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

Immunologic Disorder
Home Health Services

Diagnosis: Rheumatoid Arthritis
Treatment: Personal Care Aide Services (PCA) 6 hours per day- 7 days per week- total of 42 hours per week
The health plan denied Personal Care Aide Services (PCA) 6 hours per day- 7 days per week- total of 42 hours per week.
The determination is overturned.

The patient has a past medical history significant for rheumatoid arthritis, gout, congestive heart failure, hypertension, aortic valvular heart disease, chronic pericarditis, pulmonary hypertension, retinal artery occlusion and visual abnormalities. Other medical problems include anxiety, depression, memory loss, type 2 diabetes mellitus, sick sinus syndrome gastroesophageal reflux disease, pancreatic insufficiency and mixed incontinence. 
The patient is currently receiving 35 hours per week. Services were denied based upon medical necessity. In the denial, the plan noted the following, your abilities to perform physical functioning, daily activity stayed the same for personal hygiene, locomotion, meal preparation and ordinary housework. Many of your abilities to perform physical functioning but limited assistance therefore your hours stayed at 5 hours per day 7 days a week for a total of 35 hours a week. Giving additional hours are not provided for companionship, supervision, or when tasks are not being performed.
Personal care aide service hours 6 hours per day 7 days a week for a total of 42 hours a week are requested with a diagnosis of rheumatoid arthritis. 
The requested health service is medically necessary for this patient. The tasking tool shows excess hours needed in compared to Uniform Assessment System (UAS). The UAS State of New York noted 28 hours per week. The UAS State of New York from the next date noted 28 hours per week. The clinical tasking sheet noted the patient required a total of 31.5 hours per week. The next clinical tasking sheet  notes that the patient required a total of 45.5 hours per week. The UAS Reports which were provided do not show any increased need for additional services. However, the tasking tool shows a need for more hours than 28 hours a week.
The UAS both showed that the patient required a total of 28 hours per week. The patient is currently receiving 35 hours a week which is above both recommendations. However, there was a difference in the tasking tools between the 2 different dates of services. The differences were in locomotion, bathing, toilet use and transfer. There were no noted significant changes in the patient's underlying medical condition. She did have evidence of aging along with advancement of her rheumatoid arthritis but there is no other specific new or change in medical condition noted and reports available for review. However, the additional hours are due to the difference in the care needs noted between the tasking tool and UAS.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Altered Mental Status

Treatment: Inpatient Hospital Services

The insurer denied the inpatient hospital services. The denial was reversed. 

This is a female patient with a history of Schizoaffective Disorder-depressive type, menorrhagia, iron deficiency anemia, and previous blood transfusions. She presented to a psychiatric emergency facility with mental status changes that included combativeness and strange behavior in the presence of severe anemia. The patient was consulted by psychiatry. Laboratory work up was performed. It was reported that the patient had hemoglobin level of 6 and hematocrit level was 19.9. The patient was transferred to another medical facility for further evaluation of her anemia.  

The MCG- Milliman Criteria Guidelines for Psychiatric Disorder: Common Complications and Conclusions reports that one meets criteria for hospitalization if one is a danger to self or others and not manageable at a lower level of care, if they have severe behavioral health issues such as hallucinations, or if a less restrictive level of care is not considered feasible until acute intervention is done. This was the case with this patient as the patient was considered a danger to self and others with severe psychiatric symptoms including combativeness and strange behavior with noncompliance to medication. The patient was initially planned for a psychiatric admission until her anemia required medical treatment. This patient's altered mental status and behavioral changes in the context of severe anemia required inpatient hospital treatment. The patient's psychiatric consultant stated that the patient was not psychiatrically cleared for discharge from this hospital setting due to altered mental status in the setting of severe anemia, and it was stated that the patient had an acute psychotic episode. The patient's family confirmed that the patient exhibited odd and combative behaviors. During inpatient stay, the patient required serial monitoring and trending of her blood levels (hematocrit and hemoglobin), and required packed red blood cell transfusions, and 1:1 monitoring for safety. The psychiatric consultant recommended an antipsychotic medication, Abilify, for the patient. The patient was considered a danger to self and others due to her acute psychiatric symptoms that could have been triggered or exacerbated by her coexisting severe anemia. The patient's anemia needed to be corrected. The patient improved and was discharged.

