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

Diagnosis: Foot Pain (plantar faciitis). 
Treatment: Durable Medial Equipment (custom shoe inserts). 

The insurer denied the Durable Medial Equipment (custom shoe inserts). 
The denial is upheld. 

The patient is a male. The patient presented with the chief complaint of painful feet, specifically with pain in the anterior plantar foot (ball of the foot) with the presence of plantar callosities in the metatarsal head region. He has been treated with OTC (over the counter)/Custom (L3020) devices and debridement of the calluses. 

No, the custom shoe inserts are not medically necessary. 

The diagnosis of plantar fasciitis that is noted on the orthotic prescription and appeal letter is nowhere to be found in the medical notes. On the contrary, the notes document pain in the metatarsal head region rather than the arch/heel area, where plantar fasciitis pain would manifest itself. 

Also the appeal letter states that the patient has already been using custom devices (L3020) without success. There is no reason to suggest that new custom devices would work better than the current ones. 

Yes, the health plan did act reasonably, with sounds medical judgment, and in the best interest of the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II Diabetes, Hyperglycemia
Treatment: Janumet, Pre-service
The insurer denied the Janumet, Pre-service
The denial is upheld.

This is an adult male with type 2 diabetes.  He has tried and failed Januvia and Invokana. The request for Janumet is under review.  The request was denied as the patient has not tried and failed Jentadueto and Jentadueto XR (extended release).

No. The health plan should not cover the request for Janumet. 

This patient does not have a documented trial of the formulary alternatives Jentadueto or Jentadueto XR (extended release). These formulary alternatives are expected to be equally safe and effective as Janumet in this clinical situation.  The American Diabetes Association do not recommend the use of Janumet over the formulary alternatives.  Therefore, the health plan should not cover the request for Janumet.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Nausea and vomiting 
Treatment: Inpatient admission 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male. He presented with recent nausea and vomiting, for EGD (esophagogastroduodenoscopy). EGD (esophagogastroduodenoscopy) revealed severe esophagitis. He was admitted, hydrated, placed on a clear liquid diet and IV (intravenous) PPIs (proton pump inhibitors) and Zofran. On day two it was noted he tolerated a clear liquid diet and was advanced to a soft diet. On day three he was discharged. 

No, the inpatient admission was not medically necessary. 

The patient was found to have severe esophagitis on endoscopy. He was tolerating a clear liquid diet after the endoscopy. As there was no evidence of dehydration, electrolyte abnormalities, GI (gastrointestinal) bleeding, intractable vomiting, inability to tolerate oral intake, sepsis or complications after the endoscopy, observation status was medically appropriate. On day two, when he was tolerating a soft diet, he was medically stable for discharge. The proposed acute inpatient hospital stay was not medically necessary. 

As acute inpatient admission was not medically necessary, the health plan acted reasonably, with sound medical judgement, and in the best interest of the patient by denying it.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Coronary Syndrome

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is upheld

This patient presented to the emergency department for presurgical clearance with complaints of dyspnea on exertion and chest discomfort.  

The submitted documentation indicated he does have a history of hypertension as well as hyperlipidemia, diabetes, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD) with percutaneous coronary intervention (PCI) to the left anterior descending (LAD) artery and is an active smoker.  He was initially being seen for cardiac clearance prior to a spinal laminectomy.  The submitted documentation indicated he did complain of shortness of breath with walking to his car with chest discomfort.  An electrocardiogram (EKG) revealed non-specific ST (interval on EKG) abnormality nuclear stress test revealed a moderate sized fixed defect with a moderate sized peri-infarct ischemia.  

The physical examination revealed a heart rate of 58 with a blood pressure of 144/72.  Oxygen saturation was 96% (percent).  It was recommended he undergo laboratory diagnostic studies.  The physician indicated it was recommended he be admitted due to the abnormal EKG to assess coronary anatomy.  The documentation indicated he was admitted and underwent a cardiac catheterization with PCI without any complication.  The documentation detailed was recommended he be discharged the following day with instruction to follow-up.  

