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

Diagnosis: Pressure ulcers

Treatment: Topical Oxygen Wound Therapy (TOWT)

The insurer denied coverage for Topical Oxygen Wound Therapy (TOWT)

The denial is upheld

 
According to the surgeon's note : "This patient has a past medical history that is significant for Orthostatic hypertension, reflex disease, chronic obstructive pulmonary disease (COPD), respiratory failure, muscle weakness, generalized edema, history of ventilatory dependence, Failure to thrive, contractions of the hip, mass of the duodenum, cognitive dysfunction who has deteriorated over the past seven months. Patient has dementia which has progressed. Approximately several months ago he was walking but he lost the ability to walk. He was taken to ... hospital. He was noted to have some sort of liver failure/cholecystitis with elevated bilirubin and they placed a t-tube since he was not an operative candidate. He came back home and became fluid over-loaded and he was noted to have edema in his legs as well as lungs. He was then taken back to the hospital and was intubated and then this led to a tracheostomy. He was in the hospital as well as a care facility and developed multiple pressure ulcers."  The surgeon's note indicates that the patient continues to have inadequate nutrition and is not being turned and off-loaded adequately.  Multiple studies have been published showing efficacy for Topical Oxygen Wound Therapy (TOWT) for the management of diabetic ulcers.  There are no published well-designed studies that show TOWT is effective in healing pressures ulcers in patients with poor nutrition, dementia, and respiratory failure.  The patient's ulcers were unlikely to heal regardless of the treatment provided due to his poor overall condition, and peer reviewed evidence that TOWT is superior to standard dressings in this clinical setting is not available.

Topical Oxygen Wound Therapy (TOWT) is not considered medically necessary for this patient. There are no published well-designed studies that show TOWT is effective in healing pressures ulcers in patients with poor nutrition, dementia, and respiratory failure.  The patient's ulcers were unlikely to heal regardless of the treatment provided due to his poor overall condition, and peer reviewed evidence that TOWT is superior to standard dressings in this clinical setting is not available.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Topical Oxygen Wound Therapy (TOWT) is not substantiated.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: mobility issues.
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift). 
The insurer denied Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift). 
The health plan's determination is upheld. 

This is a case review for a female with medical history notable for mobility issues, incontinence, and dementia. The patient and her care team requested an increase to 24 hours per day, 212-hour split-shift personal care, and this request was denied by the health plan. The denial is the subject under review.

The requested health service of Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 24 Hour(s) per Day (Split Shift) is not medically necessary for this patient.
The patient is approved for live-in personal care, and the request is for split-shift. Live-in personal care aides are required to get adequate sleep at night with a minimum of 5 hours of uninterrupted sleep. If the patient has personal care needs such as toileting or turning/repositioning to treat a pressure ulcer, then split-shift care is medically necessary.
There is no clear medical necessity for split-shift personal care. The request states that the patient has wandering and other dementia-related behaviors at night; increasing personal care hours for this purpose would be for safety monitoring and security which is not a covered personal care function. There is no clearly demonstrated medical necessity for the requested increase to split-shift care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Varicose vein. 
Treatment: Outpatient procedure (37765 x 1 & 37766 x 1). 

The insurer denied coverage for outpatient procedure (37765 x 1 & 37766 x 1). 

The denial is overturned. 
 
According to medical records, the patient is an adult with symptomatic varicose veins in the popliteal space behind the right knee. An ultrasound examination has demonstrated the absence of venous reflux. The treating physician requests authorization for phlebectomy of the painful varicose veins. 

(Masuda et. al) state that "Treatment of nontruncal varicose veins with or without telangiectasia by sclerotherapy, ambulatory phlebectomy, or powered phlebectomy in a symptomatic patient with varicose veins, edema due to venous disease, skin or subcutaneous changes, healed or active ulcers " is considered appropriate. 

"Physical methods for treating chronic venous disease (CVD) are studied increasingly as an adjunct or alternative to interventional treatment. Physical exercise, targeting lower limb muscle strength and ankle mobility, and physiotherapy may improve general mobility, promote weight loss, strengthen the calf muscle pump, and increase the range of ankle movements, all these facilitating venous return. Nevertheless larger studies are still needed. Subsequently this may reduce leg edema and prevent or ameliorate skin changes caused by CVD. Despite the paucity of studies specifically on chronic venous insufficiency (CVI), the indirect evidence for the benefit of exercise on venous function is considerable and thus it should be promoted. Leg elevation and the use of insoles to improve the foot muscle pump may be beneficial but most studies are small. Other methods with less evidence for treatment of CVD, but with improvement of health related quality of life (QoL), include massage, balneotherapy, and cooling therapy." (De Maeseneer, M. G. et al. 2022). 

