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

Diagnosis: Multiple myeloma, peripheral vascular disease, leg edema with ulcers, asthma, severe arthritis of both knees, sleep apnea, diabetes

Treatment consumer directed personal assistance services (CDPAS) of 7 hours per day, 7 days per week as not medically necessary

The insurer denied coverage for CDPAS of 7 hours per day, 7 days per week as not medically necessary

The denial is upheld

This case involves a female who has a medical history that includes multiple myeloma, peripheral vascular disease, leg edema with ulcers, asthma, severe arthritis of both knees, sleep apnea, diabetes, obesity, urinary incontinence, and peripheral neuropathy. The documentation indicated due to the above issues she is able to walk slowly with a walker and has an unsteady gait. She is unable to climb stairs without assistance and cannot stand for greater than 5 minutes. She is self-correcting; however, needs help with activities of daily living (ADLs) that include bathing as well as dressing, cooking, and housekeeping. She needs assistance with edema compression device and wrapping of both legs. The physician indicated the patient was permanently and severely disabled and needed increasing services. The patient was seen for a follow-up. The documentation indicated the patient had 95% (percent) oxygen saturation on room air. Her blood pressure and heart rate were stable. It is noted she was 5 feet 2 inches tall weighing 340 pounds. She had pitting edema to the lower extremities. The physician indicated she should continue with multiple medications and continue to receive home care services.

This reviewer does not see any reason for the two additional hours requested per day based on review of the documentation. According to the Plan, the telephonic Uniform Assessment System of New York (UAS-NY) assessment, the clinical documentation and a thorough case review by the Appeals and Grievances team, she is able to walk, transfer and use a toilet with limited help, and with use of an assistive device (a rollator). She is able to feed herself with the meals that are prepared and set up for her in advance by her Personal Care Assistant (PCA) and she is able to direct her own care and activate Personal Emergency Response System (PERS) in case of an emergency. 

This reviewer agrees with the Plan that her activities of daily living (ADL) needs during a calendar day, such as grooming, dressing, bathing, ambulation, transferring, toileting, meal preparation and feeding are sufficiently infrequent and can be safely and adequately met through the combination of approved PCA service 7 days per week, 5 hours per day, combined with the Plan's coordinating member's care with the appropriate medical professionals additional specialized equipment as medically appropriate.

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

The insurer's denial of coverage for the requested Consumer Directed Personal Assistance Services (CDPAS) of 7 hours per day, 7 days per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vaso-occlusive pain due to sickle cell disease

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned. 

This male patient has a history of sickle cell disease, splenomegaly, glucose-6-phospate dehydrogenase deficiency (G6PD) and lead toxicity.

According to the appeal letter and supported in the medical record: "Upon serial monitoring, the patient suffered from severe, persistent right arm pain despite multiple doses of intravenous (IV) opioid and anti-inflammatory analgesia, which was consistent with failure to achieve symptom improvement and further supporting the necessity of acute inpatient care."

It is commonly understood and widely published that in children and young adults with sickle cell disease, the description of pain is often the only sign of sickle cell crisis. As such, for a patient in whom ambulatory analgesia has not been sufficient, or in patients who are non-compliant with home treatments, hospitalization for management of pain is standard of care. Hospitalization for management of pain with IV analgesia, IV hydration and to monitor for escalation of care as needed was within standard of care.  

According to InterQual, "Patients with vaso-occlusive crisis (VOC) present with severe pain. The diagnosis is based upon the history and physical examination... Aggressive and timely pain management is key to rapid resolution of VOC. In order to avoid undertreatment of pain, use of patient-controlled analgesia if age appropriate or scheduled analgesic administration is recommended. Additional supportive measures include hydration...".

The patient clearly meets this description. He presented with severe pain unrelieved in the ambulatory setting.

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

The carrier's denial of coverage for the inpatient admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Ascites

Treatment: Inpatient hospital

The insurer denied coverage for inpatient hospital.

The denial is overturned. 

This female patient has a history of end stage renal disease (on hemodialysis), hypertension, diabetes mellitus, and normocytic anemia.

The main issue was the abdominal pain that was significant enough that it prevented the patient from presenting for dialysis. The pain was due to ascites and the pelvic mass and management of these conditions was needed. While a paracentesis can be done as an outpatient, due to the patient's myriad medical issues and prior abdominal surgeries and concern about intra-abdominal bleeding in a patient who was already anemic, the procedure had to be performed in the hospital setting. In addition, the patient had significant abdominal pain and there was concern that she will not show up for dialysis. Note that multiple services were involved in this patient's treatment (Nephrology, Medicine Surgery, Gynecology, Interventional Radiology, Gastroenterology, Endocrinology) and the coordination of care between all those services would have been impossible as an outpatient.

