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

Diagnosis: Psoriasis and Psoriatic Arthritis
Treatment: Tremfya
The insurer denied Tremfya.
The determination is upheld.

This is a female patient with psoriasis and psoriatic arthritis. The body surface area affected is 30 percent (%). She has tried and failed Cosentyx and Humira. The medication under review for medical necessity is Tremfya.

The requested health treatment of Tremfya is not medically necessary for this patient. There are no comparative, controlled studies showing that Tremfya has a superior efficacy or safety profile to all the formulary alternatives such as Enbrel. According to the American Academy of Dermatology Psoriasis Guidelines and dermatology literature, the health plan's preferred medicines such as Enbrel are effective treatments for the management of psoriasis and psoriatic arthritis (1, 2). Within the peer-reviewed literature, Kivelevitch writes "Anti-tumor necrosis factor (TNF) agents are currently considered as first line biological therapies for the treatment of moderate to severe psoriasis and psoriatic arthritis" (3). The preferred agents are appropriate agents for the treatment of the patient's psoriasis and psoriatic arthritis. The formulary medications should be tried and failed prior to initiating Tremfya. It is noted that the patient has tried and failed many therapies. However, after review of the clinical documentation, there is no documentation provided that would justify the patient requiring treatment with Tremfya prior to the formulary alternatives such as Enbrel. The patient has no contraindications to the use of Enbrel.  A history of fatty liver disease and previous failure to TNF are not true contraindications to the use of Enbrel.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diverticulitis
Treatment: Inpatient admission
The insurer denied coverage for inpatient admission
The denial is upheld

The patient presented with abdominal pain. She was afebrile and the vital signs were stable. There was no abdominal rebound or guarding. The white blood cell (WBC) count was 13.5. A computed tomography (CT) scan showed diverticulitis with a punctate focus of air which was possibly extraluminal. The attending radiologist wrote a note which stated that the described air may simply be within the diverticulum rather than reflecting a rupture. Intravenous (IV) antibiotics were given and symptoms improved. 

Clinical indications for admission for Acute Diverticulitis per Milliman Care Guidelines (MCG M-150} include hemodynamic instability, peritoneal signs, persistent gross rectal bleeding, and a significant abnormality found on an imaging study. This abnormality can be a fistula, obstruction, or free perforation such as air under the diaphragm. The patient did not have these conditions. She also did not require a drainage procedure, have severe vomiting, severe dehydration, or the inability to maintain oral hydration after observation care. 

This patient had acute diverticulitis and required antibiotic therapy. She did not meet Milliman Care Guidelines (MCG) criteria for admission for Acute Diverticulitis. 

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 full hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: varus deformity of the left femur and tibia 
Treatment: inpatient stay
The insurer denied the inpatient stay. The health plan's determination is overturned. 

The patient is a woman with X-linked hypophosphatemic Vitamin D-resistant rickets. Treatment has included monthly injections of burosumab and osteotomies of her right femur and tibia to address varus deformity. She had varus deformity of the left femur and tibia and underwent osteotomies of the left femur and tibia with internal fixation using interlocking intramedullary nails. She also had a prophylactic fasciotomy of the compartments of the left leg. Spinal anesthesia as used, and postoperatively the patient had a Dilaudid PCA (patient-controlled analgesic) pump for pain control.

The inpatient hospital admission was medically necessary.
Osteotomy of the femur and tibia are both major surgical procedures with some risk of complication, and both could be expected to lead to substantial post-operative pain, possible need for transfusion, and the need for careful monitoring. Even with the prophylactic fasciotomy, there is some risk of compartment syndrome which can be difficult to detect. The procedure was lengthy, the patient had spinal anesthesia and a PCA (patient-controlled analgesic) pump and had surgery on both her femur and the tibia; slow mobilization and difficulty carrying out activities of daily living would be expected after this type of surgery. The intensity of the care required by this patient justifies inpatient hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cerebral palsy.
Treatment: Consumer Directed Personal Assistance Services For A Total of 26 Hours Per Week.
The insurer denied: Consumer Directed Personal Assistance Services For A Total of 26 Hours Per Week.
The denial is overturned.

