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

Diagnosis:  Hidradenitis suppurativa.
Treatment:  Humira.

The insurer denied the Humira.  The determination is upheld.

The patient has hidradenitis suppurativa (HS). The hidradenitis suppurativa is Hurley Stage II. She has tried and failed spironolactone 100 milligrams (mg) twice daily. She has also tried chlorhexidine liquid, clindamycin lotion, and doxycycline. The medication under review is Humira.

The requested health service/treatment of Humira is not medically necessary for this patient. The requested service would not be considered medically necessary based on the current peer-reviewed literature.

According to the evidence-based dermatology literature and textbooks, the preferred medicines are effective treatments for the management of hidradenitis suppurativa (1,2).
The "North American clinical management guidelines for hidradenitis suppurativa: A publication from the United States and Canadian Hidradenitis Suppurativa Foundations: Part II: Topical, intralesional, and systemic medical management" says "Systemic antibiotics have been a mainstay of HS treatment for decades, with many regimens reported" (3). Specifically, it says "Tetracyclines are recommended in mild-to-moderate HS for a 12-week course or as long-term maintenance when appropriate. Clindamycin and rifampin in combination is effective" (3). The authors go on to explain further "Clindamycin and rifampin in combination have been studied in HS more than most other antibiotics, typically with both used at a dose of 300 mg twice daily. A systematic review of retrospective and prospective series reported response rates from 71% to 93% in 187 patients, strongly favoring their use. Treatment typically lasts 8 to 12 weeks and can be repeated intermittently as monotherapy in patients with mild-to-moderate disease or as adjuvant therapy in those with severe disease." (3). Within the peer-reviewed literature, Dessinoti et al. writes "Oral clindamycin with oral rifampicin for 12 weeks is an effective and tolerable regimen for HS" (4). Bettoli et al. writes "Clinical remission can be obtained in patients with HS using oral antibiotics (clindamycin-rifampin) combinations" (5).

The abundance of evidence-based literature is consistent. The preferred antibiotic agents are appropriate agents for the treatment of the patient's hidradenitis suppurativa. The formulary medications should be tried and failed prior to initiating Humira.

After a review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Humira prior to the formulary alternatives. There is no proof or documentation provided the patient has tried these preferred drugs and had an adverse effect or proof that these tried drugs did not work for the patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary Artery Disease (CAD).
Treatment: Inpatient Hospital.
The insurer denied the inpatient hospital admission. 
The health plan's determination is upheld.


This female patient presented to the hospital for scheduled intra-coronary brachytherapy for a 95% in-stent restenosis in her mid-left anterior descending coronary artery. Her medical history was remarkable for hypertension, hyperlipidemia, type 2 diabetes with neuropathy and chronic foot ulcers, and cigarette smoking. The brachytherapy was followed by balloon angioplasty; the procedure was uncomplicated. The patient was admitted to the hospital post-procedure and remained stable overnight. She was evaluated by a vascular surgeon and the wound care team for a necrotic lesion on her right third toe with mild erythema on her lower leg. She was then discharged.
At issue is the medical necessity of the inpatient hospital admission.
The health plan's determination of medical necessity is upheld in whole.
Based on the documentation provided an inpatient level of care was not medically necessary.
While some period of observation immediately following percutaneous coronary intervention (PCI) is needed to ensure hemodynamic and access site stability, as well as recovery from sedation, inpatient admission is not generally required for most patients. The 2009 Expert Consensus Document from the Society for Cardiovascular Angiography and Interventions recommends inpatient admission in patients with acute ST segment elevation or non-ST segment elevation myocardial infarction, and unstable acute coronary syndrome with hemodynamic instability or dynamic electrocardiographic changes. Additionally, inpatient admission is recommended for patients whose procedures are associated with significant access site or other complications. This patient met none of these criteria. Per the 2018 update to this document, with the exception of patients with ST segment elevation myocardial infarction, most stable patients can be discharged post-PCI on the day of the procedure, provided they are at their baseline functional and mental status and all of their baseline comorbidities are stable.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Obesity.
Treatment:  Saxenda.