Note that the patient's ascitic fluid grew enterococcus faecalis necessitating intravenous (IV) Vancomycin which had to be given very carefully in a patient on dialysis. While the management of a pelvic mass does not usually require hospital admission and dialysis can also be performed as an outpatient, the patient's multiple medical problems required hospitalization to be able to address them.

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

The carrier's denial of coverage for the inpatient hospital is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: 75574 CT (computed tomography)

The insurer denied coverage for 75574 CT.

The denial is upheld. 

This female patient has a history of coronary artery disease (CAD), anxiety, myocardial infarction, hypertension, hyperlipidemia, pericarditis, and Takotsubo cardiomyopathy.

The use of coronary CT (computed tomography) angiography is medically necessary for evaluation of chest pain when there is a low or intermediate probability of having coronary artery disease. This patient has established coronary artery disease, with history of myocardial infarction and prior coronary revascularization. Moreover, she had undergone recent nuclear stress testing, which was negative, and therefore there is no indication for coronary CT angiography in this instance. Based on results of the ISCHEMIA Trial, in the absence of high-risk findings on noninvasive stress testing, patients have equal cardiovascular outcomes on medical therapy versus an invasive strategy. In this instance, the patient is taking anti-anginal therapies. If there were ongoing symptoms despite a trial of medical therapy despite a normal perfusion stress test, the appropriate course of action and standard of care would be to refer the patient for direct invasive coronary angiography for definitive diagnosis. The use of coronary CT angiography in this clinical context of a patient with high pre-test probability of coronary artery disease is therefore not medically appropriate or necessary.

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

The carrier's denial of coverage for the 75574 CT is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetic ketoacidosis

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is overturned. 

This male patient has a history of insulin dependent diabetes mellitus (IDDM) and diabetic ketoacidosis (DKA).

The patient met diagnostic criteria for DKA and American Diabetes Association (ADA) hospital admission guidelines: 1) Blood glucose (BG) greater than 250 milligrams per deciliter (mg/dl), [greater than 13.9 millimoles per liter (mmol/L)] with: a) arterial pH (potential of hydrogen) less than 7.35, venous pH less than 7.30, or serum bicarbonate level less than 15 milliequivalents per liter (mEq/L) and b) ketonuria and/or ketonemia.

Specifically, his BG was 254, with a low carbon dioxide (Co2) or bicarbonate of 17, calculated anion gap of 24, and he had positive ketones, namely an elevated beta hydroxybutyrate acid level of 4.0 mmol/l [normal < (less than) 0.3mmol].

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

The carrier's denial of coverage for the inpatient admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest pain

Treatment: Inpatient admission

The insurer denied coverage for inpatient admission.

The denial is upheld. 

This female patient has a history of seizure disorder, asthma, coronary artery disease, and schizoaffective disorder.

This patient presented with atypical chest pain and vomiting. She was noted to be orthostatic on examination. No other abnormalities or findings consistent with an acute coronary syndrome were noted. Based on history and presentation alone, this patient had a low short-term risk of death and nonfatal cardiac ischemia. (1) She had a cardiac catheterization several months earlier demonstrating non-obstructive coronary disease. These findings are consistent with a low one-year mortality and a low probability of significant coronary artery disease. (2) Utilizing the HEART (History, EKG [electrocardiogram], Age, Risk factors, and Troponin) score she is considered low risk for major adverse cardiac events. (3) Utilizing the Thrombolysis in Myocardial Infarction (TIMI) risk score she also had a low risk of developing major adverse cardiac events in the subsequent 30 days. (4) Risk assessment of patients presenting with chest pain and no significant ST (the interval between ventricular depolarization and repolarization) changes on EKG was reviewed by Hedayati, et al. (3). Using the HEART score risk stratification schema, this patient would have a low risk of major adverse cardiac events (defined as myocardial infarction [MI], need for percutaneous coronary intervention [PCI], need for coronary artery bypass grafting [CABG], or death) in the six weeks following presentation. Using the TIMI risk score, this patient would have a low risk of major cardiac events (defined as all- cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization) within the two weeks following presentation. In conclusion, the patient could have been managed at a lower level of care.

