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

Diagnosis:  Atherosclerotic Cardiovascular Disease (ASCVD).
Treatment:  Pharmacy/Prescription Drugs (Repatha).

The health plan denied the request for Repatha.  The health plan's determination is overturned.

The patient is a woman with atherosclerotic cardiovascular disease (ASCVD) and hyperlipidemia.  She has been intolerant to high intensity Atorvastatin and to Simvastatin 20 milligram (mg) daily.  She is currently taking Pravastatin 40 mg daily, which also causes myalgias.  However, she continues to take it.  Her low-density lipoprotein (LDL) cholesterol level was 245 milligrams per deciliter (mg/dl).  The medical necessity for Evolocumab (Repatha) is at issue.

I overturn the health plan's determination that Evolocumab is not medically necessary in this instance.

Yes. Evolocumab (Repatha) is medically necessary in this instance.  

This woman has atherosclerotic cardiovascular disease (ASCVD).  On Pravastatin 40 mg daily, her maximally tolerated statin dose, her LDL cholesterol level of 245 mg/dl is 3.6 times her National Lipid Association recommended goal level of less than 70 mg/dl.  Treatment with Evolocumab (Repatha) in situations such as this one has been shown to have a salutary effect on health outcomes.  Current guidelines, including the National Lipid Association Update on the Use of PCSK9 Inhibitors in Adults and the Focused Update of the American College of Cardiology (ACC) Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk, recommend the use of PCSK9 inhibitors, such as Evolocumab, for patients with ASCVD and LDL cholesterol levels 70 mg/dl or greater on maximally tolerated statin therapy.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis:  Type 2 diabetes mellitus with diabetic polyneuropathy.
Treatment:  Invokamet (canagliflozin and metformin) Formulary exception.

The insurer denied the Invokamet (canagliflozin and metformin) Formulary exception.  
The denial is overturned. 

The patient is a male with type II diabetes.  He has an A1C (glycated hemoglobin) of 6.8% on Invokamet and Nesina.  He was previously well controlled on Invokamet.  He has tried and failed Synjardy and Xigduo due to hyperglycemia. 

Yes, the health plan should cover the Formulary exception for Invokamet.

The prior request was denied, as the patient has not had a documented trial of Synjardy, Synjardy XR (extended release), and Xigduo XR.  This patient has tried and failed Synjardy and Xigduo, due to hyperglycemia.  It is not clinically appropriate to attempt a trial of Synjardy XR or Xigduo XR in this clinical situation, as the patient has already failed Synjardy and Xigduo.  Synjardy as compared to Synjardy XR and Xigduo as compared to Xigduo XR are expected to have the same glucose lowering efficacy in this clinical situation.  This patient has done well in the past with Invokamet.  Without Invokamet, this patient will be at risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy.  Therefore, yes, the health plan should cover the proposed Invokamet.
Appeal type: Medical necessity
Decision: Upheld

Digestive System/Gastrointestinal. 
Inpatient hospital. 

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

This is the case of a female with past medical history of Alzheimer's dementia, hydrocephalus, and hypertension, who presented to the emergency department with concerns for dysphagia without odynophagia and with reported weight loss of 30 pounds. She had a recent magnetic resonance imaging (MRI) showing dilated ventricles.
On presentation, she was afebrile with blood pressure 150/87, heart rate 83, respiratory rate 18, and with oxygen saturation 100% on room air. Exam otherwise noted cachexia and the patient to have difficulty following commands. Labs resulted with complete blood count within normal limits, basic metabolic panel with creatinine of 1.03, and elevated creatinine of 10.6. A computed tomography (CT) of the head showed prominence of her ventricles. Neurology assessment was that she did not have an acute stroke and did not require lumbar puncture or any other inpatient neurologic work-up. The patient was brought into the hospital. 

The inpatient hospital admission was not medically necessary. As previously noted, this patient presented with chronic dysphagia but ability throughout her whole hospitalization to tolerate liquids and pureed diet without prolonged nothing by mouth status required. She had no significant persistent acute kidney injury or other electrolyte abnormalities requiring inpatient level of care and underwent an extensive work-up for her dysphagia that was negative and notably could generally be accomplished at a lower level of care. Despite her prolonged hospitalization, the level of care provided did not rise to the level of inpatient treatment, and it is not entirely apparently why in the setting of the patient being able to take pureed diet throughout her hospitalization why the entirety of her work-up needed to occur in the hospital setting.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Compression of the median nerve in both hands

Treatment: Additional 5 visits of Physical Therapy Outpatient Services

The insurer denied coverage for the additional 5 visits of Physical Therapy Outpatient Services.

