Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Central Nervous System
Treatment: Pharmacy/Prescription Drug
The insurer denied: Emflaza
The denial is: overturned in whole

The patient is a male who has Duchenne muscular dystrophy (DMD). Progress notes by his neuromuscular specialist and a letter were reviewed.

The patient has a deletion of exons 46-52 in the DMD gene. He has been taking deflazacort (Emflaza). His current dose is 0.9 milligrams per kilogram per day (mg/kg/day). He has done well on the medication and is not having side effects. The provider notes that the patient appears to have a more aggressive form of DMD, as he is already non-ambulatory. He is at increased risk of developing scoliosis. He has been using a wheelchair. He had a fall at school, following which he started to use a walker and wheelchair, but soon progressed to full-time wheelchair use. He requires assistance for transfers and is unable to get to a sitting position from lying down without assistance. He has significant contractures of the knees and ankles. He has been prescribed ankle foot orthoses (AFOs). He does not have arm weakness, but has some fine motor impairment, requiring assistance with buttons and zippers, and activities of daily living, such as brushing his teeth.
The patient's physical examination was notable for enlarged calves. His ankles could not be dorsiflexed to 90 degrees, nor his knees extended to 180 degrees. He was able to lift his arms above his head. All of his leg muscles had antigravity strength, but this was thought to possibly be mechanical because of his contractures. The most recent visit was by telehealth. Reflexes were trace in the arms and at the ankles, absent at the knees.
The treating provider recommended continuing Emflaza at 0.9 mg/kg/day, together with his vitamin and calcium supplements. She recommended physiatry follow-up, and consideration of tendon releases.
At issue in this review is whether the formulary drug (prednisone) will be or has been ineffective, would not be as effective as the non-formulary drug (Emflaza), or would have adverse effects.

The health plan's determination is overturned in whole. 

The patient has not taken prednisone. The medical literature supports the non-formulary drug Emflaza (deflazacort) as being more effective in the treatment of Duchenne muscular dystrophy, with the likelihood of fewer side effects. In addition, changing the patient from his regimen of Emflaza, which he is tolerating well, to untried prednisone, is not without risk. Continued treatment with Emflaza (deflazacort) is appropriate for this patient.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rashes.
Treatment: Panniculectomy (Procedure Code 15830).
The insurer denied coverage for Panniculectomy (Procedure Code 15830). 
The denial is upheld. 

This is a female patient with a history of obesity, bariatric surgery, and obstructive sleep apnea (OSA). A Bariatric Surgery office note documents that the patient has no concerns and feels great.  A Plastic Surgery office note provides a history of rashes, but examination was not performed (video visit).  A Primary Care Physician (PCP) note documents a history of rashes in the abdominal fold despite treatment with nystatin but examination is negative for rash. 

Abdominoplasty and continued use of drying powder and nystatin is recommended.  An office note from the Plastic Surgeon documents skin breakdown under pannus.  Photos are dark and centered primarily on the patient's breasts.  The abdominal pannus appears to be small and does not hang to the pubis (based on the submitted photos).  The pannus is not elevated to confirm the presence of rashes.  The submitted information is not sufficient to confirm that panniculectomy is required to treat rashes.  Bariatric Surgery and PCP notes provide information that is inconsistent with the Plastic Surgeon's history of ongoing severe rashes. 

The medical necessity for Panniculectomy (Procedure Code 15830) is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache. 
Treatment: Inpatient admission.
The insurer denied coverage for the inpatient admission.
The denial is upheld. 

This is a male patient who presented to the Emergency Department (ED) with subjective complaints of a throbbing headache for 4 days and right lower extremity weakness.  His headache began 4 days before the presentation at the ED after increased activity.  It was rated 5/10 and was intermittent over the past 4 days.  The patient had taken ibuprofen with minimal relief.  The morning of the presentation at the hospital the patient's headache increased to 10/10 after increased activity.  He began to have right lower extremity weakness when walking to the ambulance.  He endorsed photophobia with intermittent neck pain.  His blood pressure was 159/97.  His physical examination was unremarkable and there were no focal neurologic deficits.  It was noted the provider would need to rule out sub arachnoid hemorrhage (SAH) versus hypertension related headache versus migraine.  The computed tomography (CT) was negative for ischemic or hemorrhagic process.  The computed tomography angiogram (CTA) was negative for aneurysm.  There were findings consistent with reversible cerebral vasoconstriction syndrome, and it was consistent with the presentation of thunderclap headache.  His headache was improving.  The electrocardiogram (EKG) revealed normal sinus rhythm.  The patient was admitted for further evaluation per neurology.