The patient is a toddler female with cerebral palsy. Denial of consumer directed personal assistance services for a total of 26 hours per week is being appealed. The plan approved a 
total of 11 hours per week. Her parent notes that she uses a wheelchair, is fed by G (gastrostomy)-tube and has convulsions.
Uniform Assessment System (UAS) evaluation completed 2 months ago notes the mother reports the child has frequent seizures and makes it difficult to finish ADLs (activities of daily living). An appeal statement notes that the patient has constant needs and requires 1:1 supervision and assistance with all ADLs (activities of daily living). She lives with her mother and six-year-old brother.
A letter from the patient's provider notes the patient has cerebral palsy, visual impairment, global developmental delay, hypotonia, and seizures disorder. She has total dependence for ADLs (activities of daily living) and requires constant 1:1 supervision. It is difficulty for her mother as a single parent to complete ADLs (activities of daily living). Increased personal care services are medically necessary.

The Consumer Directed Personal Assistance Services For A Total of 26 Hours Per Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of consumer directed personal assistance services for a total of 26 hours per week is being appealed. The plan approved a total of 11 hours per week. This patient has multiple chronic conditions, including cerebral palsy, global developmental delay, and seizure disorder. Uniform Assessment System (UAS) evaluation completed 2 months ago shows the patient is wheelchair bound and dependent with ADLs (activities of daily living). The patient has frequent seizures requiring the mother's care. Appeals statements support the patient is dependent with all ADLs (activities of daily living) and requires constant supervision. This patient requires total care. The approved consumer directed personal assistance services for a total of 11 hours per week is insufficient to meet this patient's needs for total care. The requested increase consumer directed personal assistance services for a total of 26 hours per week is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dental malocclusion.
Treatment:  D8080 braces.

The insurer denied coverage for D8080 braces.  The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, narrative letter as well as insurer correspondence, this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite, and ectopic eruption. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) index attaining 49 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements attaining only 24 points on the HLD index by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after the 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 completed the second portion of the index arriving at 49 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which remains above the threshold of 26 points to support 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.

The recommendation is to overturn the denial as the clinical circumstance as presented, does meet and substantiate the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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 D8080 braces is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder 
Treatment: Mental Health Residential Treatment Center
The insurer denied coverage for Mental Health Residential Treatment Center
The denial is overturned
 

This young adult was admitted to this inpatient mental health residential treatment due to mood instability, poor coping skills, emotional dysregulation, suicidal thoughts, anxiety symptoms, interpersonal struggles, and a history of self-harm behaviors. She reportedly had past suicide attempts by overdose within the past year prior to admission with resulting psychiatric hospitalizations. She had multiple psychotherapists and past medication trials including Lexapro, Prozac, Effexor, Trazodone, Wellbutrin, Lamictal, Abilify, Latuda, Seroquel, Risperidone, Ativan, Buspirone, Klonopin, and ketamine treatments, and she also had electroconvulsive therapy (ECT) treatments without efficacy reported. She had diagnoses of Borderline Personality Disorder, Bipolar Depression, and Generalized Anxiety Disorder. She was attending several Dialectical behavior therapy (DBT) groups and individual treatment per day including DBT skills acquisition group, DBT skills struggle group, DBT skills activity group, and resident led DBT activity group. 
  
The reviewer disagrees with the decision to deny coverage for inpatient mental health residential treatment as this was a high-risk patient in need of a 24-hour inpatient therapeutic inpatient mental health residential treatment. The Milliman Care Guidelines (MCG) Residential-Behavioral Health Level of Care- guidelines report that one needs to have continued danger to self or others, moderately or severe psychiatric or behavioral symptoms requiring 24-hour daily treatment, or serious dysfunction in daily living. In this case this patient had moderate psychiatric symptoms and did not have the coping skills to deal with her multiple psychiatric issues and was a high risk for another suicide attempt without this structured treatment setting. She was a complex patient with multiple psychiatric diagnoses including Borderline Personality Disorder, Bipolar Depression, and Generalized Anxiety Disorder. She had multiple psychiatric diagnoses and symptoms and required more time in a 24-hour inpatient therapeutic residential treatment to learn sustained improved coping skills to decrease dangerous and maladaptive behaviors and use health coping skills and better regulate emotions to not use maladaptive behaviors such as self-harm and suicidal behaviors. 

