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

Diagnosis: Foreign Body in the Proximal Esophagus

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission.

The denial is upheld.

This case involves an infant who was brought to the emergency department after swallowing a foreign body.  The documentation indicated the patient was awake and crying.  She had easy work of breathing and her lungs were clear and equal to auscultation.  There was no drooling noted.  The documentation indicated an x-ray showed a foreign body in the proximal esophagus.  The physical examination revealed a blood pressure of 107/63.  Her heart rate was 136 and oxygen saturation were 100% (percent) on room air.  The recommendation was made for diagnostic studies.  The physician indicated repeat x-ray revealed no migration of the colon.  There continue to be no drooling or signs of airway compromise.  ENT [ear, nose, throat] specialist was recommended for consultation.  The patient was admitted and recommended to undergo operative intervention for removal.  The documentation indicated the foreign body was removed by direct laryngoscopy and esophagoscopy.  The documentation detailed postoperatively there was no complications.  The patient was able to advance her diet as tolerated and there were no documented adverse events.  Given the above she was discharged the following day.

According to the referenced literature a patient may be admitted when there is documentation detailing a reconstruction procedure is needed to be performed or there is evidence of prior head or neck trauma with surgical intervention being planned.  Additionally, if there is evidence that the patient will be undergoing a procedure to the vocal cords inpatient admission may be needed.  However, most procedures are ambulatory.  The submitted documentation indicated patient was noted to have no migration of a foreign body upon repeat imaging and therefore was recommended to undergo a procedure to remove the object.  The patient did not have any complications during the procedure and the postoperative course was uncomplicated.  

Therefore, it does not appear an inpatient admission was needed given a lack of documentation detailing instability, airway compromise, or any of the above needed procedures.  As such, the health plan acted reasonably with sound medical judgment in the best interest of the patient.

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

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

This is a male with bilateral knee pain. He was admitted to hospital for an elective left total knee replacement (TKR). His comorbidities were reviewed; American Society of Anesthesiologists (ASA) status was three. His blood loss was 100 cubic centimeters (cc). His post surgical course was non-complicated with clearance for discharge.

No, the proposed inpatient admission was not medically necessary.

The records show the patient underwent a non-complicated total knee arthroplasty. His vital signs were stable. He did not have bleeding or problems with his wound. He was able to tolerate oral pain medication and could ambulate. His discharge summary confirmed the above and was timed at 17:34 day of surgery. 

The report of him being American Society of Anesthesiologists (ASA) status (ASA) three would not be correct as the definition is as stated:

AMERICAN SOCIETY OF ANESTHESIOLOGY PATIENT CLASSIFICATION STATUS:

1) ASA (American Society of Anesthesiologists) I
Normal healthy patient

2) ASA  (American Society of Anesthesiologists) II
Patient with mild systemic disease; no functional limitation eg, smoker with well-controlled hypertension 

3) ASA (American Society of Anesthesiologists) III
Patient with severe systemic disease; definite functional impairment eg, diabetes mellitus and angina with relatively stable disease, but requiring therapy

4) ASA (American Society of Anesthesiologists) IV
Patient with severe systemic disease that is a constant threat to life eg, diabetes mellitus plus angina plus congestive heart failure; patients have dyspnea on mild exertion and chest pain.

Based upon the above, the patient was an American Society of Anesthesiologists (ASA) status (ASA) two. He did not require treatment for an underlying condition. There were no extenuating circumstances to substantiate the requested level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Contact with and exposure to other viral communicable diseases
Treatment: Coronavirus COVID-19 Respiratory Panel (0202U-59-91)
The insurer denied the Coronavirus COVID-19 Respiratory Panel (0202U-59-91).
The denial is upheld.

This patient is a female with a history of contact with and exposure to other viral communicable diseases.  This is an appeal for denial of Coronavirus COVID-19 Respiratory Panel (0202U-59-91).  The test was denied due to lack of signs/symptoms of COVID-19.  The patient notes these tests were performed to test for COVID-19.

No, the proposed treatment was not medically necessary.

Polymerase chain reaction (PCR) Respiratory Panel Testing may be medically necessary for individuals who are at high risk for complications of respiratory viral infection, such as the immunocompromised.  The diagnosis indicates this patient was exposed to a communicable virus.  There is no documentation that the patient is immunocompromised or at high risk for complications of a respiratory infection.  Therefore, the proposed Coronavirus COVID-19 Respiratory Panel (0202U-59-91) is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exposure to COVID
Treatment: Polymerase chain reaction (PCR) testing
The insurer denied the Polymerase chain reaction (PCR) testing.
The denial is upheld.