"Lower extremity venous insufficiency is a heterogeneous medical condition whose spectrum ranges from cosmetic abnormalities including spider telangiectasias to varicose veins with or without associated signs and symptoms including severe edema, skin ulceration, and subsequent major disability. Venous hypertension caused by incompetent valves in the superficial veins is by far the most common cause of this condition. This document will review the appropriate means by which ambulatory phlebectomy (AP) is to be used to maximize the benefit for patients who undergo the procedure." (Kundu, S. et al. 2019).                                   

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

The medical necessity for outpatient procedure (37765 x 1 & 37766 x 1) is substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity.
Treatment: Mounjaro.
The insurer denied Mounjaro. 
The health plan's determination is upheld. 

This is a case review for a female being prescribed Mounjaro for the diagnosis of obesity. The prescribing physician provided a letter of support for this appeal. The letter states that the patient's current body mass index (BMI) is 34, an improvement from her BMI of 45 when she started with their program. The physician states that the patient would "benefit greatly from glucagon-like-peptide-1 (GLP-1) agonist-based treatment to improve their metabolic health and prevents the development of multiple chronic conditions."

A formulary exception is not indicated. The formulary drugs Ozempic, Rybelsus, Trulicity, and Victoza are all in the same class as the requested medication, Mounjaro, and would be expected to be of similar efficacy for weight loss. These medications are all FDA approved for type 2 diabetes. The patient does not have a diagnosis of type 2 diabetes.
There are two medications listed on the formulary in this drug class (GLP-1 receptor agonists); they include Wegovy (semaglutide, the same active ingredient as Ozempic) and Saxenda (liraglutide, the same active ingredient as Victoza).
GLP-1 agonist therapy can be a useful adjunct for the medical treatment of obesity. There is currently no strong recommendation from expert opinion to prescribe the requested medication, Mounjaro, above the established formulary alternatives.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar osteomyelitis and endocarditis

Treatment: Transfer to long term acute care services

The insurer denied coverage for 

The denial is overturned

Patient is an adult female with past medical history significant for hepatitis C, methicillin-susceptible staphylococcus aureus (MSSA) bacteremia, intravenous drug abuse and osteomyelitis, who was admitted to the hospital with complaints of lower back pain. She was diagnosed with lumbar osteomyelitis and endocarditis. Magnetic resonance imaging (MRI) showed progression of suspected lumbar (L) 3-L4 discitis/osteomyelitis. The treatment plan includes 6-weeks of intravenous antibiotics.  

At issue is the denial of coverage for admission to Long-Term Acute Care Hospital (LTACH) for administration of intravenous antibiotics for extended therapy (6-weeks). 

LTACHs provide care for patients with multiple serious medical conditions requiring a longer stay. There are certain admission criteria for admission-most common being mechanical ventilation weaning, intravenous antibiotics and complex wound care. 

According to medical records, the patient previously failed outpatient management. Treatment duration for lumbar osteomyelitis and endocarditis is a minimum of six weeks, with careful review to determine if further treatment is required. Additionally, during antimicrobial therapy, patients should be followed carefully for clinical signs of soft tissue extension, paraspinal abscess, and cord compression; as well as weekly laboratory monitoring of inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). It should also be noted that during the course of treatment for vertebral osteomyelitis, progression can change suddenly, with potential for catastrophic complications. Therefore, close observation, especially in the first two weeks after diagnosis, is essential. 

Based on the above findings, the patient is an appropriate candidate for LTACH services. Transfer to LTACH is medically necessary.

Based on the above, the insurer's denial must be overturned. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. The medical necessity for transfer to long term acute care services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Lumbar radiculopathy
Treatment: Rehab treatment (in acute rehabilitation facility)
The insurer denied the rehab treatment.  The denial has been overturned. 

The continued acute inpatient rehabilitation is medically necessary.

The patient is a male with history of general debility including lumbar radiculopathy and multiple co-morbidities including atrial fibrillation and multiple sclerosis who had atrial fibrillation ablation and closure of atrial appendage this year.  The patient sustained a fall later this year and was found to have a comminuted fracture of the left iliac and is status post (s/p) open reduction and internal fixation (ORIF) the same day.

Prior to admission, the patient required adaptive equipment with increased time and effort for activities of daily living (ADLs) and also required ambulatory rolling walker, etc for community ambulation. The patient lives with his wife in a two-level house with one flight of stairs with a railing to the upstairs bedroom and four steps to enter house without a rail.

The patient required minimal assistance for supine-to-sit, for sit-to-stand using rolling walker, was unable to ambulate to the bathroom and required minimal assistance with most activities of daily living (ADLs).