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

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

Diagnosis: Chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, muscle weakness, lung cancer.

Treatment consumer directed personal assistant services (CDPAS) of 84 hours per week.

The insurer denied coverage for consumer directed personal assistant services (CDPAS) of 84 hours per wee

The denial is upheld.

The patient is an elderly female with a history of small cell lung cancer, and she is currently on chemotherapy and immunotherapy treatment. The patient also has a history of chronic obstructive pulmonary disease, hypertension, gastroesophageal reflux disease, muscle weakness, abnormality of gait and mobility, hearing loss, osteoarthritis, anxiety and depression. Per the New York State Department of Health's Uniform Assessment System (UAS-NY), the patient and her daughter were present. The patient lives alone in a three-bedroom private home with steps. 
She is totally dependent for meal preparation, ordinary housework and shopping. The patient needs maximum assistance with managing stairs and transportation. She needs extensive assistance with managing finances, phone use, equipment management, bathing, dressing her lower body, walking, locomotion, toilet transfer and toilet use. The patient uses an assistive device for locomotion. According to the patient's daughter, she had fallen in the bathroom approximately two weeks prior. The patient needs limited assistance with personal hygiene and dressing her upper body.  The patient needs supervision, oversight or cueing with managing medications.  She is independent and needs setup help only with bed mobility and eating. The patient is bladder and bowel continent.
New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:
"(a) Definitions and scope of services.
(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.
The patient has impairments as noted above. She is requesting 84 hours/week instead of 49. Her and her physician letters and her comments on the Uniform Assessment System (UAS) indicate a risk of falling and the need for more supervision. As noted above, the requested services for safety and supervision purposes is not covered. The health plan acted reasonably with sound medical judgment in the best interest of the patient.
The insurer's denial of coverage for the Consumer Directed Personal Assistant Services (CDPAS) of 84 hours per week is upheld.  Medical Necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Substance Abuse. 
Treatment: Inpatient Substance Abuse Rehabilitation Admission. 

The insurer is denied coverage for Inpatient Substance Abuse Rehabilitation Admission. 

The denial is overturned. 

This male patient has a history of substance use and depression. 

According to the LOCADTR he met criteria for inpatient substance rehabilitation treatment as he continued to use large amounts of heroin, buprenorphine, and cannabis daily and was homeless and lacked supports and the necessary coping skills for abstinence. He also reportedly had withdrawal symptoms and was not likely to stop use without being in a 24 hour inpatient therapeutic rehabilitation treatment then. In this case this patient was considered in need of 24 hour substance rehabilitation treatment for the entire inpatient substance rehabilitation treatment stay as he could not stop using multiple serious substances of use and was at risk for overdose and severe withdrawal. He also reportedly continued to use multiple serious substance of use despite a past inpatient substance detoxification treatment and he could not maintain abstinence as he relapsed due to lack of identification of relapse triggers, limited coping and relapse prevention skills, lack of supports as he was homeless, and he had comorbid depression and anxiety. 

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 the Inpatient Substance Abuse Rehabilitation Admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Worsening Shortness Of Breath. 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with a past medical history of gastric bypass surgery. She presented to the emergency room with symptoms of shortness of breath, pleuritic chest pain, nausea, vomiting and body aches and admitted for a suspected pulmonary embolism. Of note, she had recently traveled on a flight from another country to her home state a few days prior to admission. 

The patient was ruled out for COVID-19 infection. She underwent a CT (computed tomography) chest, which demonstrated no evidence of a pulmonary embolism and a ventilation-perfusion scan, which demonstrated a low probability for pulmonary embolism. Bilateral lower extremity doppler ultrasound was also negative for a deep vein thrombosis. The patient was admitted to an inpatient level of care hospital stay for the workup of her symptoms. 

No, the Inpatient admission was not medically necessary. 

Based upon the severity of illness and intensity of required therapy, the inpatient stay was not medically necessary. This patient with a medical history of gastric bypass surgery presented to the emergency room with symptoms of shortness of breath, pleuritic chest pain, nausea, vomiting and body aches and admitted for a suspected pulmonary embolism. 

On admission, the patient was afebrile, hemodynamically stable, had a blood pressure of 114/72 mmHg (millimeters of mercury), noted to have a respiratory rate of 18 breaths per minute and oxygen saturation of 100% on room air. On exam, she was alert and cooperative, had diminished breath sounds bilaterally, but did not have any documented accessory muscle use, rales, rhonchi or wheezing on auscultation of the chest. She was ruled out for COVID-19(Coronavirus disease) infection. She underwent a CT (computed tomography) chest, which demonstrated no evidence of a pulmonary embolism and a ventilation-perfusion scan, which demonstrated a low probability for pulmonary embolism. A bilateral lower extremity doppler ultrasound was also negative for a deep vein thrombosis. 