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

The carrier denial of coverage for the inpatient hospital services from is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.  The denial is upheld.

The inpatient level of care was not medically necessary.

This is a female who presented with two days of atypical chest pain. The patient was also noted to be anemic. She received intravenous (IV) fluid and was admitted to telemetry to rule out coronary artery disease (CAD). Acute coronary syndrome (ACS) was ruled out with negative electrocardiogram (EKG), negative enzymes, echocardiogram, chest x-ray (CXR), computed tomography (CT) and nuclear stress test. Repeat complete blood count (CBC) revealed a further decrease of hemoglobin (Hgb). Hgb dropped from 9.8 to 9.2. Protonix was given; endoscopy revealed gastritis. A gastric emptying test was performed and was described as abnormal. The patient was placed on Reglan and discharged.

The appeal letter stated that the reason for admission to an inpatient unit was for urgent management of chest pain, and that the ability rule out (r/o) ACS could not be managed as an outpatient. However, there is no evidence in the records of any tests or treatment that would not be safe, effective or appropriate in an outpatient setting. There was not six days of "complex inpatient treatment", nor was there any evidence that this patient had CAD, ischemia or any cardiac findings. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome. Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. CXR was normal. Echocardiogram showed no wall motion abnormality.  Nuclear scan was negative for CAD. The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).   

The gastrointestinal (GI) work up including endoscopy, biopsy and oral medications are safe and appropriate in outpatient setting. There was no evidence of active bleeding as the drop in hemoglobin was likely dilutional and no GI bleeding was found. The patient was hemodynamically stable and the anemia is depicted as chronic. No symptoms were apparent that were related to anemia. There was no clinical urgency to address this issue.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.

The denial explanation was consistent with guidelines and usual community care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Advanced dementia
Treatment: Consumer Directed Personal Assistance Services (CDPAS) - two shifts/day, 12 hours/day, seven days/week, totaling 168 hours/week
The insurer denied the Consumer Directed Personal Assistance Services (CDPAS) - two shifts/day, 12 hours/day, seven days/week, totaling 168 hours/week.
The denial was overturned. 

The patient is a male with a history of advanced dementia, rendering him nonverbal. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). 

An appeal review requested for potential approval of an increase in Personal Assistance Services to two shifts/day, 12 hours/day, seven days/week, totaling 168 hours/week to offer increased ADL support.

Yes, the proposed treatment of an increase in Personal Assistance Services to two shifts/day, 12 hours/day, seven days/week, totaling 168 hours/week is deemed medically necessary. 

This is a male with a history of advanced dementia, rendering him nonverbal. Due to impairments related to these conditions, he requires assistance for completion of the majority of his activities of daily living (ADLs). Recent documentation from the patient's physician indicates that the patient has demonstrated progressive functional decline, that the patient is now unable to perform any self-care due to his diagnoses of advanced dementia, and that the patient is currently bedbound. Furthermore, he is unable to indicate when he needs toileting assistance and hence needs to be checked multiple times per day, and three to four times during the overnight hours. Hence, the currently approved plan of 12 hours/day, seven days/week, total 84 hours/week is insufficient to meet the patient's current needs. For these reasons, the proposed treatment of an increase in Personal Assistance Services to two shifts/day, 12 hours/day, seven days/week, totaling 168 hours/week is deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Pneumonia.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is overturned.

The patient is a woman with a history of gastric bypass, breast reduction, cholecystectomy, appendectomy, cesarean section, hernia repair, diabetes, and hypertension.  She was admitted to the hospital with a chief complaint of cough, fevers, and body pain for the past five days.  She reported that her cough was nonproductive and that she had a fever to 102 Fahrenheit.  The patient was admitted with acute influenza, sepsis and suspected pneumonia.  The plan of care included intravenous (IV) antibiotics, Tamiflu, Zofran, IV fluids, surgery consult, and continue other home medications.

