumer Directed Personal Assistant Services (CDPAS) 40 hours per week. The denial was reversed.  

This is an elderly female patient who had been receiving Consumer Directed Personal Assistant Services (CDPAS) 26 hours per week and had requested an increase in hours to CDPAS 40 hours per week due her knee pain and the associated swelling. The patient had a history of Coronary artery disease (CAD), heart failure, non-rheumatic mitral valve disease, pulmonary hypertension, polymyalgia rheumatic, hyperlipidemia, and amaurosis fugax. She was status post cardiac catheterization which demonstrated stent restenosis and de novo obstructive lesions, bilateral knee osteoarthritis; she had mixed results from various injections. Documentation revealed that there had been a decline in her Uniform Assessment System (UAS) from the one previously recorded. It was reported that the patient's son no longer lived with her. His absence in the home significantly changed the dynamic in which she had functioned with her activities of daily living (ADLs).

The UAS reports that the patient lives with her son, but the patient and son state that they do not live together.  He is available evenings and weekends to provide assistance to his mother. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services.  As a result of the patient's medical conditions and functional impairments, it is medically necessary for the patient to have assistance in order to safely and effectively perform daily activities; including ADLs that occur throughout the day (i.e. transfers, walking, and toileting). When assistance from informal caregivers is not available, then assistance from personal care services (in this case CDPAS) is indicated.  The patient currently is receiving CDPAS 26 hours per week distributed over 5 days.  The patient is asking for an increase to 40 hours per week. This would provide assistance for most of the morning and afternoon on weekdays which covers a more substantial part of the day until the son is available.

Based on the above, the medical necessity for consumer directed personal assistant services (CDPAS) 40 hours per week is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: peripheral vertigo or stroke/TIA.  

Treatment: inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial was reversed.

This patient is a female with past medical history (PMH) notable for: diabetes mellitus (DM), hypertension (HTN), obesity, fibromyalgia, who came to the emergency room after a few days of dizziness and difficulty walking.  Her initial systolic blood pressure was 190.  Neurological Exam was notable for nystagmus and possible facial palsy. The computer tomogram (CT) showed asymmetric frontal ischemic changes of indeterminate age. The differential diagnosis was peripheral vertigo or stroke/TIA.  She was admitted for work up and monitoring. She had a magnetic resonance imaging (MRI) which showed no acute changes.  She had an echo which was benign. She developed hip pain and orthostatic hypotension and these problems were managed. A note from a utilization review nurse notes that the patient was appropriate for inpatient level of care based on InterQual criteria for acute neurologic event because she had a new neurologic sign (nystagmus) and two interventions: an imaging study (MRI) performed within 24 hours and neurological assessment at least every 4 hours.

The insurer has denied coverage for the inpatient admission. They state that the admission was not deemed medically necessary. The inpatient admission is denied based on Milliman Care Guidelines 23rd Edition using the guideline of ORG: M-152 (ISC) Dizziness.  
 
While this patient's symptoms turned out to be of peripheral etiology, a central etiology (i.e. a stroke/TIA) was a documented diagnostic possibility which needed to be ruled out. This patient had an ABCD2 score of 5 or 6 (over age 60, elevated BP, possible unilateral facial weakness, diabetes, symptoms lasting 10-50 minutes).  The ABCD2 score is a validated, seven-point, risk-stratification tool to identify patients at high risk of stroke following a TIA. (1)  Patients with scores greater than or equal to 5 such as this patient are at considerably higher risk of stroke in the period following a TIA, and may potentially require urgent intervention as inpatients, making inpatient admission appropriate. (2)  

The health care plan did not act reasonably or in the patient's best interest in denying the admission.

The admission was medically necessary to evaluate this possible TIA and minimize her risk of subsequent stroke.