The patient developed a severe headache after increased activity.  His neurological examination was normal.  His CT scan and CTA were negative.  There is no clear evidence of acute change in the neurological examination; no acute motor, sensory or visual deficit that suggest an acute stroke.  There is no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure.   Therefore, the acute inpatient care admission is not medically necessary.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient.  The inpatient admission is not medically necessary.

The medical necessity for the inpatient admission is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Syncope. 
Treatment: Hospital admission.
The insurer denied coverage for the hospital admission. 
The denial is upheld. 

This is a female patient who presented to the hospital status post fall.  She had no past medical history.  The patient reported she was standing and fell.  She was not sure why she fell.  The patient hit her face on the floor.  She complained of neck pain and pain in the back of the head.  She denied a loss of consciousness.  The physical examination revealed the patient was alert and oriented with no focal deficits.  She had no motor or sensory deficits.  The patient was admitted to the telemetry floor for syncope.  She was to undergo an evaluation by cardiology and neurology.  The computed tomography (CT) scan of the head and spine were negative for acute pathologies.  The echocardiogram was within normal limits.  The patient did not have orthostatic hypotension.  The stress test was negative.  The patient was subsequently discharged.

The patient had a fall with suspicion of syncope.  Her neurological exam was normal.  Her CT scan was negative for acute pathology. 

There is no clear evidence of acute change in the patient's neurological examination.  No acute motor, sensory or visual deficit that suggest an acute stroke.  There is no instability, new focal neurological signs, acute stroke, hemodynamic or cardiovascular compromise or acute prolonged metabolic decompensation or seizure.  Therefore, acute inpatient care admission was not medically necessary.

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

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

Diagnosis: Chronic obstructive pulmonary disease exacerbation, and rule out myocardial infarction. 
Treatment: Inpatient Admission.
The insurer denied coverage for the Inpatient Admission. 
The denial is overturned. 

This is a male patient with a past medical history notable for an immunocompromising disease, chronic obstructive pulmonary disease (COPD), diabetes mellitus, hypertension, and substance dependence. The patient presented to the Emergency Department (ED) with complaints of chest tightness and wheezing. The patient was picked up off the street for alcohol intoxication. In triage, vital signs (VS) included heart rate (HR) 67, pulse oximetry 95%, blood pressure (BP) 125/75. Exam in the ED showed the patient was in no acute distress, lungs were clear, cardiac exam negative. Abdomen exam was negative. Neurological/Psychological- no issues noted and affect/mood normal. The patient's Clinical Opiate Withdrawal Scale (COWS) score was 11. The patient was found to have a cardiac troponin level of 0.33, with a subsequent level of 0.01. Brain natriuretic peptide (BNP) was markedly elevated which decreased to near normal. The patient had an abnormal electrocardiogram (EKG), demonstrating T-wave inversions in the inferior leads; however, these had normalized compared to his prior EKG. 

The patient was admitted for COPD exacerbation and to rule out myocardial infarction. The patient's cardiac biomarkers remained flat, and a cardiology consult recommended an outpatient stress test. It was felt that the patient's abnormal troponin was secondary to strain related to his COPD exacerbation and diastolic dysfunction, and that acute coronary syndrome (ACS) was unlikely. The patient had acute kidney injury (AKI) on stage II baseline chronic kidney disease (CKD). The patient's echocardiography noted ejection fraction (EF) 41%. The patient was treated for substance abuse, as he had admitted to heroin abuse. The patient's urine toxicology screen was positive for opiates. The patient demonstrated opiate withdrawal symptoms with diffuse aching of body, stomach cramps, tremors, irritable and anxious. COWS score was 11 and the patient was treated with methadone. 

Based on the review of the medical record and literature, the patient presented with complaints of chest pain, EKG changes, elevated cardiac troponins and BNP, both of which improved, against a baseline of acute COPD exacerbation and acute renal insufficiency. In addition, the patient was showing signs of opiate withdrawal requiring management. He required management for acute withdrawal in the presence of evidence of an acute ischemic event possibly secondary to the withdrawal. Inpatient management was appropriate in this setting. 

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

The medical necessity for the Inpatient Admission is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Infectious gastroenteritis.
Treatment: Inpatient Hospital Admission. 
The insurer denied coverage for the Inpatient Hospital Admission. 
The denial is upheld. 

This is a female patient with a history of hypertension, diabetes, obesity, and pulmonary embolism who presented to the hospital with abdominal pain and bloody diarrhea.  She was afebrile and her vital signs were stable.  There was no abdominal rebound or guarding.  There was no leukocytosis.  Her hemoglobin level was 12.0.  A computerized axial tomography (CAT) scan found colitis.  She was diagnosed with an infectious gastroenteritis and treated with antibiotics.  Her symptoms then improved. 

