Persius/hicric huggingface dataset:
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Coronary artery disease, hypertension and osteoarthritis

Treatment: personal care assistant (PCA) services to 24 hours/day split-shift service

The insurer denied coverage for personal care assistant (PCA) services to 24 hours/day split-shift service

The denial is modified.

 
This is an elderly patient with coronary artery disease, hypertension and osteoarthritis.  She lives alone in a 1-bedroom apartment. The insured approved PCA services 12 hours/day, 7 days/week and the request is for 24 hours/day split shift.  

The Uniform Assessment System (UAS) was reviewed. The patient's cognition is described as minimally impaired. She is totally dependent to maximal assistance for her Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. Extensive assistance is needed for bathing, dressing, personal hygiene, locomotion, ambulation and toilet transfer/use. She is frequently incontinent of bladder and continent of bowel. Limited assistance is needed for bed mobility and eating. She reportedly fell and loss consciousness at her grandson's house 1 month prior. There were no reported falls in her home over the prior 90 days. Her functional ability has decreased compared to the previous UAS report. The patient's cognitive and functional deficits are not at a level or unpredictable as to require the requested PCA services 24 hours/day (split shift). Based on the records reviewed, a live-in PCA is more appropriate as they are likely capable of providing for the patient's functional needs with the ability to consistently obtain uninterrupted 5 hours of sleep. Based on the enclosed documents reviewed, the patient's health and safety are more appropriately provided and maintained at home by increasing PCA services to 24 hours/day, 7 days/week (live-in).

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

The medical necessity for an increase in personal care assistant (PCA) services to 24 hours/day split-shift services is not substantiated. However, increasing PCA services 24 hours/day (live-in) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: COVID (coronavirus disease) 19 pneumonitis
Treatment: Inpatient admission
The insurer denied coverage for the inpatient admission.
The denial is overturned.
 
This patient has a past medical history significant for atrial fibrillation, hyperlipidemia, hypertension, and osteoporosis who presented to the emergency department with complaints of cough, fever, shortness of breath, pleuritic chest pain, and confusion.

Vitals on presentation included: T (temperature) 100.3 degrees F (Fahrenheit), Blood pressure (BP)-139/101, Pulse-123, Respiratory Rate (RR)-20, and oxygen saturation 95% on room air. Laboratory values were notable for the following: White blood cells (WBC)-7.8, Hemoglobin-14.5, Hematocrit-42.9, creatinine-0.7, glucose-124, and COVID positive.

The patient was admitted to the hospital for possible COVD-19 pneumonitis and rapid rate atrial fibrillation. The chest x-ray was negative. She was treated with Remdesivir. Cardiology gave her intravenous digoxin. A transthoracic echocardiogram showed normal left ventricular function with severe bi-atrial enlargement. She reverted to normal sinus rhythm. The patient remained afebrile and hemodynamically stable. She was discharged to continue outpatient management.

According to medical records, the patient presented with fever and respiratory complaints. She had low-grade fever (100.3 degrees F), hypertension, and tachycardia (heart rate-123). She was found to be COVID positive and in rapid rate atrial fibrillation. She required monitoring on telemetry and loading with digoxin to convert her to normal sinus rhythm. Based on above findings, the patient was hemodynamically unstable requiring monitoring and restoration of normal sinus rhythm; a hospital admission was medically necessary in this high-risk COVID positive patient.  

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

Diagnosis: hernia
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who initially presented to the emergency department with concerns for left groin pain. Pertinent history included a left inguinal hernia. Initial vital signs revealed a temperature of 97.9oF, heart rate (HR) 88, blood pressure (BP) 122/92, respiratory rate (RR) 18, and SpO2 (pulse oximetry) 99% on room air. Initial examination documented a left inguinal firm hernia without peritoneal signs. An electrocardiogram (EKG) was unremarkable. Initial laboratory testing revealed a white blood cell count (WBC) 7.3, Hemoglobin (HGB) 10.9, platelets (Plt) 234, magnesium (Mg) 2.1, blood urea nitrogen (BUN) 14, Creatinine 0.49, Glucose 161, carbon dioxide (CO2) 27, and Tbil (total bilirubin) 0.2. A CT abdomen/pelvis revealed a fat-containing left inguinal hernia similar to prior studies without herniation of bowel included. A hospital ice pack was placed and the hernia was reduced. The patient was placed in the hospital. 