The patient met all the criteria for acute rehabilitation care INTERQUAL Criteria 2022 for Acute Rehabilitation in a patient with general debility and weakness due to a sustained fall with fracture status post open reduction and internal fixation and with ongoing clinical issues as stated above.  The patient required minimal assistance for supine-to-sit, for sit-to-stand using rolling walker, was unable to ambulate to the bathroom and required minimal assistance with most activities of daily living. In addition, he needs to be able to navigate stairs to enter his house.  Also, the patient fell recently likely making things worse for ambulation as he sustained a fracture and later had open reduction with internal fixation (ORIF).       

The health plan has not acted reasonably in this instance and its decision lacked sound medical judgment which was not in the best interest of the patient based on the above rationale.

As of recently, the patient was ambulating ten feet with total assist/maximum assistance and using hand-rail, requiring maximum assistance for lower body dressing, requiring moderate assistance for toilet transfers, requiring minimum assistance for bed transfer, requiring supervision for upper body transfer, and the patient was a high fall risk.

The recommended length of approval at which time a new review for continued medical necessity should be completed is two weeks.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a female who initially presented to the emergency department with concerns of right-sided facial numbness. Pertinent history included prior cerebrovascular accident (CVA) with residual right-sided deficits on aspirin and rivaroxaban, migraine headaches, non-epileptic seizures, and psychiatric disorders. Initial vital signs revealed a temperature of 98.1oF (degrees Fahrenheit), heart rate (HR) 118, blood pressure (BP) 128/56, respiratory rate (RR) 16, and peripheral capillary oxygen saturation (SpO2) 97% (percent).

The inpatient hospital admission was not medically necessary. A lower level of care was appropriate. The patient had a history of cerebrovascular accident (CVA) with right-sided residual deficits on aspirin and Xarelto who presented with right-sided facial numbness. A comprehensive evaluation was performed an essentially unremarkable. Without intervention, presenting symptoms resolved on the day of hospitalization and did not recur. Repeat CT (computed tomography) of head did not reveal any acute pathology and the patient was cleared for discharge. No other issues or complications were documented.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention-Deficit Hyperactivity Disorder.
Treatment: Vyvanase.
The insurer denied Vyvanase. 
The health plan's determination is overturned. 

This case involves an adult female diagnosed with attention deficit hyperactivity disorder (ADHD)-combined type and comorbid depressive disorder with anxiety. There are no other comorbid psychiatric disorders or co-occurring substance use disorders in this case and no general medical condition that is a focus of treatment, nor is there a reported diagnosis of narcolepsy or binge eating disorder.

A formulary exception is indicated. In this case scenario, the formulary drugs will be or has been ineffective, and would not be as effective as the non-formulary drug primarily due to the unavailability of all of the remaining formulary medication treatment options.
The use of the non-formulary medication is reasonable, in the best interest of the patient and reflects sound clinical judgment in view of the case scenario and unavailability of formulary alternatives. The use of Vyvanse is Food and Drug Administration (FDA) approved for the treatment of attention deficit hyperactivity disorder (ADHD) and is indicated in this case scenario. The patient is unable to take formulary alternatives, and to discontinue a medication that is effective and well-tolerated would be detrimental to the patient's functioning.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Asthma
Treatment: Alvesco (Ciclesonide) inhaler
The insurer denied coverage for Alvesco (Ciclesonide) inhaler
The denial is upheld

Patient is an adult who has a history of mild persistent asthma and allergic rhinitis. She was followed by her allergist. As per clinical notes, the allergist was recommending an inhaled corticosteroids (ICS) Alvesco (Ciclesonide) instead of the formulary preferred ICS Flovent (Fluticasone) hydrofluoroalkane (HFA) and Pulmicort (Budesonide) Flexhaler. 

Patient is followed for her asthma by her allergist and is on Alvesco (Ciclesonide) inhaler and nasal steroids (Flonase) and Allegra for allergies. Reportedly she had seen her dentist and was to undergo a dental procedure and her dentist was recommending another product instead of Pulmicort which according to her was causing cuts and sores in her tongue and mouth. Her allergist recommended Alvesco as it as a different breakdown in the oral cavity and is mainly activated in the lungs. However, the physical examinations documented in the medical records  does not reflect any pathology such as thrush etc. 

Moreover, comparative studies between these products - Ciclesonide, Budesonide and Fluticasone have not shown any superiority of Ciclesonide over these two products which are similar products (which are on the preferred drug list of the insurance company) Though theoretically there may be some lower deposition of the product in the mouth because of its mechanism of activation, the clinical notes provided do not reveal any such findings on this patient's clinical exam. 