Based on the above, the medical necessity for the inpatient hospital admission at the acute inpatient level of care is substantiated. The insurer's previous denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Allergy
Pharmacy/Prescription Drugs

The patient is a female who is requesting for Xolair for urticaria. She has tried Claritin, Zyrtec, hydroxyzine and prednisone in the past. She has tried levocetirizine once a day per pharmacy fills. Clinic note indicates that patient has tried Zyrtec 40 milligrams (mg) once a day and 320 mg of Allegra. She has tried Xolair samples. The subject under review is the medical necessity for Xolair.

The health plan's determination is upheld.

No. Treatment with Xolair is not medically necessary. While the most recent note indicates that the patient is on Zyrtec 40 mg once a day and 320 mg of Allegra, the medical information does not indicate how long she has been on these doses of second generation antihistamines
Xolair is an immunoglobulin E (IgE) monoclonal antibody. The formulary alternatives Cetirizine (up to 40mg daily), levocetirizine (up to 20mg daily), Loratadine (up to 40 mg daily) or Fexofenadine (up to 720mg daily) are second generation antihistamines. 
Per standard practice guidelines, first line treatment for chronic urticaria is high dose second generation antihistamines up to 4 times the normal doses. The patient has not yet shown adequate failure of first line treatments.  Therefore, the treatment with Xolair is not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Osteoporosis
Issue under review: Formulary exception for Forteo

Determination:
The health plan should not cover the Formulary exception for Forteo.

The patient is a female diagnosed with Osteoporosis. 

The use of Forteo is sanctioned by the American Academy of Clinical Endocrinologists [1]. Forteo is effective for the treatment of osteoporosis and is a first line therapy for women with severe osteoporosis or prior fractures [2-16]. Forteo is indicated and FDA approved for the treatment of women with osteoporosis who are at high risk of fracture[17]. "These include women with a history of osteoporotic fracture, or who have multiple risk factors for fracture, or who have failed or are intolerant to previous osteoporosis therapy, based upon physician assessment." 

A FRAX score of >20% for a major osteoporotic fracture or >3% for a hip fracture is considered high risk. FRAX of 10 year probability of an osteoporotic fracture is 13.9%, and hip fracture is 5.1%.  She meets nationally accepted criteria for Forteo use. However, there are no studies showing superiority of the requested medication over the formulary alternative, Tymlos. The patient can use the formulary alternative. The health plan should not cover the requested treatment assuming that Tymlos is covered.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Tracheoesophageal [TE] fistula with esophageal atresia, status post TE fistula repair, duodenal narrowing, G tube placement, left severe hydronephrosis, hydroureter with right sided renal dysplasia

Treatment:  Private duty nursing, 24 hours/day x 7 days/week

The insurer denied coverage for private duty nursing, 24 hours/day x 7 days/week.  The denial was reversed.

This patient is a male child born at 37+1 weeks gestation with multiple congenital anomalies (tracheoesophageal [TE] fistula with esophageal atresia, status post TE fistula repair, duodenal narrowing, G tube placement , left severe hydronephrosis, hydroureter with right sided renal dysplasia, distended bladder, right choanal atresia, esophageal narrowing, dextrocardia, cervical spinal segmentation anomalies, coloboma, and hypoplastic right semicircular canal).  He is status post right pelvic kidney nephrostomy, has chronic kidney disease with anemia.  The patient is currently hospitalized.  Per the Infectious Diseases Resident progress note, the patient is currently being treated for a urinary tract infection with intravenous (IV) Bactrim via peripherally inserted central catheter (PICC) line.  He is clinically stable and afebrile.  Interventional Radiology is likely to replace the nephrostomy tube later. 

The patient has significant morbidities after multiple surgeries within the span of his life.  The CHARGE syndrome itself poses significant compromises in different organ systems and with added complications of surgeries; the patient needs a continued care in a long term care facility or at home.  It is well known that after the TE fistula repair, tracheomalacia, tracheal stenosis, recurrence of the TE fistula can occur.  In a fragile child like this, the complications of tracheomalacia can be fatal, particularly the sudden "death spells".  These death spells can be triggered by Gastro esophageal reflux disease, which is common in TE and CHARGE patients.  Hence, a skilled nursing person, such as an RN, needs to be assisting this child 24/7 for a month.  During this month parents/caregivers can be educated about the home care, and then the level of care needs can be reassessed.  Thus, at this juncture, it is medically indicated that patient needs skilled nursing 24/7 for a month. 