Based on the clinical documentation provided, evidence based literature and standards of care, the acute inpatient level of care was not indicated medically necessary. The patient had a known chronic left inguinal hernia who presented with left groin pain. Initial examination documented stable hemodynamics and a left groin bulge without peritoneal signs. Initial evaluation revealed unremarkable laboratory findings and a left inguinal fat-containing, bowel-sparing, hernia. The hernia was successfully reduced. A general surgeon and the patient elected to repair the chronic left inguinal hernia and did so without issue or complication. During the same day the patient was placed in the hospital, the patient was deemed medically stable for discharge.
Moreover, clinical indications for admission to inpatient care were not met. The patient did not have hemodynamic instability, severe pain requiring acute inpatient management, peritoneal signs, bowel perforation, bowel ischemia, intestinal obstruction, visceral organ torsion, or a procedure needed that cannot be performed on an ambulatory basis.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cerebral palsy
Treatment: Personal Care Aide 40 hours per week, Consumer Direct, 1 Client
The insurer denied coverage for Personal Care Aide 40 hours per week, Consumer Direct, 1 Client
The denial is upheld.

This is an adult patient with cerebral palsy. The patient lives in a 1-bedroom apartment with a brother. The insurer approved Consumer Directed Personal Care Assistant Services (CDPCAS) 30 hours per week and the request is for 40 hours per week.

The Uniform Assessment System (UAS) report was reviewed. The patient's cognition is described as "modified independent." The patient requires maximal assistance to total dependence for much of the Instrumental Activities of Daily Living (IADL) tasks including ordinary housework, meal preparation and shopping. The patient is "able to use the microwave, grab a snack, but is not able to prepare meals on the stove." The patient requires limited assistance for bathing, personal hygiene, dressing and toilet transfer/use. The patient is continent of bowel and bladder. The patient is independent with bed mobility and supervision for locomotion and ambulation. The patient's condition and functional deficits are not at a level or unpredictable as to require the requested 40 hours/week. The patient also has no nighttime needs at this time. This physician would agree the patient may require additional monitoring for safety. However, safety monitoring under Personal Care Aide (PCA) does not include monitoring an individual when no other Level I or Level II personal care services task is being provided. Based on the enclosed documents reviewed, the patient's health and safety are appropriately provided and maintained by the approved PCA services 30 hours/week. The patient also has the option under CDPCAS of restructuring and flexibly using the 30 PCA service hours weekly to better maintain and meet the functional needs.  

From a physical medicine and rehabilitation perspective, the requested increase to PCA 40 hours/week is 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 Personal Care Aide 40 hours per week, Consumer Direct, 1 Client is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Rheumatoid Arthritis and Multiple Joint Arthropathy. 
Treatment: 92 Consumer Directed Personal Assistance Services (CDPAS) hours weekly. 

The insurer denied: 92 Consumer Directed Personal Assistance Services (CDPAS) hours weekly. 

The denial is upheld. 

The patient is a female with medical history notable for rheumatoid arthritis and multiple joint arthropathy. The patient was approved for 92 hours per week of consumer directed personal assistance services (CDPAS), but this was reduced to 51 hours weekly. The patient and her care team requested a return to 92 hours per week, and this request was denied by the health plan. This denial is the subject under review. 