The inpatient stay was medically necessary.  The patient presented with evidence of sepsis in the setting of both viral and possibly bacterial infection.  She had a high fever and did ultimately defervesce rapidly, but this was not known at the time of admission.  Because of the characteristics of her presentation she was at significantly increased risk of an adverse outcome particularly considering her comorbidities.  A patient with this type of presentation is managed at the inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exploratory Laparotomy.

Treatment: Ambulance transportation.

The insurer denied the ambulance transportation.

The denial was upheld.

The patient was hospitalized for an exploratory laparotomy, mesh for hernia, and excision of neurofibroma or neurolemmoma. He was transported from an acute hospital to a rehabilitation. He was unable to ambulate on his own. The transfer was provided by a non-participating provider for non-emergent reasons. The denial stated that he had no out of network benefits except for emergency. The patient stated that it was an emergency.  Based on the data provided the patient was clinically stable following his back surgery. 

The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. There was no indication as to why he needed to use a non-participating provider. He was not transported due to an emergency. 

The ambulance transportation for date of service is not considered medically necessary for this patient. While he needed non-emergent transportation to a lower level of care, the transportation was provided by a non-participating provider. There was no emergent basis found in the medical records for transportation.

An emergency is defined by national guideline, CMS, "An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
1) Serious jeopardy to the health of the individual or, in the case of a pregnant woman,
  the health of the woman or her unborn child;
2) Serious impairment to bodily functions; or	
3) Serious dysfunction of any bodily organ or part.

The data provided make it clear that there was no evidence of an emergent situation. 

Based on the above, the medical necessity for the ambulance transportation for date is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

This is a female who presented with chest pain and dyspnea. The patient has complex past history including myocardial infarcts (MIs), transient ischemic attack (TIA), gastroesophageal reflux disease (GERD), and polysubstance abuse. The patient was assaulted four days prior with injury to her left arm (bruising present). She described her pain as sharp in the upper chest. She was treated with analgesics and intravenous (IV) fluids. Electrocardiogram (EKG) did not show ischemic changes.  Cardiac enzymes were negative.  The patient had a normal echocardiogram with no wall motion abnormality (WMA) seen. She was found to be self-medicating with narcotics. There was no evidence of acute coronary syndrome (ACS).  The patient was discharged; the diagnosis on discharge was chest pain with assault to left shoulder.

No, inpatient level of care was not medically necessary.

There was never a clinical suspicion that patent had angina. The pain was explained by recent trauma. The patient was treated with analgesics and all tests were negative for ischemia. 

Determination of level of care is primarily dependent on the actual care a patient receives and, whether a higher level of acuity is needed to give this care. This is best reflected in the presentation, physical exam findings, and laboratory orders and their results; and highlighted in the orders for care. 

In this case, the symptoms were atypical and unlikely to be representative of acute coronary syndrome (ACS). Exam and cardiac findings were normal. Biomarkers and EKG showed no evidence of acute ischemia. Chest x-ray (CXR) was normal. Echocardiogram showed no wall motion abnormality.  The physicians' treatment did not reflect any serious concern about patient's cardiac condition.  Orders did not include medical therapy for ACS such as IV heparin, dual antiplatelet inhibitors, high dose beta blockers or IV nitroglycerin (NTG).  
 
The letter of appeal was carefully considered but it offered no evidence to support inpatient level of care. It is not clear what the appeal letter meant by "aggressive management and multitude of variables" that would have made the patient unsafe in a lower level of care. The only cardiac care provided was telemetry, frequently performed in a lower level of care. The patient was admitted for monitoring and subsequent tests and therapy did not require an inpatient level of care. There was no complex care that required inpatient care. This patient had no evidence of coronary artery disease (CAD). All tests showed absence of ischemia. While there is always a potential for an adverse event (and in this case a very low probability), one did not happen, and no actual treatment was added.

Milliman criteria requirements were not fulfilled as there was never any evidence of ACS present.

All testing and therapy would be appropriate, safe and guidelines consistent to be in lower level of care. Thus, inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis (scalp). 
Treatment: Otezla. 

The insurer denied the Otezla. The denial is overturned. 