The insurer denied Saxenda.  The denial is overturned.

The patient is a female with obesity and autoimmune thyroiditis. The medical necessity for Saxenda is the subject under review. The prior request was denied, as the patient has not been currently enrolled in a qualified complete weight management program for at least the past 3 months, with proof of current and prior enrollment and at least monthly participation. The patient's weight is 196 pounds with body mass index of 33.6 kilograms per square meter (kg/m2).

Saxenda is medically necessary for this patient for the treatment of obesity. The prior request was denied, as the patient has not been currently enrolled in a qualified complete weight management program for at least the past 3 months, with proof of current and prior enrollment and at least monthly participation. The Endocrine Society guidelines on the management of obesity indicate that diet, exercise, and behavioral modification should be included in obesity management and pharmacotherapy can be used as an adjunct to these measures, as drugs may amplify adherence to behavior change and may improve physical functioning. These guidelines indicate that patients who have a history of being unable to successfully lose and maintain weight loss and who meet label indications are candidates for weight loss medications. The guidelines do not indicate a 6-month trial of a comprehensive weight management program is needed. This patient is obese with a body mass index of 33.6 kg/m2, and Saxenda is being prescribed as an adjunct to reduced-calorie diet and increased physical activity, consistent with the Saxenda label. The documentation includes detailed fitness logs as well as physician notes indicating patient is tracking calories and eating healthy meals. Despite this, she is gaining weight. Without Saxenda, this patient will be at increased risk of the complications of untreated obesity, including type 2 diabetes. Therefore, the requested Saxenda is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: chronic pain.
Treatment: 10 additional visits of physical therapy.
The insurer denied: 10 additional visits of physical therapy.
The denial is: Upheld.

This is a female diagnosed with neck pain, temporomandibular joint (TMJ), sacroiliac (SI) joint and gluteal pain. Records indicate the patient has been treating for chronic pain with physical therapy and completed 20 sessions of physical therapy. It is noted that the provider requested approval for an additional 10 sessions of physical therapy that was determined to be not medically necessary as physical therapy is only medically necessary when the patient has an acute (short-term) restorative (healing) condition and records show that the patient is treating for chronic pain. The condition is not acute. The patient continues to have trouble with normal daily activities and ongoing pain. There is a note from the physical therapist stating that they agree with the denial at this point. It was noted that have been providing manual therapy which gives the patient temporary relief, but the patient does not improve (more of a maintenance treatment). He states that when the insurance denies further treatment, she self pays. The subject under review is the medical necessity for 10 additional physical therapy visits. 

The health plan's determination is upheld.

The requested health service/treatment of 10 additional physical therapy visits is not medically necessary for this patient. Per Official Disability Guidelines (ODG) by Milliman Care Guidelines (MCG), "Allow for fading of treatment frequency (from up to 3 visits per week to 1 or less), plus active self-directed home PT. Treatment should be "active", with formal re-assessment after a "6-visit clinical trial" to evaluate whether therapy has resulted in positive, negative, or no impact, prior to continuing or modifying treatment."
In this case, the patient is noted to have an ongoing chronic condition with pain in the neck, TMJ, SI joint and gluteal pain and has a diagnosis of Ehlers Danlos syndrome. The patient has had extensive ongoing physical therapy and appears to have long since entered the maintenance phase of treatment. There would be no expectation of further significant objective improvement or sustained functional benefit that would result from further physical therapy sessions. It appears that the patient is relying on modalities such as manual therapy/massage. It would be expected the patient can transition to a self-directed home exercise and stretching program at this point as no further significant progress would be expected for this chronic condition. An additional 10 visits of physical therapy are not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Malocclusion
Treatment: Braces (comprehensive orthodontic treatment)
The insurer denied coverage for braces (comprehensive orthodontic treatment)
The denial is upheld

 
Upon review of the submitted documentation including lateral cephalometric radiograph and tracings, panoramic radio graph, montage of extraoral and intraoral clinical images, as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to excessive overjet among other clinical findings. The orthodontist completed the Handicapping Labio-Lingual Deviations (HLD) index as required asserting the patient exhibits the automatically qualifying condition of overjet greater than 9 millimeters (mm) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties to support orthodontic necessity. 