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 Mental Health Residential Treatment Center is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional.Other/Hyperlipidemia
Treatment: Pharmacy/Prescription Drugs/Livalo 4mg (milligrams) tablet
The health plan denied the requested medication Livalo 4 mg tablet as not medically necessary. The health plan's determination is overturned.

The patient is a man with a history of hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), coronary artery disease and multiple percutaneous coronary interventions. He developed myopathy and creatine kinase elevation with Atorvastatin 20 milligrams (mg) daily. He was also intolerant to Rosuvastatin 5 mg daily, Pravastatin 40 mg daily and, per the appeal letter, Simvastatin and Lovastatin. He has been treated with Pitavastatin (Livalo) 4 mg daily and has tolerated it well. Continued coverage for Pitavastatin is at issue.

I overturn the health plan's determination that Pitavastatin is not medically necessary in this instance.

The patient has experienced adverse effects with several of the formulary agents including Rosuvastatin, Atorvastatin, Lovastatin, Pravastatin and Simvastatin. The remaining formulary agent that the patient has not tried is Fluvastatin. Pitavastatin is less likely to cause adverse effects and is likely to result in a greater reduction in this patient's low-density lipoprotein (LDL) cholesterol level as compared to Fluvastatin.

This man meets accepted criteria for a diagnosis of statin intolerance in that he has been intolerant to two or more statins, including one at the lowest recommended starting dose. He has tolerated Pitavastatin. While he has not had a trial of Fluvastatin, due to its unique metabolic properties, Pitavastatin has been associated with significantly less muscle toxicity than other statins and has been shown to be tolerated by a substantial proportion of patients previously intolerant to other statins. Pitavastatin is also the most potent statin on a milligram-by-milligram basis, with significant reductions in LDL cholesterol levels seen with doses as low as 1 mg daily. The ability to treat with such low doses further minimizes the risk for adverse effects. Thus, Pitavastatin offers the advantage of reducing the risk for myotoxicity in high-risk patients. Given this man's history of intolerance to six other statins, Pitavastatin would be the least likely to cause adverse effects. Moreover, maximum dose Pitavastatin (4 mg daily) results in a 40-45% reduction in LDL cholesterol levels whereas maximum dose Fluvastatin (80 mg daily) reduces levels by approximately 35-38%.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart disease, diabetes and rheumatoid arthritis.

Treatment: denied coverage for personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours a week.

The insurer denied coverage for denied coverage for personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours a week.

The denial is overturned.
 

This is an elderly patient with  chronic medical problems including heart disease, diabetes and rheumatoid arthritis.  She lives alone in a private residence.  The insurer approved personal care services (PCS) 11 hours/day, 7 days/week for a total of 77 hours/week.  The request is for PCS 24 hours per day - 7 days per week (12 hour split shifts) for a total of 168 hours per week.

The Uniform Assessment System (UAS) was reviewed.  The patient's cognition is described as "severely impaired."  She is totally dependent for much of her Instrumental Activities of Living (IADL) tasks including meal preparation, ordinary housework and shopping.  Maximal assistance is reported for bathing, personal hygiene, dressing, and toilet transfer/use.  Extensive assistance is reportedly needed for eating, bed mobility, locomotion and ambulation She has "frequent wandering episodes during the day and night.  The patient is incontinent of bladder and bowel. 

This patient's functional impairments are at a level or unpredictable as to require PCS 24 hours/day (split shift).  This physician would agree that the patient may benefit from monitoring for safety; particularly due to her severe cognitive deficits and episodes of "wandering both day and night."   In this case there is sufficient need for assistance with ADLs and IADLs to warrant around the clock personal care services.  Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained at home with personal care services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours a week.

Based on the above, the insurer's denial must be reversed. 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 services, 24 hours a day, 7 days a week (split shift) for a total of 168 hours is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient Hospital Stay
The insurer denied the inpatient hospital stay.
The determination is upheld.