This patient presented to undergo a preoperative assessment and was found to have acute coronary syndrome (ACS). ACS in addition to abnormal stress test and cardiac catherization and PCI all meet 48-hour observation status not inpatient level of care status. Prolonged hospital care in an inpatient level of care was not indicated. 

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

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

Diagnosis: Diabetes

Treatment inpatient admission

The insurer denied coverage for inpatient admission

The denial is overturned

The patient presented to the emergency room (ER) with complaints of new onset diabetes. Findings at the Pediatrician's office were significant for hyperglycemia, hypercholesterolemia, and ketonuria. He was given intravenous (IV) fluids and Lispro. The patient was admitted.

Diabetes education consists of several components, nutritional counseling, self-monitoring of blood glucose and treatment of hyper and hypoglycemia. The standard of care is that all patients with diabetes should receive all these components (1, 2). 

Practice patterns differ depending on the availability of educators etc. Whether a patient gets hospitalized for intensive insulin therapy initiation depends on the available program where the patient is seen.

The majority (75% [percent]) of medical centers in the US [United States] (3) that treat new onset type 1 diabetes admit their patients. According to the American Diabetic Association (ADA) statement on treatment of type 1 diabetes(4), hospitalization is necessary regardless of severity if, "the center is not experienced in the outpatient management of newly diagnosed children with diabetes or is not adequately staffed to provide outpatient care because regional health care reimbursement is inadequate for initial outpatient care and education."  

In pediatric patients the differentiation between type I diabetes and type II diabetes is not straightforward at admission. The final diagnosis is made after a patient's antibodies return showing positive antibodies consistent with type I or negative antibodies consistent with type II. All patients with hemoglobin A1c [glycated hemoglobin] in the double digits or who are symptomatic are admitted for insulin initiation and diabetes education(5-8). 

This patient had symptomatic diabetes with polyuria, polydipsia, weight loss, ketosis and a hemoglobin A1c of greater than 14%. The patient was appropriately admitted for diabetes education for insulin injections, sliding scale, and insulin to carbohydrate ratio, treatment of hypoglycemia. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

Based on the above, the medical necessity for the inpatient admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD) on home oxygen, and congestive heart failure (CHF) 
Treatment: Inpatient admission 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a male with coronary artery disease (CAD), chronic obstructive pulmonary disease (COPD) on home oxygen, and congestive heart failure (CHF) who was transferred from one facility to another for the management of acute on chronic respiratory failure due to COPD exacerbation and CHF exacerbation. In the initial hospital emergency department (ED), the patient was treated with supplemental oxygen, intravenous (IV) steroids, and intravenous Lasix. At the second hospital emergency department, the patient was started on bi-level positive airway pressure (BiPAP) and was admitted to acute in-hospital level of care for further management. At the time of admission, the patient was doing well and was considered stable to be discharged home. The inpatient emergency admission is denied due to lack of medical necessity. This denial is being appealed. 

No, the proposed treatment was not medically necessary. 

The patient was treated with supplemental oxygen, intravenous steroids, intravenous Lasix and bi-level positive airway pressure (BiPAP) in the emergency room with good clinical improvement. At the time of admission, the patient was doing well and was considered stable to be discharged home. The patient was hemodynamically stable and off bi-level positive airway pressure (BiPAP). The patient was on home oxygen. The patient was able to take oral diet and oral medications. The inpatient emergency admission was not medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Central Nervous System/Neuromuscular Disorder.
Treatment: Pharmacy/Prescription Drug: Ubrevly. 
The insurer denied Ubrevly. 
The denial is upheld.

The patient is a female who has been under the care of a neurologist for migraine headaches.
The patient had reported a history of migraine since her teenage years. The patient's medical history also included low back pain, anxiety, and depression. The patient was reported to have started duloxetine 10 milligrams (mg) 3 weeks prior to the consult for depression. The patient had also trialed propranolol 2.5mg for anxiety on a as needed (PRN) basis. The patient had been using sumatriptan for acute treatment of migraine.
At the time of the visit the patient was advised to titrate duloxetine to at least 20mg/day. She was advised to increase propranolol to at least 10mg three times per day (TID). The patient was advised to use sumatriptan PRN. She was also prescribed Ubrelvy or Reyvow for the acute treatment of her headaches and she was prescribed both drugs.
The patient was seen for follow-up. At that time the patient reported having headaches only 1-2 times per week. The patient reported no taking propranolol but had increased duloxetine to 30mg. The patient reported a positive response to Ubrelvy including a lack of side effects.
A request has been made of the patient's health plan for coverage of Ubrelvy.