Upon review of the submitted documentation, it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist claims an automatic qualifying condition of overjet greater than 9mm (millimeters) with incompetent lips or reverse overjet greater than 3.5 mm with reported masticatory/speech difficulties. This reviewer finds that this automatically qualifying condition is not met and does not support comprehensive orthodontic care using this criterion. In this case, the clinical circumstance does not meet insurer and plan criteria to justify orthodontic care.

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

Braces (comprehensive orthodontic treatment) are not considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for braces (comprehensive orthodontic treatment) is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic obstructive pulmonary disease, bipolar disorder, schizophrenia, cerebrovascular accident

Treatment: Long-term care admission

The insurer denied coverage for long-term care admission

The denial is overturned.

This is an adult patient with chronic medical problems including chronic obstructive pulmonary disease (COPD), bipolar disorder and schizophrenia. The patient was admitted to the skilled nursing facility (SNF) for subacute rehabilitation after transfer from the hospital for left hemiparesis due to a stroke. Under review is the medical necessity for long-term care admission. 

The patient was medically stable, and care is primarily custodial. However, long-term care placement was medically necessary, as services could not have been provided at a lower level of care (home with custodial home health aide services) in this particular situation. In addition, and according to the therapy notes, the patient made improvements with functional mobility during the time period under review. While modest, the improvements were sufficient to support the medical necessity of long-term care. This is particularly salient given the patient's eventual discharge to a shelter and need for highest functional level attainable in that specific environment. This physician would agree long-term care (custodial room and board) was clinically appropriate and medically necessary in this particular case. From a physical medicine and rehabilitation perspective, long-term care admission was medically necessary. 

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, 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.

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 long-term care admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ischemic heart disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

 
This is a patient with a history of ischemic heart disease, hypertension, and past coronary artery bypass grafting (CABG) that presented to the hospital for cardiac catheterization following complaints of exertional chest pain and dyspnea on exertion. Prior cardiac catheterization, performed several weeks earlier, revealed patent left internal mammary artery (LIMA) to the left anterior descending (LAD) artery, patent saphenous vein graft to the left circumflex (LCx) artery and patent right internal mammary artery (RIMA) to the right coronary artery (RCA). An occluded saphenous vein graft to the ramus intermedius artery was noted. Left main coronary artery stenosis and in stent restenosis of the RCA, proximal left circumflex and ramus intermedius arteries were noted. Left ventricular (LV) ejection fraction was preserved. The patient underwent successful percutaneous transluminal coronary angioplasty (PTCA) with atherectomy to the distal left main coronary artery and the bifurcation of the ramus intermedius and left circumflex arteries.  No perioperative complications were noted, and the patient was discharged the following day.

This patient presented for elective percutaneous revascularization. He underwent an uncomplicated procedure and successful intervention was performed to the distal left main, left circumflex and ramus arteries. The patient had a history of previous bypass surgery and was known to have normal left ventricular systolic function and patent grafts to the LAD, LCx and RCA arteries. He was discharged the following day. Several investigators have studied the safety surrounding same day discharge following percutaneous intervention and demonstrated no difference between patients that are discharged on the same day as compared to patients admitted to the hospital. (Reference1-4) Current expert consensus from the Society of Cardiovascular Angiography and Interventions support treatment at a lower level of care. (Reference 4) In conclusion inpatient admission was not medically necessary.  The patient could have been managed at a lower level of care.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Parkinson's Disease. 
Treatment: Personal Care Aide (PCA) Live in services, 7 days a week. 

The insurer denied coverage for Personal Care Aide (PCA) Live in services, 7 days a week. 

