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

Diagnosis: Spinal cord injury

Treatment: Long term care

The insurer denied coverage for long term care

The denial is upheld.

 
This is an adult with paraplegia due to a spinal cord injury.  She has been a long-term care resident for the past several years.  Under review is the medical necessity for continued long term care.

The nursing facility clinical documents were reviewed.  There are no specific medical, nursing or rehabilitation therapy indications for continued long term care.  According to the appeal letter, "the facility tried to discharge the patient to a shelter however, due to the patient's lacking state credential (social security number) we also had difficulty with the plan to transfer to a shelter.  The Supplemental Security Income (SSI) application was denied, and the Nursing Home issued a 30-day notice to the patient due to non payment of facility. "This paperwork will be sent to New York City Department of Homeless Services (NY DHS) referral."  A Transfer/Discharge Notice regarding the patient indicated "the interdisciplinary team has determined that the resident will be discharged to a shelter."  The reasons for continued inpatient stay are non-clinical, administrative and not supported as medically necessary.  

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued long term care inpatient admission was not medically necessary.

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 the continued long term care inpatient admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left supracondylar fracture

Treatment: Inpatient admission

The insurer denied coverage for Inpatient admission

The denial is overturned

According to the documentation submitted, this is a child who presented to the hospital as a transfer from another facility with complaints of a left supracondylar fracture. The patient underwent a left humerus open reduction and percutaneous pinning. 

The medical records show the young child sustained a complex fracture. There was gross instability. The physician reported to have attempted a closed reduction for 30 minutes which was unsuccessful. He thus performed an open reduction internal fixation. After surgery, the patient was given oral (PO) Tylenol and PO Motrin as needed (PRN). Intravenous (IV) fluids were given. The patient was discharged after a period of hemodynamic stability. 

These findings support the statement of need to admit secondary to risk of compartment syndrome. Multiple attempts at closed reduction increase the likelihood of bleeding and excessive swelling. 

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 inpatient admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Facial burns, COVID 19

Treatment: Continued stay at a skilled nursing facility (SNF)

The insurer denied coverage for continued stay at a SNF

The denial is upheld.

The patient is an adult male who is oxygen dependent via nasal cannula with chronic obstructive pulmonary disease (COPD) and has a history of hypertension and osteoarthritis. He was admitted to a SNF after being hospitalized for facial burns. He tested positive for Coronavirus disease 2019 (COVID 19) and was placed in isolation. During his stay he received physical and occupational therapy.  

The patient was initially appropriate for the SNF level of care. (1, 2, 3) His clinical condition and functional deficits were amenable to medical intervention and comprehensive rehabilitation. However, the clinical records do not document the patient receiving physical or occupational therapy on the dates in question. In addition, there were no specific acute medical or complicated nursing issues that required continued stay at the SNF during the time period under review.  

The insurer's denial of coverage for a continued stay at a skilled nursing facility (SNF) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral palsy. 
Treatment: Durable medical equipment (E0482RR x3) Cough Assist Device. 

The insurer denied: Durable medical equipment (E0482RR x3) Cough Assist Device. 
The denial is overturned. 

The patient is a school-aged female child with medical history significant for meconium aspiration with nine-day NICU (neonatal intensive care unit) hospitalization, cerebral palsy, generalized hypotonia with spastic quadriplegia, dorsal scoliosis, seizure disorder, failure to thrive and dysphagia status post gastrostomy tube placement, optic degeneration, laryngeal cleft status post repair, valgus leg deformity, and global developmental delay. Swallow study confirmed aspiration. She is unable to manage her secretions, drooling frequently, and requires assistance with airway clearance. Manual chest physiotherapy has been tried but does not increase her cough reflex to move secretions. She cannot tolerate the necessary positioning either. Suctioning clears her oropharynx but cannot facilitate lower airway clearance. She has used nebulized medications and inhaler with spacer, neither of which is sufficient to clear airway secretions. A cough assist device has been prescribed to facilitate airway clearance. 

The requested Cough Assist Device is medically necessary and appropriate for this child. 