The requested health service/treatment of 92 CDPAS hours weekly has not been clearly demonstrated to be medically necessary for this patient. 
The patient's current approval of 51 hours per week aligns with the recommended allowance from the Uniform Assessment System (UAS) task tool. The UAS states that she has needs for activities of daily living (ADL's) that are greater than what is reflected in the primary care office visit notes. Given that this is the more conservative estimate, it is an appropriate number of hours for her care. Furthermore, office visit notes state that she takes pain medication to allow her to perform ADL's and other household tasks. It has not been clearly demonstrated that the patient would have unmet personal care needs at 51 hours per week.
Appeal type: Medical necessity
Decision: Overturned

Skin Disorders
Pharmacy/Prescription Drugs

Diagnosis: Vitiligo
Treatment: Opzelura 1.5 percent (%) cream
The insurer denied the request for Opzelura 1.5% cream.
The health plan's determination is overturned.

The patient is a female with non-segmental vitiligo. The request is for coverage of Opzelura 1.5% cream. The initial request was denied per plan policy which lists non-segmental vitiligo as a cosmetic condition.

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

The requested health service/treatment of Opzelura 1.5% cream is considered medically necessary for this patient. The prescriber is requesting coverage of Opzelura 1.5% cream for the treatment of this patient's vitiligo. Vitiligo is an autoimmune disease of the skin characterized by the destruction of melanocytes by an individual's own T-lymphocyte (T) cells. It is a recognized medical disease with psychosocial effects and a negative effect on quality of life that are well-documented in the published medical literature. It is not considered a cosmetic condition. Opzelura is the only Food and Drug Administration (FDA) approved medication for the treatment of vitiligo and its use in this patient is an appropriate indication. Therefore, the use of Opzelura 1.5% cream for the treatment of this patient's vitiligo is considered medically appropriate and necessary at this time.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: difficulty breathing.

Treatment: Full hospital admission.

The insurer denied coverage for full hospital admission.

The denial is overturned.

This is an adult patient with a history of atrial fibrillation with rapid ventricular response, cardiomyopathy, obesity, gastroesophageal reflux disease (GERD), and hypothyroidism. The patient presented to the hospital for an elective atrial fibrillation ablation.

The atrial fibrillation ablation was conducted as scheduled and was completed with extubation. Upon extubation the patient was observed to have respirations regular and unlabored, color normal, and chest excursion symmetrical.

The patient was observed to have difficulty breathing shortly after extubation. The patient was then treated with a nebulizer and Decadron. Following this, the patient was transferred to the inpatient service for observation. 

The patient underwent a transnasal fiberoptic laryngoscopy which observed "Larynx with normal vocal fold motion noted bilaterally, no mucosal lesions are seen, glottal closure is complete. Subglottic is widely patent. Mild nonobstructive edema noted in right arytenoid cartilage, mild post-cricoid edema. No pooling, penetration or aspiration."

The patient had no further airway symptoms or signs and was discharged the day after the procedure.

The Milliman Care Guidelines (MCG) 26th edition states that Ambulatory Surgery Exception Criteria for "a potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: Complicating features requiring inpatient care, as indicated by 1 or more of the following: Severe complications of procedure (such as bowel injury, airway compromise, vascular injury, severe hemorrhage). The patient was observed to have airway compromise shortly after extubation. The patient was appropriately cared for including observation for further airway difficulty.

The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The patient was observed to have airway compromise post-extubation and required medication and observation of the airway.

The full hospital admission is considered medically necessary for the patient as the patient was observed to have post-extubation airway compromise and required the hospital admission for observation. 

The denial should be reversed as the patient required the hospitalization as the patient fulfilled the criteria of the MCG 26th edition for "a potentially ambulatory procedure or surgery warrants inpatient care due to 1 or more of the following: complicating features requiring inpatient care, as indicated by 1 or more of the following: severe complications of procedure (bowel injury, airway compromise, vascular injury, severe hemorrhage)".

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 full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion
Treatment: D8080 braces, D8670 monthly visit x 12
The insurer denied coverage for D8080 braces, D8670 monthly visit x 12
The denial is overturned
 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, open bite, and anterior crowding. The orthodontist has completed the Handicapping Labio-Lingual Deviation (HLD) Index Report attaining 29 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 21 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, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist completes the second portion of the index arriving at 29 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 confirmed by several referenced studies. 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. 