The health plan's determination is upheld.

The patient is only noted to have trialed sumatriptan for the acute treatment of her migraines (based on the medical records provided for review). It otherwise cannot be concluded from the information provided or by current medical literature that the remaining formulary drugs dihydroergotamine mesylate injection; eletriptan tablet; ergotamine with caffeine tablet; frovatriptan tablet; naratriptan tablet; rizatriptan orally disintegrating tablet [ODT]/tablet; zolmitriptan ODT/tablet; zolmitriptan nasal spray) would be inferior to the non-formulary drug (Ubrelvy).
There otherwise have not yet been comparison studies completed between Calcitonin gene-related peptide (CGRP) drugs used for the acute treatment of migraine and triptans. Rather, as Dodick and colleagues noted: "Further trials are needed to determine the durability and safety of ubrogepant for acute migraine treatment and to compare it with other drugs for migraine" (2019).
Nor can it be determined based on current literature that the requested drug is expected to have a superior side effect profile to the preferred agents.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hirschsprung disease

Treatment: The private duty nursing (PDN) services, 366 hours of Registered Nursing and 1,098 hours of Licensed Practical Nursing

The insurer is denied coverage for the private duty nursing (PDN) services, 366 hours of Registered Nursing and 1,098 hours of Licensed Practical Nursing.

The denial is upheld. 

This male patient has a history of Hirschsprung disease and ileostomy.

This patient's medical condition and care needs do not meet standards for medical necessity for continuation of 24 hours of private duty nursing per day. His peri-operative surgical complications have resolved, and his chronic care needs appear routine and within the family's ability to perform independently meriting the proposed reduction and termination in hours of skilled nursing coverage. I agree with the insurer's assertion that his care needs are those of a peer aged child (without added complexity related to a well-functioning ileostomy). Despite the burdens of this toddler's care, his needs are custodial in nature and do not require skilled nursing. Periodic adjustments in this patient's treatment plan will continue to occur guided by his chronic multidisciplinary treatment team and can be reassessed after his next surgery. This decision was rendered based on review of the medical record, the criteria for private duty nursing and from UpToDate reviewing the assessment and management of aspiration due to swallowing dysfunction in children.

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the private duty nursing (PDN) services, 366 hours of Registered Nursing and 1,098 hours of Licensed Practical Nursing is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, arthritis, heart disease, heart failure, benign hyperplasia and incontinence

Treatment: Consumer directed personal care assistance services (CDPAS), 24 hours per day, 7 days per week, live-in

The insurer denied coverage for consumer directed personal care assistance services (CDPAS), 24 hours per day, 7 days per week, live-in.

The denial is overturned.

The patient is an elderly male with a medical history of dementia, arthritis, heart disease, heart failure, benign hyperplasia and incontinence. He has had multiple falls and a stage 1 decubitus ulcer. Per the Uniform Assessment System - New York (UAS-NY) Comprehensive Community Health Assessment Report, the patient lives alone. He has dementia. Assistance is needed for activities of daily living (ADLs) and instrumental activities of daily living (IADLs). He needs extensive-maximal assistance with ADLs including bed mobility, locomotion, dressing and transfers.  

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The patient has impairments as noted above. Of note are cognitive problems, requirement for assistance with all functions, urinary incontinence, and skin breakdown. The patient has diapers and durable medical equipment (DME). But he cannot manage them on his own. He would have unscheduled nighttime needs and cannot move in bed. There are no scheduled informal caregivers.

The provision of diapers is not by itself adequate for prevention of pressure sores. Changing diapers regularly and positioning are also necessary. The patient has 24-hour requirements for assistance. The denial is overturned. 