The patient is a male child. During the time frame in question, the father tested positive for COVID (coronavirus). They brought the child to the doctor's testing site for COVID-19 testing. A BioFire respiratory pathogen polymerase chain reaction (PCR) panel was performed instead. The results were ultimately negative.

No, the proposed treatment was not medically necessary.

The BioFire respiratory pathogens panel was not medically necessary. The child required testing solely for COVID-19 and the primary care practitioner performed a complete respiratory pathogen polymerase chain reaction (PCR) panel at his testing site.

The world-wide pandemic was declared as a result of COVID-19, a disease caused by a novel coronavirus, SARS-CoV-2. To date there have been almost 235 million cases confirmed world-wide, with almost five million deaths. There have been over 43 million confirmed cases in the United States alone. Since the availability of vaccination, over six trillion doses of vaccine have been administered. Since the arrival of the delta variant, cases in children have begun to rise, with almost six million children testing positive. Almost half a million cases are added every week at this time. Although COVID-19 has been diagnosed in people of all ages and cases have been rising in children, those at highest risk of severe disease remain older adults and those with severe underlying medical conditions such as cardiopulmonary disease and diabetes. Currently, the risk of COVID-related hospitalization and death in children remains small, yet families are still terrified and look to their medical practitioners for appropriate guidance and proper intervention.

This child did not require a full BioFire respiratory pathogen polymerase chain reaction (PCR) panel at the time of presentation to the primary care practitioner's testing site; the patient only required testing for COVID-19.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Diabetes mellitus, congestive heart failure and hypertension. 
Treatment: Continued long term custodial care. 

The insurer denied coverage for continued long term custodial care.

The denial is upheld.

This is an adult male with chronic medical problems including diabetes mellitus, congestive heart failure and hypertension. He was admitted for rehabilitation following a hospitalization, with reported planned transition to long term care placement. 

There are no complicated nursing issues that require inpatient physician monitoring or skilled nursing services, respectively. According to the therapy notes, the patient is at the supervision to stand by assistance level for activities of daily living. 

The patient is medically stable and care is primarily custodial. Services can be provided at a lower level of care (e.g., home with custodial home health aide services). From a physical medicine and rehabilitation perspective, continued long term custodial care rehabilitation is not medically necessary.

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

The insurer's denial of coverage for continued long term custodial care is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Exposure to other viral communicable disease
Treatment: Polymerase Chain Reaction (PCR) Testing
(0202U-59-91) 
The insurer denied the Polymerase Chain Reaction (PCR) Testing
(0202U-59-91) 
The denial is upheld.

The patient is a female child. During the time frame in question, the father tested positive for COVID. The family brought the child to the doctor's testing site for COVID-19 testing. A BioFire respiratory pathogen polymerase chain reaction (PCR) panel was performed instead. The results were ultimately negative.

No. The testing that was done was not medically necessary.
The BioFire respiratory pathogens panel was not medically necessary. The child required testing solely for COVID-19 and the primary care practitioner performed a complete respiratory pathogen polymerase chain reaction (PCR) panel at his testing site.

A world-wide pandemic was declared as a result of Covid-19, a disease caused by a novel Coronavirus, SARS-CoV-2. To date there have been almost 236 million cases confirmed world-wide, with almost 5 million deaths. There have over 44 million confirmed cases in the United States alone. Since the availability of vaccination, over 6 trillion doses of vaccine have been administered. Since the arrival of the delta variant, cases in children have begun to rise, with almost 6 million children testing positive. Almost half a million cases are added every week at this time. Although Covid-19 has been diagnosed in people of all ages and cases have been rising in children, those at highest risk of severe disease remain older adults and those with severe underlying medical conditions such as cardiopulmonary disease and diabetes. Currently, the risk of Covid-related hospitalization and death in children remains small.

This child did not require a full BioFire respiratory pathogen polymerase chain reaction (PCR) panel at the time of presentation to the primary care practitioner's testing site; the patient only required testing for COVID-19.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chest pain
Treatment: Heart Catheterization And Ventriculography (93458)
The insurer denied the Heart Catheterization And Ventriculography (93458)
The denial is overturned. 

The patient is a male. He presented with chest pain with dyspnea and dizziness. His risk factors include tobacco use, hypertension, and family history.