The patient is a female with psoriasis of the scalp for whom Otezla is requested. She has tried and failed clobetasol, Taclonex and fluocinonide. 

Yes, the treatment with Otezla is medically necessary. 

The patient has severe psoriasis of the scalp and has failed topical steroids and calcipotriene. 

Phototherapy is not appropriate for sensitive areas (scalp, hands, pubic skin) and impossible to obtain during the COVID-19 pandemic. She is not a candidate for conventional systemic therapy (methotrexate, acitretin) due to her gender and childbearing age. Cyclosporine is not a reasonable long-term treatment for moderate to severe psoriasis due to their severe side effect profile. 

Otezla, an inhibitor of phosphodiesterase 4 (PDE4), is indicated for the treatment of adult patients with active psoriatic arthritis and patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. (Celgene, 2015)  Otezla is an oral small molecule inhibitor of phosphodiesterase 4 (PDE4) specific for cyclic adenosine monophosphate (cAMP) and is indicated for the treatment of adult patients with active psoriatic arthritis (PsA) as well as the treatment of patients with moderate to severe plaque psoriasis. (Celgene, 2016) The patient has moderate to severe psoriasis for which therapy with Otezla is appropriate and medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Foot Disorder. 
Treatment: Orthotics. 
The insurer denied custom orthotics. 
The denial is overturned in whole.  

The patient is a male who was seen for evaluation of painful calluses to the plantar aspects of both feet. He reported that he had orthotics in the past, which helped, but had not worn them in some time. On examination, calluses were noted sub-2nd and 3rd metatarsal heads bilaterally. A request was made for custom functional orthotics (L3000) but was denied. The subject under review is the medical necessity for the custom shoe inserts (L3000 x 2) for this patient.

The requested health service/treatment of custom shoe inserts (L3000 x 2) is medically necessary for this patient. Based on the clinical practice guidelines of the American College of Foot and Ankle Surgeons, as well as the American College of Foot and Ankle Orthopedics and Medicine orthotics, custom or otherwise, are considered an appropriate first-line treatment for lesser metatarsalgia. These devices are often effective in offloading calluses under metatarsal heads, thus decreasing plantar forefoot pain. A systematic review and meta-analysis by Martin et al. (4) found the use of custom-made foot orthoses improved the level of forefoot pain in rheumatoid arthritis, hallux abductus valgus and secondary metatarsalgia as it increases sole pressures.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Stiff Person Syndrome.
Treatment:  Gamunex-C (IVIG).

The insurer denied Gamunex-C (IVIG).  The denial was overturned.  

This is a female patient with a history of polyneuropathy, neck pain, stiff person syndrome and intrathoracic teratoma removal.  She consulted a neurologist with complaints of with axial stiffness, considered Stiff Person Syndrome (SPS).  It was reported that the patient also had polyneuropathy and chest teratoma. The patient's SPS symptoms have been incompletely controlled with benzodiazepine, baclofen and dantrolene treatments.  The provider prescribed intravenous immunoglobulin (IVIG).  The patient received one treatment and reported some benefit.  

Based on the review of the medical record and literature, the patient's treating physician's clinical impression for this patient's Stiff Person Syndrome (SPS) is reasonable.  The patient has documented axial stiffness at an in-person visit, and not all patients with SPS have anti-glutamic acid decarboxylase antibodies.  According to Bhatti and Gazali, "treatment modalities for SPS have included benzodiazepines and baclofen as the first line of drugs followed by IVIG, plasmapheresis, immune modulators, and Rituximab.  IVIG and plasmapheresis are either used alone or in combination in refractory cases.  Corticosteroids are used as monotherapy or in combination with other drugs for SPS.  However, their efficacy is not determined by any clinical trials."  In this case, the patient's symptoms were not well-controlled on first line treatment, benzodiazepine and baclofen.  Literature supports that IVIG is an appropriate next treatment option for this patient.  Thus, Gamunex-C (IVIG) treatment is considered medically necessary for this patient.

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

The carrier's denial of coverage for Gamunex-C should be overturned.  The medical necessity is substantiated.