Children with neurologic impairment may have deficits in any (or all) of the three phases of cough: inspiratory, compressive, and expiratory. For children with spastic quadriplegic cerebral palsy specifically, dystonia and dyscoordination contribute to ineffective cough. Additional issues contribute, such as chronic aspiration, decreasing sensitivity to cough and scoliosis with decreased mobility contributing to poor ventilation. Taken together, these children develop atelectasis, inadequate clearance of lower airway secretions, increased frequency of infection, and resultant prolonged hospitalization. It is difficult for children with spastic quadriplegic cerebral palsy to tolerate manual chest physiotherapy because of their chest deformity, cognitive delay, and inability to cooperate. Additional techniques have been developed to facilitate airway clearance in this population. 
This young female child has significant disability from spastic quadriplegic cerebral palsy. She is not able to tolerate her secretions and is at risk for aspiration. The family has attempted manual chest physiotherapy, but the child is not able to tolerate the necessary positioning. Chest physiotherapy is also not able promote cough to help expectorate deep secretions. The requested cough assist device is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epigastric pain and nausea
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adult male patient who had a history of hemorrhoids. The patient reported a month history of intermittent epigastric pain associated with nausea and emesis. The patient had undergone several outpatient evaluations with no significant findings and supportive therapy recommendations. Antecedent to this admission, the patient had episodes of watery diarrhea, abdominal discomfort, and fevers to 103 degrees - as per the patient. The patient had an isolated leukocytosis of 17.1. 
In the emergency department, the patient evidenced hemodynamic stability. Right lower quadrant tenderness was noted on physical exam. A computed tomography scan showed possible enterocolitis of the terminal ileum and colon. The patient received supportive care including intravenous fluid and antibiotics for the treatment of the diagnosis of Yersinia enterocolitica. The patient responded to treatment and cultures were negative on discharge.

The proposed inpatient hospital admission was not medically necessary.

The evaluation and treatments as rendered were medically appropriate; however, the level at which the care was provided was not medically necessary. Despite the patient's presentation, the care as provided could have been rendered in its entirety at 
a lower level of care. This patient had a gastrointestinal infection; yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for nothing by mouth status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias, failure of outpatient therapy or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma.
Treatment: Inpatient Hospital Admission.

The insurer denied the Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female with asthma. She presented to the ER (emergency room) with shortness of breath. The patient was found to be in asthma exacerbation. The patient received duonebs, IV (intravenous) steroids, and IV (intravenous) magnesium sulfate. The patient was admitted to acute inpatient level of care for further management. The patient was started on IV (intravenous) steroids and duonebs. The acute inpatient admission was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

The patient had asthma exacerbation. The patient improved with ER (emergency room) care and was hemodynamically stable and was not in any respiratory distress. The patient did not need any supplemental oxygen. Given the patient's signs and symptoms due to asthma exacerbation improved significantly with ER (emergency room) care, the patient's treatment course would have been expected to be safe and effective at a lower level of care. The treatment provided to this patient was reasonably expected to be provided but did not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck Pain
Treatment: Facet Joint Injections (64490x1, 64491x1, 64492x1)
The insurer denied facet joint injections (64490x1, 64491x1, 64492x1).
The denial is overturned.

The patient is an adult female with axial neck pain. As of recently, the patient's pain was a seven to eight out of ten (7-8/10). She has tried three months of physical therapy and non-steroidal anti-inflammatory drugs (NSAIDs). On physical exam, the patient was shown to have positive facet loading. Cervical x-ray obtained was significant for degenerative disc disease and facet arthropathy per physician. No signs of fracture, tumor, infection, or extraspinal lesion were seen on imaging. The request for cervical (C) medial branch block at right C4-C7 was denied due to lack of imaging reports.

The proposed treatment is medically necessary.

The patient is an adult female with axial neck pain. As of recently, the patient's pain was a seven to eight out of ten (7-8/10). She has tried three months of physical therapy and NSAIDs. On physical exam, the patient was shown to have positive facet loading. Cervical x-ray obtained is significant for degenerative disc disease and facet arthropathy per physician. No signs of fracture, tumor, infection, or extraspinal lesion were seen on imaging. As such, the proposed treatment is considered medically necessary as per standard guidelines for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypertension, arthritis and dementia.
Treatment: Consumer directed personal assistance services (CDPAS), 7 days per week, 2-12 hours split shift.
The insurer denied coverage for CDPAS, 7 days per week, 2-12 hours split shift.
The denial is overturned.