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

The insurer's denial of coverage for consumer directed personal care assistance services (CDPAS), 24 hours per day, 7 days per week, live-in is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Alpha 1 Deficiency
Treatment: Alpha-1-proteinase inhibitor
The insurer denied alpha-1-proteinase inhibitor.
The determination is upheld.

The patient is a never smoker, with a history of alpha-1-antitrypsin deficiency (protease inhibitor Z allele [PiMZ]) with the most recent alpha 1 antitrypsin (AAT) serum concentration level of 84 milligrams per deciliter (mg/dL). Her pulmonary function testing demonstrates a restrictive lung defect with a normal gas diffusion capacity. There is no computed tomography (CT) scan of the chest or chest x-ray evidence of emphysema.
At issue is the medical necessity of alpha-1-proteinase inhibitor.

The requested health service/treatment of alpha-1-proteinase inhibitor is not medically necessary for this patient.
Per the clinical information, the patient has with a PiMZ genotype alpha 1-antitrypsin (AAT) deficiency, a baseline alpha 1 antitrypsin serum concentration of 84 mg/dL, is a never smoker, does not have emphysema as demonstrated on CT chest and has pulmonary function testing demonstrating a restrictive lung defect with a normal gas diffusion capacity.
The Current American Thoracic Society (ATS) and European Respiratory Society (ERS) statement on the diagnosis and management of AAT deficiency does not recommend augmentation therapy for patients with heterozygous phenotypes whose plasma AAT level exceeds 11 micromoles per liter (mol/L) (corresponds to 80 mg/dL measured by radial immunodiffusion), such as in this patient. In addition, the ATS/ERS guidelines further state, benefits in individuals with no airflow obstruction, such as in this patient, are less clear. In this patient the request was for alpha-1-proteinase inhibitor was to reduce the decline of lung function (eg. forced expiratory volume in one second [FEV1] ). At this time, there is limited evidence that supports the hypothesis that AAT augmentation therapy slows the deterioration of lung function. Therefore, it would not be considered medically necessary, as it is not reasonably expected to prevent an illness or expected reduce/improve developmental effects of an illness and is not considered generally accepted standard of medical practice per the literature/national guidelines. In addition, without a genotype of protease inhibitor ZZ (PiZZ), PiZ(null),or Pi(null)(null) or other rare AAT deficiency, AAT level less than (<) 80 milligrams per deciliter (mg/dL) and emphysema confirmed by pulmonary function testing, the alpha-1-proteinase inhibitor would not be considered medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Opioid use disorder. 
Treatment: Buprenorphine-Naloxone sublingual (SL) film. 

The insurer is denied coverage for Buprenorphine-Naloxone sublingual (SL) film. 

The denial is upheld. 

This male patient has a history of opioid use disorder. 

This reviewer agrees with the decision to deny coverage for formulary exception for buprenorphine-naloxone sublingual (SL) film 8 mg/2 mg three times per day as the medical records did not provide enough specific evidence to support that he could not tolerate the recommended formulary medication such as Buprenorphine-naloxone tablets. 

The medical records did not document that this patient took any formulary recommended medications with lack of reported efficacy or reports of adverse effects or contraindication to them. Also, there were no reports of documented inability to tolerate tablets or difficulty swallowing with inability to take tablets of Buprenorphine-naloxone. 

The American Psychiatric Association (APA) Practice Guidelines for the Treatment of Patients with Substance Use Disorders reports that there are two forms of the sublingual tablet: a buprenorphine-only tablet and a combination tablet of buprenorphine and the opioid antagonist naloxone which is Suboxone. Either one is considered medically necessary and appropriate for treatment of opioid dependence. It states that both forms of buprenorphine tablets are schedule III medications in the United States. Like methadone, buprenorphine can suppress opioid withdrawal and block the effects of other opioids. Another notable difference from methadone is that overdose with buprenorphine or buprenorphine-naloxone generally does not produce significant respiratory depression which probably reflects buprenorphine's partial mu agonist effects.

There was no specific reported documentation supporting that Buprenorphine-Naloxone sublingual (SL) film 8 mg/2 mg three times per day would more likely be effective than formulary medications. 

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient. 

The carrier's denial of coverage for Buprenorphine-Naloxone sublingual (SL) film is upheld.