The health plan did not act reasonably with sound medical judgment in the best interest of the patient.
	
Based on the above, the medical necessity for private duty nursing, 24 hours/day x 7 days/week is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Opiate related constipation

Treatment: Movantik 25 mg OR TABS 

The insurer denied coverage for Movantik 25 mg OR TABS. The denial was reversed.

This patient is a female with opiate related constipation and a request for Movantik 25 mg OR TABS. The patient's formulary record shows the Movantik being ordered but not the Senna or Bisacodyl.  It is important to note that both Senna and Bisacodyl are available as over the counter medications. The patient's physician stated that Bisacodyl and Senna did not work.

Movantik is indicated (1) for opiate related constipation in chronic non-cancer pain patients, which is what this patient is suffering from. As per Chey, et al. "Treatment with naloxegol, as compared with placebo, resulted in a significantly higher rate of treatment response, without reducing opioid-mediated analgesia."

A VA Pharmacy monograph (2) and review concluded that:
"Naloxegol may be effective for short-term use in Veterans who have failed non-pharmacologic strategies and multiple therapeutic alternatives (i.e., stimulant  surfactant and osmotic agents) for promoting spontaneous bowel movements.  Naloxegol has potential advantages over similar products.  Other FDA-approved PAMORAs [peripherally acting mu-opioid receptor antagonists] either require subcutaneous injection or have an unacceptable cardiac profile for use in opioid-induced constipation."

This medication is medically necessary for this patient. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for Movantik 25 mg OR TABS is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Coronary artery disease/CAD
Pharmacy/Prescription Drugs

The patient is an old age female with diabetes and atherosclerotic cardiovascular disease. She has had myalgias with rosuvastatin, atorvastatin and with pravastatin 10 mg daily. The myalgias resolved with drug discontinuation. Her low density lipoprotein (LDL) cholesterol level was 172 milligrams per deciliter (mg/dl). The subject under review is the medical necessity of the Repatha.

The health plan's determination is overturned.

Yes, Repatha is medically necessary for this patient. Per the physician's appeal letter, this patient has atherosclerotic cardiovascular disease. She has been intolerant to three statins, including pravastatin 10 mg daily. Therefore, she meets the definition of statin intolerance in that she has been intolerant to two or more statins, including one (pravastatin) that was tried at the lowest recommended starting dose. Per the case notes, the patient has also tried ezetimibe. While the reason for discontinuation is unclear, the average reduction in LDL cholesterol that is achieved with ezetimibe is approximately 17%. This patient is in need of an almost 60% reduction in her most recent LDL cholesterol level in order to reach her National Lipid Association recommended goal of less than 70 mg/dl. It can be assumed with virtual certainty that this would not happen with ezetimibe.
Repatha is a relatively new non-statin lipid lowering agent. It is Food and Drug Administration (FDA) approved to reduce the risk of myocardial infarction, stroke, and coronary revascularization in adults with established cardiovascular disease. Given this patient's atherosclerotic disease, statin intolerance and her LDL cholesterol level, the use of a PCSK9 inhibitor (such as Repatha) in this instance is endorsed by both the 2017 National Lipid Association Update of the use of PCSK9 Inhibitors in Adults and the 2017 Focused Update of the 2016 American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk.
Appeal type: Medical necessity
Decision: Upheld

Appendicitis
Inpatient Hospital

This case involves young man who is otherwise healthy and presented to the emergency department with right lower quadrant abdominal pain and diarrhea for the prior four days. Ultrasound of the appendix demonstrated a somewhat enlarged and fluid filled structure. A computed tomography (CT) scan showed a borderline appendix with possible appendicitis. The patient was admitted and underwent antibiotic treatment prior to laparoscopic appendectomy. Subsequently, the patient was transferred to the recovery room and monitored overnight in the hospital before being deemed ready for discharge on the following day. 