Based on above, Alvesco cannot be approved at this time without demonstration that the patient has tried the 2 available alternatives and has either failed to respond or has side efficacy from them. 

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication. 

The formulary drug is not expected to be ineffective. 

The non- formulary drug is not expected to be more effective than the formulary alternatives. 

The carrier's denial of a request for a Formulary Exception for Alvesco (ciclesonide) is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Back Pain
Treatment: Lumbar Spine MRI (Magnetic Resonance Imaging)
The health plan denied: Lumbar Spine MRI
The determination is: Overturned

The patient is a male with low back pain since a lifting incident. Per his provider, he has attended 6 weeks of physical therapy (PT) without improvement. He has radiating pain to his right leg and numbness on the left. His provider has recommended lumbar spine magnetic resonance imaging (MRI). 
At issue is the medical necessity of the lumbar spine MRI. 
The health plan's determination of medical necessity is overturned in whole. 
The requested health service/treatment of lumbar spine MRI is medically necessary for this patient. After failure of conservative treatment, and with radicular signs such a radiating pain and positive straight leg raise, MRI of the lumbar spine is appropriate. This patient has attended six weeks of PT without improvement. Therefore, a lumbar spine MRI is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Acne.
Treatment: Formulary exception for Winlevi.
The health plan denied Winlevi. 
The denial is upheld.

The patient is a teen-aged male with acne, treated with benzoyl peroxide, Isotretinoin, Winlevi, and Tretinoin. The provider is requesting Winlevi cream. The health plan requires use of at least 3 formulary agents, including adapalene, benzoyl peroxide, clindamycin, erythromycin, Tretinoin and tazarotene.

The formulary agents would also be effective, can possibly be as effective as the requested agent, and would have similar adverse effects such as dryness and irritation.

The patient has tried benzoyl peroxide and Tretinoin, but has not tried clindamycin and erythromycin.  These would also be appropriate and effective therapies.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal cord compression

Treatment: Neck surgery (procedure codes: 22551, 22552, 22853) and related hospital admission

The insurer denied coverage for neck surgery (procedure codes: 22551, 22552, 22853) and related hospital admission

The denial is Overturned

The medical record demonstrates presence of significant pathology to the patient's cervical spine. The physician documented acute exacerbation of cervical pain with change in neurologic status. The patient had weakness and sensory changes. The patient had a positive Spurling sign. The patient was evaluated in emergency department with intractable pain. Image interpretation by the neurosurgeon was noted for herniation and cord compression. Based upon these findings (intractable pain, new neurologic deficit and imaging showing cord compression), surgical intervention would be appropriate. Alternatives of epidural steroid injection, narcotic medication, Physical Therapy, or traction would not be appropriate. A pain generator was defined with clinical correlation. The next step would be surgery. 

The medical record supports the admission and length of stay. The patient had undergone a complex neurosurgical procedure with associated risks of bleeding. Although no drain was placed, the physician ordered a tracheotomy set by bedside. The treating provider also placed the patient in the Surgical Intensive Care Unit with monitoring. The patient received Patient Controlled Analgesia for the pain. The patient had undergone a two level Anterior Cervical Discectomy and Fusion (ACDF) which has a higher incidence of complications. Most surgeons would admit their patient after undergoing this type of surgery. This procedure would not be commonly performed in an Ambulatory Surgical Unit.

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

The medical necessity for neck surgery (procedure codes: 22551, 22552, 22853) and related hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Status post mechanical fall
Treatment: Inpatient admission
The health plan denied inpatient admission. The denial is upheld.

The patient is an adult female who sustained a slip and fall on ice. She was evaluated at an outside hospital and diagnosed with a comminuted tibial plateau fracture. She was placed in a knee immobilizer and referred to another hospital.

The patient underwent ORIF (open reduction internal fixation) to her tibial plateau. Her post-surgical course was non-complicated. The patient was admitted to the hospital, discharged days later. Of note, she refused pain medication the night of admission.

The medical records do not substantiate the necessity the inpatient admission. The treatment could have been provided at a lower level of care.

The important facts were that this was a closed injury, of low energy, with no associated comorbidities, and single site. The fracture management was direct with exposure, reduction and placement of fixation devices. The procedure was approximately two and a half hours in duration, with limited blood loss. There were no complications after the procedure. There was no drain placed. The patient's vital signs were stable, with no evidence of bleeding. There was no evidence or suspicion for compartment syndrome. Pain medication was tolerated orally. PT (physical therapy) services were provided timely with progress.

There was no need for additional imaging nor treatment for any underlying medical condition.

Utilizing the MCG (Milliman Care Guidelines) criteria, there were no subsets identified that would qualify as needing the admission. This also included the Fracture to Tibia and Fibula topic.