This is a female patient with a past medical history (PMH) of opioid dependence, bipolar disorder, and obsessive-compulsive disorder (OCD) who was admitted with complaints of (c/o) syncope associated with fevers and shortness of breath (SOB). Her vital signs were unremarkable. The physical exam was notable for no acute distress. Lab work was unremarkable. Imaging studies included a chest x-ray (CXR) which showed multifocal pneumonia and possible septic emboli, and computed tomography angiography (CTA) of the chest which showed no pulmonary embolism (PE). The patient was diagnosed with multifocal pneumonia and treated with intravenous (IV) antibiotics. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient level of care.

The hospital stay was not medically necessary at an acute inpatient level of care.

This patient presented to the emergency department (ED) with c/o SOB associated with syncope. The patient was found to have community acquired pneumonia (CAP) and was treated with antibiotics. The patient was hemodynamically stable, did not require intubation, non-invasive positive pressure intubation, did not have any severe respiratory distress, persistent tachypnea, use of accessory muscles in neck, severe intercostal retractions, cyanosis, new altered mental status (AMS), hypoxia, and the CURB-65 [confusion, urea, respiratory rate, blood pressure, age greater than or equal to 65] score was 0, indicating a low-risk patient. The pneumonia severity index was risk class I, indicating that outpatient therapy was reasonable and a 0.1 percent (%) mortality risk. The patient was diagnosed with non-severe CAP and treated with IV fluids and antibiotics all of which could have been safely provided at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Weight Loss.
Treatment: Inpatient admission.
The insurer denied: Inpatient admission.
The denial is upheld.

The patient is an adult male. The patient had a PMH (past medical history) of Helicobacter pylori (status post triple therapy 5 months ago), thrombocytosis, elevated lipids, and pre-diabetes.  Per the hospital's appeal letter, "This patient presented to the ED (emergency department) due to progression of symptoms/weight loss and frustration with lack of answer for etiology of weight loss from his outpatient evaluations. The ROS (review of systems) was notable for progressive weakness, lethargy, and recently dizziness upon standing. The patient also endorsed intermittent visual blurriness and bilateral shoulder pain. In the ED (emergency department), the patient's labs were notable for bicarb 18, UA (urinalysis) was with protein greater than 300, leukocytosis (white blood count 13.7). Other ED (emergency department) tests included XR (x-ray) abdomen, CT (computed tomography) chest, pain management and 
reassessment. The patient was admitted for further evaluation and management. Ongoing through discharge, he was followed by lnternal Medicine. Stool Helicobacter pylori antigen, SPEP/UPEP (serum protein electrophoresis/urine protein electrophoresis) and QuantiFERON Gold were sent and remained pending. CRP (C-reactive protein) was elevated to 6. The patient was also evaluated by Gastroenterology. Hydrocortisone suppository was given for hemorrhoid. EGD 
(esophagogastroduodenoscopy)/colonoscopy were performed. Colonoscopy was notable for a continuous area of ulcerated mucosa with overlying exudate and edema, friability, with contact bleeding in the rectum, which was biopsied. An EGD (esophagogastroduodenoscopy) was notable for gastric ulcers and non-bleeding duodenal ulcer with a clean ulcer base (Forrest Class III), ulcers were biopsied. GI (gastroenterology) recommendations were to continue pantoprazole 40mg (milligrams) QD (daily) for 8 weeks."
The patient was discharged with follow-up for the pathology results.

The Inpatient admission was not medically necessary.

There was no cogent medical reason for a full acute admission for this patient with chronic weight loss. There was no clear reason as to why the patient could not have received an endoscopy as an outpatient. Despite the patient's presentation, the care as provided could have been rendered in its entirety at a 
lower level of care. The patient had chronic weight loss, yet he did not evidence a change in mental status, high fevers, neurologic changes, hypotension, signs of sepsis, hemodynamic changes, renal abnormalities, need for NPO (nothing by mouth) status, need for invasive surgery, need for invasive monitoring or treatments, severe electrolyte dyscrasias or any other indication for an acute admission. As such, the care could have been rendered at a lesser level.