The health plan's determination is upheld. The inpatient hospital stay was not medically necessary. The patient could have been safely and appropriately managed at a lower level of care. Moreover, patients with acute non-perforated appendicitis like this child had can often be discharged home the same day from the hospital, without an overnight stay.
Indeed, in one study authored by Aguayo et.al., in over 500 cases, approximately 28% (n=128) were discharged on the day of surgery. Of the remaining patients, 12.9% (n=59) stayed overnight for medical reasons, 0.4% (n=2) stayed for social reasons, 3.9% (n=18) stayed because the operation ended late in the evening, and 82.8% (n=381) stayed because of clinical care habits. Compared with patients who stayed overnight, there was no statistically significant difference in readmission rates (0.7% versus 1.9%, P=0.6%), follow-up before scheduled appointment (5.4% versus 5.4%, P=1.0), and complication rate (0.7% versus 2.6%, P=0.3). Patients whose operation ended later in the day had a longer hospital stay. Thus same day discharge is safe for children undergoing laparoscopic appendectomy for nonperforated appendicitis. Indeed, these data strongly suggest that for most patients with acute, nonperforated appendicitis who undergo an uncomplicated appendectomy, observation in the hospital thereafter is entirely appropriate since their needs are low acuity and the recovery is generally smooth and uneventful.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Subcutaneous edema 
Treatment: Inpatient stay

Summary:
The patient is a male child. He presented to the ED in the early morning with two-day history ankle pain, swelling, and redness. He was unable to walk on the first day and unable to sleep prior to presentation. He had been playing on the playground several days before and had come home with some ankle pain. The patient's mother denied fevers.

The patient's vital signs included temperature 36.9, heart rate 97, respiratory rate 18. Physical examination was significant for no distress, moist mucous membranes, regular heart rate and rhythm, clear lungs, swelling of the right ankle with some redness extending to the dorsum of the foot with questionable cellulitis, pain with flexion and extension of the ankle, tenderness to palpation of the right ankle, and normal gait. The differential diagnosis included cellulitis versus septic joint. He was treated with ibuprofen, after which he was resting comfortably.

The Inpatient admission was not medically necessary. This young male child presented after sustaining some sort of trauma or mild injury to his right ankle on the playground with worsening pain, swelling, and redness. All diagnostic testing indicated presence of cellulitis, but until the MRI was completed, osteomyelitis and septic arthritis could not be completely ruled out. It was not unreasonable to monitor the child while performing necessary tests to provide empiric treatment and confirm the diagnosis. However, he was hemodynamically stable with no signs or symptoms consistent with sepsis. He was able to tolerate food and fluids by mouth, and his pain was manageable with over-the-counter medications. He did not require acute inpatient admission, and he could have been safely managed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: TBI
Issue under review: Personal care assistance level II, eight hours per day, six days per week, for a total of 48 hours per week

Determination:
The Personal care assistance level II, eight hours per day, six days per week, for a total of 48 hours per week is medically necessary.

This is an elderly male with a history of traumatic brain injury (TBI). Due to impairments related to this condition, he requires assistance with the majority of his activities of daily living (ADLs). Per documentation from the patient's Attending Physician, the patient requires extensive assistance with all ADLs including toileting, bathing, dressing and feeding. For these reasons, the currently approved plan of personal care assistance level II four hours per day, six days per week; for a total of 24 hours per week is insufficient to meet the patient's current medical needs. Hence, the proposed treatment of an increase in personal care assistance level II to eight hours per day, six days per week, for a total of 48 hours per week to offer increased assistance with the patient's ADLs is deemed medically necessary.