According to Milliman Care Guidelines (MCG), clinical indications for admission for gastroenteritis include having evidence of a severe infection, severe abdominal pain, peritoneal signs, hemodynamic instability, severe vomiting, severe dehydration, and an inability to maintain oral hydration after a period of observation treatment.  The patient did not have these conditions. 

This patient had gastroenteritis.  Intravenous (IV) hydration and potassium replacement could have been given in the Emergency Room (ER) with observation status.  Afterwards, she could have been discharged on a course of oral antibiotics as an outpatient.  She did not meet MCG criteria for an inpatient admission for gastroenteritis.   

The healthcare plan acted reasonably and with sound medical judgment.  An inpatient stay was not medically necessary.  

The carrier's denial of coverage for the Inpatient Hospital Admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Pharmacy/Prescription Drugs (Stelara)
The health plan denied the requested prescription medication. The health plan's determination is upheld.

The patient is a male with severe psoriasis since age 4 years, and with more than 10% body surface area involvement. The patient's psoriasis affects his chest, back, and scalp. The patient has tried and failed topical Mometasone, Triamcinolone, and other topicals, as well as phototherapy.
The medical necessity of Stelara is under review.

The health plan's determination of medical necessity is upheld, in whole.

No. The patient has no documented treatment failure with, or true medical contraindication to, standard, first-line oral/systemic therapies such as either Methotrexate or Cyclosporine that the health plan will cover. 
Stelara is being prescribed out of convenience, and not out of medical necessity. Methotrexate and Cyclosporine have been used as first-line systemic therapies for moderate to severe psoriasis for years to decades and is medically appropriate and commonly used for many dermatologic and rheumatologic conditions in both genders and in pediatric patients much younger than this particular patient.
Modern dermatology literature [1-4] supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Stelara, particularly for a patient with a limited history of systemic psoriasis therapy previously utilized and recommend use of these preferred agents as appropriate for this patient's clinical scenario. Therefore, as per current medical standards of care, Stelara is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems. 
Treatment: Home Health Care. The insurer denied consumer directed personal assistance services 24 hours per day (live-in). 

The denial is overturned.

The patient is a male with a past medical history significant for hyperlipidemia, hypertension, coronary artery disease, atrial fibrillation, congestive heart failure, osteoarthritis, and gait abnormality. The patient was previously receiving 56 hours per week personal care services.  This review is for the medical necessity of increased consumer directed personal assistance services from 56 hours a week to 24 hours per day (live-in).

The health plan's determination is overturned.

The requested health service is medically necessary for this patient. The current care hours being provided are not enough to meet the patient's unscheduled nighttime needs. The included Uniform Assessment System (UAS) State of New York was reviewed. This patient is a male with multiple medical problems. He has had two relatively recent hospitalizations one secondary to valve replacement, transarterial and also bacterial urinary infection. Based upon physical therapy notes there appears to be a significant change/decompensation in the patient's physical abilities. Back in the Fall,  it appears he could walk 75 feet at physical therapy with a roller walker. Now the patient needs moderate assistance in order to ambulate 5 feet. The patient has mixed incontinence along with stage I sacral decubitus ulcer. He is also maximal assist for most all activities of daily living (ADLs) and Instrumental activities of daily living (IADLs) including personal hygiene and toiletry.  CDPAS services for 24 hours per day live in is medically necessary for his unscheduled needs which include nocturnal diaper change, especially with a stage I decubitus ulcer. The patient is functionally unable to do these things for himself and he is at risk for progression of the decubitus ulcer without frequent changing.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's
Treatment: Personal care assistant
The insurer denied Personal Care Aide (PCA) Services, Level 2: Live-In per diem - 24 hours per day, 7 days per week. The health plan's determination is overturned. 

The patient is a male with past medical history of congestive heart failure, hypertension, hyperlipidemia, benign prostatic hyperplasia (BPH), coronary artery disease (CAD), Parkinson's, AAA (abdominal aortic aneurysm) with repair, aortic valve replacement, memory deficit, urinary incontinence, and spondylosis of the lumbar spine who had been assigned PCA (personal care aide) hours. The patient was assessed at total assistance with tasks of ordinary housework and shopping while maximum assistance with task of meal preparation, managing finances, managing medication, stairs, transportation, and bathing. With tasks of equipment management, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, and bed mobility the patient was assessed at extensive assistance while supervision with task of eating and setup only with task of phone use.

