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

Diagnosis: chronic pancreatitis

Treatment: inpatient admission

The insurer is denied coverage for inpatient admission

The denial is upheld. 

This male patient has a history of polysubstance abuse, diabetes, and pancreatitis.

Clinical indications for admission for Pancreatitis (MCG M-250) include having acute pancreatitis and as manifested by 2 of the following: abdominal pain, pancreatic enzymes greater than 3 times the upper limit of normal, and characteristic findings on imaging studies. In this case, the patient did not have pancreatic enzymes greater than 3 times the upper limit of normal or characteristic findings on a CAT (computed axial tomography) scan. He also did not have hemodynamic instability, an abscess, hypoxemia, acute renal failure, severe electrolyte abnormalities, or an inability to maintain oral hydration.

This patient had chronic pancreatitis. IV (intravenous) hydration, antiemetics, and pain control could have been given in the ER (emergency room) with observation status. He did not meet Milliman Care Guidelines (MCG) criteria for admission for Pancreatitis. The health care plan acted reasonably and with sound medical judgment. An inpatient admission was not medically 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 inpatient admission is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Depression/Obsessive-Compulsive Disorder/OCD.
Treatment: Inpatient Behavioral Health Level of Care, Child or Adolescent.

The health plan denied the Inpatient Behavioral Health Level of care, child or adolescent.  The reviewer has upheld in whole the health plan's determination. 

The patient was admitted to inpatient behavioral health level of care. Prior to admission the patient was impulsive with possible mania. The patient had not been sleeping for 4 days. The patient was diagnosed with major depressive disorder (MDD), obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), body dysmorphia and post-traumatic stress disorder (PTSD). As of the first date in question the patient had improved. The patient was not suicidal, homicidal, psychotic, or manic. The patient was not sexually inappropriate. The patient was medication compliant with no side effects to medications. There were no other imminent risk concerns.

The requested health service/treatment of Inpatient Behavioral Health Level of Care, Child or Adolescent is not medically necessary for this patient for the dates of service in question. The patient had no suicidal ideation with a plan, homicidal ideation with a plan or command hallucinations.  There was no physical aggression and no other acute concerns that required around the clock monitoring. The patient had improved and did not have emotional or medical concerns that required 24-hour level of care monitoring. A serum level of Lithium could have been managed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dental Disorder. 
Treatment: Braces; monthly visit; retainer. 

The insurer denied braces; monthly visit; retainer. 
The determination is upheld. 

The patient has a Class I occlusion with 3 millimeter (mm) overbite and 3 mm overjet. She has minor maxillary and severe mandibular crowing. She is treatment planned for orthodontics to correct her malocclusion. At issue is the medical necessity of braces; monthly visit; retainer. 

The requested services are not medically necessary. There is no medical reason to correct her malocclusion with braces. While the patient has crowding, there is no anterior or posterior crossbite. There is no evidence of wear or periodontal recession. There are functional problems that may occur in the dentition that become more difficult, if not impossible, to correct if not addressed in adolescence. (1) However, this patient presents with none of those conditions. Aligning her teeth will likely not increase chewing efficiency since masticatory efficiency is already highest in patients with a Class I occlusion. (2) If her teeth were aligned it would provide an esthetic improvement but it would not create a medically significant improvement to the patient's health. 

Therefore, the requested orthodontic treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, heart disease, depression, sleep problems, osteoarthritis, seizures

Treatment: Consumer Directed Personal Assistance Services (CDPAS)

The insurer denied coverage for CDPAS.

The denial is overturned.

The patient is a male with a history of Alzheimer's dementia, heart disease, depression, sleep problems, osteoarthritis, seizures, bowel and bladder incontinence, and irritable bowel syndrome (IBS). He is wheelchair dependent. Uniform Assessment System (UAS) indicates maximal assistance-total dependence with all functions except extensive assistance with bed mobility. He needed limited assistance with toileting. He needs 2 people to transfer to commode. MMSE (mini-mental state exam) score is 2. He was hospitalized with dehydration, behavioral changes and pneumonia. Stage I sacral skin changes were noted. 

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 patient has severe dementia. He is incontinent x (times)2 and has had pressure skin changes. He has been provided with durable medical equipment (DME) but due to cognitive and physical limitations he cannot manage them on his own. He is unable to turn and position (T&P) himself in bed. Any verbal instructions will not be retained. The request for 24-hour care is approved. 

The provision of diapers and alternate pressure beds is not by itself adequate for prevention of pressure sores. As noted in changing diapers regularly and positioning are also 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 consumer directed personal assistance services (CDPAS) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Orthopedic/Musculoskeletal. 
Treatment: Home Health Care. 
The insurer denied an increase in PCA hours. 
The denial was overturned. 