The patient was treated with therapeutic dose Lovenox, Zofran, dexamethasone and pain control medications (opioids). She did not have evidence for impending or actual respiratory arrest, a severe airflow or ventilation abnormality or severe respiratory findings not responsive to observation level of care treatment. She did not have a history of chronic lung disease with severe deterioration, tuberculosis, severe pulmonary arterial hypertension, right heart failure, pulmonary vascular disease, cystic fibrosis, bronchiectasis, interstitial lung disease, allergic pneumonitis or a lung injury requiring an inpatient level of care. There is no documentation of a specific through outpatient work-up and evaluation was conducted or have treatment refractory lung disease. Therefore, the inpatient level of care was not medically necessary.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Moderate to Severe Persistent Asthma

Treatment: Dupixent 300 mg/2ml (milligram per milliliter) pen injector

The insurer denied coverage for Dupixent 300 mg/2ml (milligram per milliliter) pen injector

The denial is upheld

The patient is uncontrolled on ICS/LABA [Inhaled Corticosteroid (ICS)/Long-Acting Beta-Agonist] needing systemic steroids despite normal pulmonary function. A 10% [percent] increase in lung function is mentioned but not shown in the actual pulmonary function test (PFT) results written on the letter. The listed medications include Symbicort, budesonide and Protonix but not prednisone or methylprednisolone. The other significant comorbidity is EoE [Eosinophilic esophagitis] which apparently is still symptomatic and requiring dilation and emergency department (ED) visits, despite proton pump inhibitor (PPI)/swallowed budesonide treatment. The provider argues that Dupixent would also help this disorder.  Documents relating to biologics and asthma/EoE are also included. No asthma control scoring is listed. An eosinophil level was 700. There is no documentation of when systemic steroids were given for asthma (as opposed to for EoE).

The definition of severe asthma by the European Respiratory Society looks at the number of steroid bursts in the past year as one marker of severe asthma, as well as having poor asthma control using a scoring methodology. Both of these types of information are lacking in the documents reviewed. Thus, it cannot be stated that the requested service is likely to be more beneficial than any of the standard treatments/procedures for this patient.

Thus, there is inadequate evidence to support severe asthma and the specific need for
Dupixent in this patient. Currently, none of the asthma biologics are approved for EoE.

The carrier's denial of Dupixent 300 mg/2ml (milligram per milliliter) pen injector should be upheld.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Moderate to Severe Persistent Asthma

Treatment: Dupixent 300 mg/2ml (milligram per milliliter) pen injector

The insurer denied coverage for Dupixent 300 mg/2ml (milligram per milliliter) pen injector

The denial is overturned

This case involves a patient who has a diagnosis of moderate to severe persistent asthma as well as eosinophilic esophagitis.  The documentation does indicate the patient has been treated with a high-dose ICS/LABA [Inhaled Corticosteroid/ Long-Acting Beta-Agonist] however remains poorly controlled as evidenced by frequent symptoms along with reliance on systemic steroids.  The documentation indicated although she has normal lung function even in the setting of normal lung function, she has demonstrated reversibility of 10% (percent) in the past which was suggestive of ongoing obstructive lung disease despite her FEV1 [forced expiratory volume] being greater than 80%.  Given her asthma remains poorly controlled she has been recommended to utilize monoclonal antibodies.  The physician indicated in deciding which of the 3 medications recommended is the best option it is important to consider comorbidities.  The physician does indicate eosinophilic esophagitis is poorly controlled leading to multiple trips to the emergency department.  Given the above conditions it has been recommended she utilize the requested Dupixent.

Literature does support a result in improvement.  This medication is approved for moderate-to-severe asthma with an eosinophilic phenotype or with oral corticosteroid dependent asthma.  She is a good candidate for use.  This is the best available treatment given a failure of other medications to include steroids.  There are no increased risks with use of this medication.

As noted above, this patient is appropriate to utilize this medication given her clinical picture and a failure of other medications. This medication is likely to be more beneficial than any other standard treatment and the adverse risks would not be increased.

The carrier's denial of Dupixent 300 mg/2ml pen injector should be overturned.