This is an elderly patient with multiple medical problems including hypertension, arthritis, and dementia. She lives alone. The insurer reduced CDPAS hours from split-shift to live in reportedly due to the patient no longer meeting the criteria for the split shift level of service. The insurer asserts, the patient's live-in CDPAS worker can get 5 hours of continuous sleep, which does not need to happen during the nighttime hours. The patient is requesting reinstatement of CDPAS 7 days per week, 2-12 hours split shift.

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." She requires maximal assistance for bathing, personal hygiene, dressing, toilet transfers/use. She is frequently incontinent of bowel and bladder. Extensive assistance is needed for bed mobility and eating. The patient's medical condition and essentially total dependence to maximal assistance for instrumental activities of daily living (IADL) and functional needs are at a level or unpredictable as to require the requested personal care aide (PCA) services 24 hours/day, 7 days/week (split shift). Based on the records reviewed, the live-in CDPAS is unlikely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. The patient's health and safety was more appropriately provided and maintained at home with the previously approved CDPAS services 24 hours/day, 7 days/week split shift.

From a physical medicine and rehabilitation perspective, CDPAS, 7 days per week, 2-12 hours (split shift) is medically necessary.    

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 consumer directed personal assistance services (CDPAS), 7 days per week, 2-12 hours split shift services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, stroke with left hemiplegia, joint contractures, and aphasia
Treatment: Personal care aide (PCA) level 2: live-in per diem - 1 days - 7 days per week - a total of 7 days per week
The insurer denied coverage for PCA level 2: live-in per diem - 1 days - 7 days per week - a total of 7 days per week.
The denial is overturned.

This is an elderly adult with multiple medical problems including coronary artery disease, stroke with left hemiplegia, joint contractures, and aphasia. He also has chronic obstructive pulmonary disease (COPD) and pressure ulcer. He lives with his wife in a 3-bedroom apartment.  

The recent Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "Modified independence." However, he is totally dependent for bathing, lower body dressing and toilet transfer/use. He requires maximal assistance for personal hygiene, upper body dressing and bed mobility. He has a Foley catheter that is managed by the caregiver and completely incontinent of bowel. He is non-ambulatory. The patient's medical condition and essentially total dependence to maximal assistance functional needs are at a level or unpredictable as to require the requested PCA services 24 hours/day, 7 days/week (live-in). Of particular concern is his need for maximal assistance with bed mobility, complete bowel incontinent and pressure ulcers that place at high risk for falls and severe infections.  

From a physical medicine and rehabilitation perspective, PCA services level 2: live-in per diem - 1 days - 7 days per week - a total of 7 days per week is medically necessary.    

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 PCA level 2: live-in per diem - 1 days - 7 days per week - a total of 7 days per week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: hypogammaglobulinemia
Treatment: Gammagard
The insurer denied Gammagard.
The health plan's determination is upheld.

This is a female patient with hypogammaglobulinemia, NOD2 (Nucleotide-binding oligomerization domain-containing protein 2) disease. The request is for Gammagard.
A patient letter states that she has recurrent infections. She has periodic fever syndrome and is on Actemra and Xolair and has recurrent prednisone use. She has waning strep titers post pneumovax but the initial post vaccine titers were low. She has immunoglobulin G (IgG) as low as 557, low IgA (immunoglobulin) and low IgM (immunoglobulin M). She has low CD19 B (Cluster of Differentiation 19) cells.

Gammagard is not medically necessary.
The patient's initial vaccine titers were good although they are waning. She has low IgG/IgA and IgM. She has hypogammaglobulinemia. Bonilla et al and practice guidelines recommend prophylactic antibiotics for this diagnosis prior to the use of immune globulin which she has not done yet. Therefore, Gammagard is not medically necessary and is not SOC (standard of care).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic back pain
Treatment: Procedure codes 63650 and 63685
The insurer denied coverage for procedure codes 63650 and 63685.
The denial is upheld.

This patient has chronic back pain from scoliosis with neuropathic pain in the lower extremities. The patient has failed conservative measures including medication trials and Physical Therapy, and recently had a spinal neurostimulator trial which provided greater than 50% pain relief, improved their quality of life and ability to function. The patient is a candidate for percutaneous implantation of spinal neurostimulator, targeting the bilateral thoracic (T) 12 and sacral (S) 1 dermatomes. She declines corrective spine surgery.
	