Personal Care Aide (PCA) Services, Level 2: Live-In per diem - 24 hours per day, 7 days per week is medically necessary for this patient.
The patient has Parkinson's disease which is a progressive illness. There is documentation of a change in functional status compared to the date of his last assessment tool which underestimate his current assessment needs. The patient requires assistance with all activities of daily living (ADL) / Instrumental activities of daily living (IADL) tasks. The patient has unpredictable and unscheduled care needs over a continuum of time and therefore the plan should not have utilized the Uniform Assessment System (UAS) to determine PCA hours. The insurer failed to document a plan of care for the patient's unscheduled and unpredictable care needs. The recent logs documents the need for assistance with toileting, walking, and transferring outside the time the patient has PCA. The increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide (PCA) Services, Level 2: Live-In per diem - 24 hours per day, 7 days per week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in his own home.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Cardiac/Circulatory Problems
Treatment: Pharmacy/Prescription Drugs
The insurer denied Edarbyclor as a formulary exception
The denial was overturned in whole.

The patient is a female with hypertension, hyperlipidemia, and obesity. She was on Losartan 100 milligrams (mg) daily and Hydrochlorothiazide 25 mg daily and her blood pressure was 142/80 millimeters of mercury (mmHg) when measured during an office visit with her cardiologist. The patient was on Losartan 100 mg daily and Chlorthalidone. Her blood pressure was 140/80 mmHg. She was then started on Edarbyclor 40/12.5 mg daily. A subsequent blood pressure measurement while on Edarbyclor was 130/72 mmHg. Her blood pressure was 132/78 mmHg. The effectiveness of Edarbyclor is at issue. The health plan's determination is overturned. Edarbyclor is a combination of Azilsartan, which is an angiotensin receptor blocker (ARB) and Chlorthalidone (a diuretic). Azilsartan has proven superior to other ARBs in controlling blood pressure. Likewise, Chlorthalidone, which is a diuretic, has proven superior to hydrochlorothiazide (a diuretic) in reducing blood pressure. The formulary alternatives listed include ARBs alone (Candesartan, Irbesartan, Losartan, Olmesartan, Telmisartan and Valsartan) and ARBs in combination with Hydrochlorothiazide. Since Azilsartan and Chlorthalidone are more effective in blood pressure lowering than other ARBs and Hydrochlorothiazide, respectively, and the listed formulary alternatives are limited to ARBs or ARB/hydrochlorothiazide combinations, based on the published literature, the formulary alternatives would be less effective than Edarbyclor 40/12.5 mg.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Central Nervous System/Neuromuscular Disorder/Other/Dementia
Treatment: Home Health Care-Personal Care Aide
The health plan denied the requested increase in personal care assistance hours. 
The health plan's determination is overturned.

The patient is a female with a past medical history of severe dementia, urinary incontinence, bowel incontinence, chronic low back pain, gastroesophageal reflux disease (GERD), hypertension, anxiety, insomnia, and atrial fibrillation who had been assigned personal care assistance (PCA) services 7 hours/day, 7 days/week to total 49 hours per week. The patient was assessed at total assistance with tasks of meal preparation, ordinary housework, managing finances, and shopping while maximum assistance with tasks of managing medication, bathing, and dressing lower body. The patient was assessed at extensive assistance with tasks of phone use, stairs, transportation, personal hygiene, dressing upper body, walking, locomotion, transfer toilet, toilet use, and bed mobility while limited assistance with tasks of eating. The family reported the patient was unable to go to the bathroom on her own and refused to wear undergarments and thus there were daily accidents of bladder and bowel. The family also reported sundowning with the patient's daughter having to waken every hour to check on the patient. The family was letting the patient go down the stairs on her buttocks for safety when the patient was trying to go downstairs even though she had everything she needed in her own apartment. 

The health plan's determination of medical necessity is overturned, in whole.

Yes. The patient has progressive dementia with documented decline in physical and mental functioning. The patient requires assistance with all ADLs/Instrumental activities of daily living (IADLs). The patient had 24-hour care needs and therefore the assessment tool should not have been utilized to calculate PCA hours. The patient had unscheduled and unpredictable care needs over a continuum of time and the insurer did not document a plan to address these unscheduled and unpredictable care needs. The patient no longer has the level of informal support as previous, as her daughter cannot provide care due to her own medical illnesses. The patient requires turning and positioning every two hours. An aide would not obtain at least 5 hours of uninterrupted sleep and therefore would require split- shift aide services. Increase in PCA hours is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. Considering the plan's clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 24 hours/day, split-shift, 7 days/week, to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.