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, D8670 monthly visit x 12 is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis.
Treatment: Dupixent.
The insurer denied Dupixent.
The determination is overturned.


This is a female patient with atopic dermatitis, treated with topical steroids (fluocinolone, triamcinolone, clobetasol, and hydrocortisone), tacrolimus, antibiotics and anti-histamines. The provider is requesting Dupixent. The patient has greater than 50 percent (%) body surface area (BSA) and investigator global assessment (IGA) score of 4. The health plan requires a trial of Tacrolimus for 12 weeks, which the appeal letter states the patient has done. At issue is the medical necessity of Dupixent.

The patient has tried and failed Tacrolimus and this medication is difficult to apply to such a large body surface area. In May 2020, the Food and Drug Administration (FDA) also approved dupilumab for the treatment of patients aged 6 years and older with moderate to severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. This approval followed a phase 3, randomized, double blinded placebo controlled trial that enrolled 367 patients to evaluate the safety and efficacy of dupilumab in children (ages 6-11 years) for treatment of atopic dermatitis (Paller et al). Significantly and clinically meaningful improvements in patients signs and symptoms of atopic dermatitis as well as quality of life were reported. As seen in adults, treatment in the pediatric population was reportedly well-tolerated with the most commonly reported side effects including injection site reactions and conjunctivitis. Dupixent would be more appropriate than topical therapy for this patient with widespread disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: low back pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure. 
The health plan's determination is upheld.

The patient is a male with low back pain. Pain is still present for one year. Prior treatments include home exercises, medications, physical therapy, as well as injections. Pain impacts activities of daily living (ADL). Pain can be as high as 5 out of 10. Magnetic resonance imaging (MRI) lumbar spine showed Modic changes at L4 and L5.

The proposed Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. The patient has complaints of low back pain.
This procedure is not recommended despite promising early reports, and further trials with longer-term outcomes and less risk of bias are required. An Food and Drug Administration (FDA) investigational device exemption trial examined 225 chronic low back pain patients with type I or II Modic changes who were randomized to the requested procedure or sham treatment, resulting in decreased Oswestry disability index (ODI) of 20.5 and 15.2 points, respectively. The authors noted that these marginally clinically meaningful improvements suggested some potential as a minimally invasive treatment, however, there is lack of data to recommend this procedure as treatment modality. In general, there is lack of substantial support for this procedure, and it is currently not considered standard of care.
Given the above, the Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: low back pain.
Treatment: Intracept procedure.
The insurer denied the Intracept procedure. 
The health plan's determination is upheld.

The patient is a male with chronic lower back pain (LBP) for > (greater than)1 year. The patient (pt) works construction and notes the pain is causing significant impact on his quality of life (QOL) and activities of daily living (ADL). The pt was very active and now reports difficulty with extension, twisting, prolonged standing, and walking. The pt has tried multiple conservative therapies including massage, physical therapy x 6 weeks, pain medications, anti-inflammatories, and muscle relaxants. He had MBB (medial branch blocks)/facet injections with 80% relief and MBB radiofrequency ablation (RFA) with good (80%) relief for 2 months but returned after COVID. 

The Intracept Procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
With respect to this case, the patient appears to have some physical limitations due to his chronic pain. There is no ODI (Oswestry Disability Index) score to give a better picture of the degree of disability. It is not entirely clear with the information supplied if the patient's complaints are resulting primarily from facet arthritis or from anterior column pain. A majority of the information included supports the diagnosis of facet joint pain as the primary generator. These include the robust improvement in pain after the MBB (medial branch block) radiofrequency ablation (RFA) and the return of pain with time. The history and physical exam findings also support the facets as the cause. Some factors missing from the report include evidence of prolonged morning stiffness, pain greatest in the morning, midline pain etc. Due to the excellent results, 80% relief, it appears that MBB RFA should be continued as the nerves, unfortunately, continue to regrow. Alternatively facet joint platelet-rich plasma (PRP) can be tried.