The denial is upheld. 

This is an elderly patient living in a 2nd floor apartment with elevator. Son is very involved in care. Cognitive skills are minimally impaired. The physician letter of appeal reports medical conditions and hardship for: transferring, toileting, food preparation, dressing, mobility and bathing. Comparing Uniform Assessment System (UAS) regarding activities of daily living (ADLs), bathing and lower body dressing are similar, personal hygiene is unchanged at limited assistance, frequently incontinent of bladder with some control and continent of bowel are unchanged. No falls in last 90 days.  Ambulation currently is noted as very limited but is inconsistent with physical therapy (PT) report noting ambulates 300 feet with rolling walker with assist. In sum, the change over time is not such that these problems cannot be handled with current level of service. There is no need for the 24 hour of coverage. There were no reported safety nor communication issues. 

The current records do not provide a medical reason why 7 days a week live in are necessary. There has been no change in medical status. There have been no recent falls. The last admission was a few months ago with subsequent stabilization for return to home. There are no reasons why an awake caregiver at bedside would be required. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide (PCA) Live in services, 7 days a week is not substantiated.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Dementia and rheumatoid arthritis
Treatment: Personal Care Aide (PCA) services for a total of 126 hours per week
The insurer denied coverage for Personal Care Aide (PCA) services for a total of 126 hours per week.
The denial is modified.

This is a patient with diagnoses that include dementia and rheumatoid arthritis. She lives with her spouse who is supportive and involved in her care. She is currently approved for Personal Care Aide (PCA) level 2: 6 hours/day- 7 days/week - for a total of 42 hours per week, and the request is for PCA Level 2: 6 hours/day- 7 days/week; 12 hours/day- 7 days//week for a total of 126 hours/week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as severely impaired. She is totally dependent for performing much of her Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires maximal assistance for bathing, dressing, bed mobility, ambulation (uses a walker) and toilet transfer/use. Extensive assistance is needed for personal hygiene and eating. The patient is frequently incontinent of bladder and occasionally incontinent of bowel. Her functional ability is much the same when compared to the previous UAS report. The patient's condition and functional needs are not at a level, unpredictable or significantly declining as to require the requested PCA 126 hours/week. This physician would agree the patient may require additional monitoring, particularly due to her nighttime wandering. However, safety monitoring under a PCA does not include monitoring an individual (with dementia) when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained by increasing PCA services to 12 hours/day, 7 days/week, totaling 84 hours/week. 

Based on the above, the insurer's denial must be modified. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Personal Care Aide (PCA) Level 2: 12 hours per day- 7 days per week for a total of 84 hours per week is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Mild Intermittent Asthma.
Treatment: Formulary exception for QVAR RediHaler (beclomethasone).

The insurer denied: Formulary exception for QVAR RediHaler (beclomethasone).  The denial is upheld.

The patient is an adult female with asthma. She was prescribed Qvar Redihaler. The medication was denied coverage by the health plan, due to lack of clinical documentation of trial and failure of formulary alternative, Flovent HFA (hydrofluoroalkane-134a), or Pulmicort Flexhaler. This denial is being appealed. The patient has tried and failed Anoro Ellipta and Bevespi Aerosphere.

The health plan should not cover the Formulary exception for QVAR RediHaler (beclomethasone). 

The patient has mild intermittent asthma. The patient has tried and failed Anoro Ellipta and Bevespi Aerosphere. The patient has not tried and failed or has contraindication to formulary alternatives Flovent HFA (hydrofluoroalkane-134a), or Pulmicort Flexhaler. There is lack of peer-reviewed medical literature that supports the use of Qvar Redihaler over the available formulary alternatives Flovent HFA (hydrofluoroalkane-134a), or Pulmicort Flexhaler. The health plan should not cover the requested health service. There is lack of clinical documentation that the formulary drug would be ineffective for this patient or would be not as effective as the requested non-formulary drug or has adverse effects for this patient.