The patient's exam was normal except for high blood pressure. His labs were normal, including normal troponin x 4. ASA (aspirin) was given. EKG (electrocardiogram) showed non-specific ST-segment abnormality. CXR (chest x-ray) was negative. Echocardiogram was normal without any wall motion abnormality. Nuclear stress test was abnormal.

The patient was pain-free while in hospital. His blood pressure was treated. He was discharged on medications with follow up for probable cardiac cath. Discharge medications included beta blocker, calcium antagonists, ASA (aspiring), ACE (Angiotensin Converting Enzyme) inhibitors, statin, diuretic. and NTG (nitroglycerin).

Yes, the Heart Catheterization And Ventriculography (93458) is medically necessary.
Cardiac catheterization is reasonable with symptoms of chest pain, positive nuclear scan with reversible ischemia, abnormal EKG (electrocardiogram), with risk factors of tobacco, hypertension, and strong family history. While it is common to have a false positive inferior wall defect, it does require an angiogram to make that determination.

Therefore, given the above, the Heart Catheterization And Ventriculography (93458) is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hearing Loss

Treatment: Durable Medical Equipment - Bilateral Hearing Aids (both ears)

The insurer is denied coverage for Durable Medical Equipment - Bilateral Hearing Aids (both ears)

The denial is overturned. 

This patient has evidence of hearing that slopes to a moderately severe sensorineural hearing loss rising to within normal limits at 8 kHz [kilohertz].  The documentation indicated she has excellent word recognition ability with speech made loud enough to accommodate her hearing loss.  She indicates her hearing loss is causing significant difficulty conversing with her family, friends, and at work.  The recommendation was made for application for both right and left ears.  The patient presented complaining of hearing loss.  She indicated it started years prior.  Her hearing loss is progressive.  Upon physical exam there was a cerumen impaction bilaterally.  The recommendation was made to undergo further assessment for hearing aids as there was evidence of sensorineural hearing loss bilaterally.

Per peer-reviewed literature, most hearing impairments can be helped with a modern hearing aid. Young, middle-aged, and independent older adults who have hearing difficulties that interfere with work and social interactions, and who are highly motivated to improve their hearing, make excellent candidates for hearing amplification. Hearing aids improve hearing-specific health-related quality of life, general health-related quality of life, and listening ability in adults with mild to moderate hearing loss. The submitted documentation indicated the patient has a history of hearing loss.  The documentation indicated she has a moderately severe sensorineural hearing loss rising to within normal limits at 8 kHz.  She does complain of difficulty due to hearing loss when trying to converse with her family, friends, and perform work-related duties.  The documentation therefore does indicate she has undergone the proper evaluation and is an appropriate candidate to receive bilateral hearing aids.  As such, the requested durable medical ointment-bilateral hearing aids for both ears are medically necessary. 

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

The insurer's denial of coverage for Durable Medical Equipment - Bilateral Hearing Aids (both ears) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease. 
Treatment: Stelara (dosed every 4 weeks). 

The insurer denied the Stelara (dosed every 4 weeks). 
The denial is overturned. 

The patient is a male with moderate to severe Crohn's. He has failed budesonide, 6-MP (mercaptopurine) and Humira. He has had some, but not a complete response to Stelara 90 mg (milligrams) every 8 weeks, with improvement in symptoms, but ongoing active disease on colonoscopy. Serum Stelara level is low at 3.5 His provider is requesting to increase Stelara to 90 mg (milligrams) every 4 weeks. 

Yes, the Stelara every 4 weeks is medically necessary. 

Medical literature supports dose intensification of biologics in patients who lose response to FDA (United States Food and Drug Administration) approved dosing. Stelara has been found to be safe and effective at doses as high as 90 mg (milligrams) every 4 weeks. 

Results from a retrospective cohort study of patients with CD (Crohn's disease) reported that among 122 patients on ustekinumab, 21 (17%) patients on every 8 week maintenance dosing required dose intensification (frequency increased to every 4 weeks, every 6 weeks, or a combination of IV [intravenous] booster and frequency increase to every 6 weeks or every 4 weeks). A total of 11 patients (52%) had clinical response after dose escalation (2 [18%] were primary nonresponders to induction while 9 [82%] had poor initial clinical response).

A multicenter, retrospective, open-label cohort study of adults with moderate to severe CD (Crohn's disease) was conducted to evaluate the long-term maintenance efficacy of ustekinumab therapy. During the maintenance therapy, dose escalation was required in 16.3% (17/104) patients and a combination strategy of reinduction and dose escalation was required in 6.7% (7/104) of patients. The most common escalated maintenance dosing was 90 mg (milligrams) every 4 or 6 weeks. Clinical response was regained in 52.9% (9/17) of patients who had dose escalation, and 57.1% (4/7) of patients who had combined reinduction and dose escalation. 