The patient is a female with a past medical history significant for displaced femoral condyle fracture, malleolar fracture, gait abnormality, congestive heart failure and postherpetic neuralgia. The patient is currently non-weightbearing secondary to her recent fracture. The patient is requesting 24 hour a day live-in services. These services were denied by her health plan based upon medical necessity and the patient is appealing the decision.
At issue is the medical necessity of Increase in personal care aide (PCA), Level 2: live-in per diem, 24 hours a day-7 days per week.

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

The requested health service/treatment of Increase in personal care aide (PCA), Level 2: live-in per diem, 24 hours a day-7 days per week is medically necessary for this patient.
Additional services are medically necessary for this patient recuperating from her fracture. The patient is a female with multiple medical problems, recent fracture of the femoral condyle and malleoli which limits her mobility and independence. The patient was hospitalized and then subsequently transferred to skilled care for rehabilitative services.  The patient was previously receiving services of 63 hours a week. Subsequent to the evaluation, the patient fell and fractured her leg resulting in progressive problems with mobility and independence. Review of physical therapy notes from the skilled care facility, notes the patient shows significant deficits and independence with maximal assist in most activities of daily living (ADL)s. She is dependent in all ADLs. Of note, the patient was non ambulatory secondary to her recent fracture. Her worsening health status secondary to the fracture impairs her ability to function independently, and additional services for 24-hour per day living services would be medically necessary.
Therefore, the requested health service/treatment of Increase in personal care aide (PCA), Level 2: live-in per diem, 24 hours a day-7 days per week is medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Progressive supranuclear palsy

Treatment: Personal Care Services, Level 2 to 24 hours per day, 7 days per week (Split-Shift) for total of 168 hours per week 

The insurer denied coverage for an increase of Personal Care Services, Level 2 to 24 hours per day, 7 days per week (Split-Shift) for total of 168 hours per week

The denial is overturned.

The patient has a history of progressive supranuclear palsy. He requires assistance with activities of daily living. Uniform Assessment Syestem (UAS) notes he is self-directing. He needs limited-extensive assistance with all activities of daily living (ADL). He needs frequent turning and positioning (T&P). He has durable medical equipment (DME).  The family notes he is frequently incontinent of urine and soaks the bed. He needs assistance with all functions. He cannot turn himself in bed. In a letter his Neurologist notes the same.  He receives Personal Care Services, Level 2, 24 hours per day, 7 days per week (Live in). The request is for an increase of Personal Care Services, Level 2 to 24 hours per day, 7 days per week (Split-Shift) for total of 168 hours per week.

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 is impaired in all ADLs including bed mobility, transfers and locomotion. He is incontinent of urine. While he has a commode and other DME as well as diapers, he is unable to manage using these on his own. He is continent of bowel, but this only helps if he is able to use the bathroom or commode. He cannot T&P himself. The UAS states his needs can be scheduled but this is not supported. 

The provision of diapers and DME such as alternate pressure beds is not by itself adequate for prevention of pressure sores, changing diapers regularly and positioning are also noted to be necessary. 

The request for split-shift is approved. 

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 an increase of Personal Care Services, Level 2 to 24 hours per day, 7 days per week (Split-Shift) for total of 168 hours per week is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes mellitus, heart disease, cancer, arthritis, urinary incontinence, and cognitive decline

Treatment:  an increase of Personal Care Worker (PCW) services from 7 days per week, 4.5 hours per day to 7 days per week, 6 hours per day

The insurer denied coverage for an increase of Personal Care Worker (PCW) services from 7 days per week, 4.5 hours per day to 7 days per week, 6 hours per day

The denial is overturned.

The patient had a history of diabetes mellitus, heart disease, cancer, arthritis, urinary incontinence, and cognitive decline. She has difficulty ambulating. She needs limited-extensive assistance with all activities of daily living (ADL) except bed mobility (independent). She receives personal care worker (PCW) services 4.5 hours, 7 days per week. The request is for an increase in PCW services to 6 hours, 7 days per week.

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 documentation notes that the patient needs assistance with all activities of daily living (ADLs) except bed mobility. She has cognitive problems. She is incontinent and cannot independently go the bathroom or change diapers and clean herself. She cannot transfer out of bed or ambulate without assistance. Informal caregivers cover part of the hours beyond the 4.5/day allotted by the plan, but this is not sufficient to cover the hours informal caregivers are not available. Safety is provided by the services rendered, but the services are needed for more than just safety. 

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 Personal Care Worker (PCW) services 7 days per week, 6 hours per day is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Ulcerative colitis and psoriasis
Treatment: Stelara
The insurer denied Stelara.
The determination is upheld.

The patient has a history of Crohn's disease and psoriasis, based on the appeal letter. He tried and failed corticosteroids. The clinical notes indicate a normal skin exam and no active rashes. There is no documentation of confirmed psoriasis in the clinical notes.
The requested service is Stelara to treat both Crohn's disease and psoriasis. At issue is whether this is medically necessary.