Deer et al (1) have published a Consensus recommendation guide and specifically in Table 5
(Table 5. Consensus Recommendations Regarding Dorsal Root Ganglion (DRG) Stimulation From the Neuromodulation Appropriateness Consensus Committee (NACC).) it states:

"The NACC appreciates that the current evidence for non-diabetic peripheral neuropathy is limited. More robust prospective trials are needed to determine if the efficacy seen in the diabetic population can be extrapolated to other populations. The NACC recommends these patients be treated on a case-by-case basis, and that if the pain is neuropathic in nature there is a good likelihood of response. Level III, Grade B, Consensus Moderate"

Stelter et al (2) also conducted a systematic review and concluded:

"Dorsal root ganglion stimulation (DRGS) continues to lack supportive evidence from well-designed, high-level studies and recommendations from consensus committee experts. However, we present repeated and consistent evidence from lower-level studies showing success with the use of DRGS for various non- complex regional pain syndrome (CRPS) chronic pain syndromes in reducing pain along with increasing function and quality of life (QOL) from one week to three years. Due to such low-level, high bias evidence, we strongly encourage the continuation of high-level studies in order to provide a stronger foundation for the use of DRGS in non-CRPS chronic pain patients. However, it may be reasonable and appropriate to evaluate patients for DRGS candidacy on a case-by-case basis particularly if they manifest focal pain syndromes refractory to noninterventional measures and may not be ideal candidates for other forms of neuromodulation."

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 procedure codes 63650 and 63685, date to be determined is not substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine
Treatment: Nurtec 75 milligrams (mg) orally disintegrating tablet (ODT)
The insurer denied the Nurtec 75 mg ODT.
The denial is overturned.

The treating provider has diagnosed the patient with chronic severe migraines happening at least 15 times a month. The patient has tried and failed two triptans. The patient's provider noted that the patient stopped Propranolol and Relpax due to side effects and ineffectiveness. The patient could not take Topamax due to suspected nephrolithiasis. The treating provider is requesting therapy with Nurtec (Rimegepant) 75 milligrams (mg) orally disintegrating tablet (ODT) as abortive and preventative migraine therapy. 

Rimegepant is a small molecule inhibitor of the receptor for the calcitonin gene-related peptide (CGRP), which is believed to play a role in the pathogenesis of migraine headaches. CGRP is a potent vasodilator and pain-signaling neurotransmitter that is found throughout the central and peripheral nervous system but is particularly common in trigeminal ganglia. Levels of CGRP are elevated during episodes of migraine headache, and administration of the peptide can induce migraines in susceptible patients. For this reason, approaches to inhibition of CGRP signaling were developed as potential therapies for migraine, both as preventive therapies to decrease the rate of migraines as well as for treatment of acute attacks. [4] Taken every other day, Rimegepant was effective for preventive treatment of migraine. Tolerability was similar to that of placebo, and no unexpected or serious safety issues were noted. [2]

The patient has already tried and failed two triptans. There is suspected nephrolithiasis. The use of non-steroidal anti-inflammatory drugs (NSAIDs) can cause kidney injury and gastrointestinal (GI) side effects. The formulary drugs that have been trialed have been ineffective based on the patient's clinical history. The formulary medications do list CRGP antagonists. However, all 3 are preventative. In contrast, small-molecule CGRP antagonists (also termed gepants) are oral options available for the acute treatment of migraine in patients with either insufficient response or contraindication (such as coronary artery disease) to treatment with triptans. Nurtec (Rimegepant) is a type of small-molecule CGRP antagonist and is an option for the acute treatment of migraine in patients with either insufficient response or contraindication (such as coronary artery disease) to treatment with triptans. [1] Nurtec can provide both abortive and preventative effects [3] and is an appropriate next step in this patient's care.

The formulary drugs are expected to cause adverse effects. The formulary drugs were tried, and the patient did have an adverse reaction or contraindication. The formulary drugs are expected to be ineffective. The non-formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of request for formulary exception for Nurtec 75 mg ODT to treat chronic severe migraines is overturned.