Results from a retrospective, multicenter, open-label study of patients with refractory CD (Crohn's disease) receiving ustekinumab, demonstrated that, among 11 patients who required a dosing interval reduction (includes 90 mg [milligrams] every 8 weeks to every 4 weeks, 90 mg [milligrams] every 8 weeks to every 6 weeks), clinical improvement was seen in 73% (8/11) of patients. 

Results from a retrospective, open-label, observational study of ustekinumab for the treatment of anti-tumor necrosis factor (anti-TNF) resistant CD (Crohn's disease) patients, demonstrated that, among patients who achieved clinical response at the last followup, dose escalation was required in 35% (7/20) of patients who received ustekinumab 90 mg (milligrams) every 8 weeks.

Therefore as the patient has not had a complete response to Stelara 90 mg (milligrams) every 8 weeks, with low serum Stelara levels, the requested drug Stelara at the dosage of 90 mg (milligrams) every 4 weeks is clinically appropriate, accepted standard of medical care, and is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Type 2 diabetes mellitus, hyperlipidemia, and essential hypertension

Treatment: Personal Care Services (PCS), Level 2, 6 hours per day, 7 days per week, total of 42 hours per week

The insurer denied coverage for Personal Care Services (PCS), Level 2, 6 hours per day, 7 days per week, total of 42 hours per week.

The denial is upheld.

The patient has a past medical history of type 2 diabetes mellitus, hyperlipidemia, and essential hypertension. According to a Uniform Assessment System (UAS) assessment done, the patient reported that he needs more assistance with activities of daily living (ADLs)/instrumental activities of daily living (IADLs) due to functional decrease. The patient lives in a 2 bedroom apartment with his wife on the 9th floor of a building with a working elevator. His wife assists at night but cannot during the day, and his children cannot. Recent physician visits do not note new medical problems. UAS notes maximal assistance with IADLs and limited assistance with ADLs. He has incontinence but uses the toilet with contact guard assistance (CGA). No substantial change is noted from UAS done. 

Coverage for Personal Care Services (PCS), Level 2, 6 hours per day, 7 days per week, total of 42 hours per week is being requested. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(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 tasking tools seem to be consistent with the observed functional impairments. Deterioration has not been documented. The additional hours are being requested for supervision because of a possible hypoglycemic episode. As noted above that is not a criteria for coverage. The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient. 

The insurer's denial of coverage for Personal Care Services (PCS), Level 2, 6 hours per day, 7 days per week, total of 42 hours per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Crohn's Disease
Treatment: Remicade 10mg/kg (600mg) At Week 0, 2, 6 Then 10mg/kg (600mg) Every 6 Weeks
The insurer denied the Remicade 10mg/kg (600mg) at week 0, 2, 6 then 10mg/kg (600mg) every 6 weeks.
The denial is overturned. 

The patient is a female with severe fistulizing Crohn's. She was previously treated with Remicade, titrating up to 10 mg/kg (milligrams per kilogram) every 6 weeks, with good results. She was changed to Humira for any easier mode of administration, but lost response, and then Entyvio and Stelara and did not respond. Her provider is requesting to resume Remicade at 10 mg/kg (milligrams per kilograms) every 6 weeks.

Yes, the requested health service is medically necessary.

Medical literature supports dose intensification of biologics in patients with CD (Crohn's disease) who fail treatment with FDA (United States Food and Drug Administration)-approved dosing. Over 25% of patients with CD (Crohn's disease) treated with biologics require dose intensification. Remicade has been found to be safe and effective at doses as high as 20 mg/kg (milligrams per kilogram) every 4 weeks. Therefore, as this patient lost response to Remicade 5 mg/kg (milligrams per kilogram) every 8 weeks, did well in the past after previously titrating up to 10 mg/kg (milligrams per kilogram) every 6 weeks, and has not responded to Humira, Entyvio or Stelara, the requested dose and frequency is supported by current peer-reviewed medical literature, clinical practice guidelines, and is standard of care. The requested Remicade 10 mg/kg (milligrams per kilogram) weeks 0, 2, 6 and every 6 weeks is medically necessary.

As the patient has previously not responded to Remicade 10 mg/kg every 8 weeks and has responded to 10 mg/kg every 6 weeks,  the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient by denying Remicade 10 mg/kg every 6 weeks.