Stelara is not medically necessary in this case.

Stelara is approved by the Food and Drug Administration for treating Crohn's disease in adults and psoriasis in pediatric patients and adult patients.
This patient has inflammatory bowel disease, likely Crohn's disease. His clinical records do not indicate the presence of severe refractory psoriasis that requires biologic therapy. The records indicate a normal skin exam and no psoriatic rashes.
In terms of bowel disease, there are more appropriate and FDA approved treatments, such as adalimumab (Humira) and infliximab {tumor necrosis factor alpha inhibitors}. Biologics are considered first line treatment in pediatric inflammatory bowel disease and are supported by clinical practice guidelines.
Stelara is appropriate in pediatric patients with Crohn's disease who have tried and failed tumor necrosis factor alpha inhibitors or the ones who have contraindications to this class of medications. This patient has not tried and failed available and more appropriate alternatives. There are no documented contraindications to using these. The diagnosis of psoriasis is not well supported by the provided clinical records.
Therefore, the off-label use of Stelara in this case is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Stroke, immunosuppression. 
Treatment: Personal care aide (PCA) 7 days x 6 hours. 

The insurer denied coverage for personal care aide (PCA) 7 days x 6 hours. 

The denial is overturned. 

According to the documentation submitted, this is patient has a history of immunosuppression, stroke, fall with left shoulder fracture and wheelchair bound status. The patient lives alone in an apartment building on the 4th floor with elevator access. He receives enteral feeds via percutaneous endoscopic gastrostomy (PEG) tube. The patient is approved for personal care aide (PCA) services 6 hours/day x 6 days per week. Assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) are needed. He is wheelchair/bedbound and needs assistance with transfers, dressing, toileting and locomotion. The patient is requesting additional hours on the 7th day. 

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 currently receives services 6 hours/d for 6 days a week. A 7th day of coverage was denied. It is not apparent why this is so. It is true that the patient has not deteriorated based on assessments, but he has the same impairments on the 7th day as he does the rest.  This reviewer cannot find a rationale as to why the coverage for the 7th day should be any different from the other 6. 

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 personal care aide (PCA) 7 days x 6 hours is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraine
Treatment: Ubrelvy, Pre-service
The insurer denied the Ubrelvy, Pre-service.
The denial is overturned.

The patient is a female with migraine headache disorder. She has tried and failed sumatriptan, zolmitriptan and rizatriptan for abortive therapy. The provider is requesting Ubrelvy for acute treatment of migraine. The requested medication was denied coverage as the member has not failed three preferred formulary agents.

Yes, the proposed treatment with Ubrelvey is medically necessary.

The patient has tried and failed adequate trials of three preferred triptans as required by the plan. Previous clinical trials have demonstrated that persons who fail two triptans are unlikely to respond to additional trials of other triptans (Thorlund, et al; Tepper, et al). Furthermore, Ubrelvy is Food and Drug Administration (FDA) approved for the patient's condition and has been demonstrated to be effective in high quality clinical trials (Dodick, et al).

No, the health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The patient has tried and failed three preferred agents as required by the plan.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Lumbar Spinal Stenosis, Spondylolisthesis, and Spondylosis.
Treatment:  0275T, percutaneous laminotomy/laminectomy (interlaminar approach) for decompression or neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT [computerized tomography]), single or multiple levels, unilateral or bilateral; lumbar.

The insurer denied coverage for 0275T, percutaneous laminotomy/laminectomy (interlaminar approach) for decompression or neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar.  The denial is upheld.

This patient has lumbar spinal stenosis, spondylolisthesis, spondylosis, and hypertension. She had a telemedicine visit with Pain Management physician for the evaluation of lower back pain. The patient had an epidural steroid injection (ESI) to the midline at L (lumbar) 4-L5. She reported a 50% (percent) improvement in pain. She stopped doing physical therapy (PT) due to pain. The patient reported taking Tylenol and Celebrex with minimal relief. The physician recommended the minimally invasive lumbar decompression (MILD) procedure.

Kaye et al. (2) conducted an evidence-based review of the available current scientific literature, the novel interventions for symptomatic lumbar spinal stenosis, such as the MILD procedure and the Superion interspinous spacer, generally appear to be safe and effective. There is a possibility in the future that these interventions could disrupt current treatment algorithms for lumbar spinal stenosis.

In sum, this requested service is not likely to be more beneficial than any of the standard treatments/procedures for this patient. Whether the adverse risks are increased over standard therapies is yet to be determined.

The carrier's denial of 0275T, percutaneous laminotomy/laminectomy (interlaminar approach) for decompression or neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar should be upheld.