The denial is upheld. 

This is a female patient with a history of compression of the median nerve in both hands; status post right carpal tunnel release. The patient had surgery performed for a right carpal tunnel release. She had a postoperative visit with the surgeon and was instructed to have 2-3 Physical Therapy sessions a week. The patient completed a total of 30 Physical Therapy sessions. Therapy sessions were interrupted for a few weeks. 

The patient continues to complain of right hand (incision) pain, stiffness and weakness. She reportedly has difficulty performing activities of daily living. An additional 18 therapy sessions were recommended by the treating surgeon.  However, currently under review are 5 additional visits of Physical Therapy outpatient services.
 
The earliest Physical Therapy note documents a pain level of 6/10.  

Range of motion and strength measured: 
Flexion: 0-58; 3-/5 
Extension: 0-50; 3-/5 
Pronation: 0-65; 3-/5 
Supination: 0-65; 3-/5 
Ulnar deviation (UD): 0-15; 3/5 
Radial deviation (RD): 0-15; 3/5 
Quick Dash rating was 38.49 

The most recent note does not document any significant improvement. Pain level is rated 6-7 and Quick Dash ratings were no longer obtained.

Range of motion and strength are also unchanged:  
Flexion: 0-58; 3-/5 
Extension: 0-50; 3-/5 
Pronation: 0-65; 3-/5 
Supination: 0-65; 3-/5 
UD: 0-15; 3/5 
RD: 0-15; 3/5 

The healthcare plan acted reasonably, with sound medical judgment and in the best interest of the patient. The clinical records are insufficient to support the medical necessity of the requested 5 additional Physical Therapy visits. 

From a physical medicine and rehabilitation/pain management perspective as well as within a reasonable degree of medical certainty, 5 additional visits of Physical Therapy outpatient services cannot be supported as medically necessary.

The carrier's denial of coverage for the additional 5 visits of Physical Therapy Outpatient Services is upheld. The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left lower extremity amputation; amputation of right forefoot secondary to diabetic foot disease and osteomyelitis; Kaposi's sarcoma; pressure ulcer left heel; baseline cognitive impairment due to age-related disease
Treatment: Personal Care Services 24 hours/day, 7 days/week (split-shift) 
The insurer denied the Personal Care Services 24 hours/day, 7 days/week (split-shift).
The denial is overturned. 

The patient is a male with a complex medical history, including left lower extremity amputation; amputation of right forefoot secondary to diabetic foot disease and osteomyelitis; Kaposi's sarcoma; pressure ulcer left heel; baseline cognitive impairment due to age-related disease; lumbar degenerative disc disease with chronic low back pain; generalized muscle weakness; postural instability; lack of coordination; shortness of breath with exertion; severe progressive stamina loss; recurrent vertigo; impaired vision due to diabetic retinopathy/macular degeneration; hearing loss progressive; chronic insomnia and chronic fatigue secondary to averaging only four hours of sleep per night; urinary and fecal incontinence for which he wears diapers and requires multiple day time and night time changing of soiled garments to prevent skin breakdown; high fall risk based on the Morse Fall Scale Assessment.  

The patient lives alone and is immobile and subsequently wheelchair bound, due to his bilateral lower extremity amputation.  The patient's baseline cognitive impairment has demonstrated rapidly deteriorating cognitive and physical health in recent weeks following his left lower extremity amputation. 

Yes, the Personal Care Services 24 hours/day, 7 days/week (split-shift) is medically necessary and required to maintain the patient's current health and to prevent his illness from progressing and to provide the necessary assistance and supervision.

The patient's primary care physician documented a rapid cognitive physical and functional decline which medically necessitate 24/7 split shift around the clock personal care assistance.  The physician recommends and documents that it is very important and medically necessary for the patient to have two split shifts of 12 hours of home care daily and nightly seven days per week to maintain his current health and to prevent his illness from progressing and to provide the necessary assistance and supervision for the patient to remain in his current living environment.

Initially, when the healthcare plan decision was made based upon available information, the plan acted reasonably.  However, additional information has subsequently been provided by the patient's primary care physician which documents in detail the patient's cognitive, physical and emotional decline in recent weeks, making it medically necessary for the patient to have two split shifts of 12 hours home care daily and nightly, seven days per week to maintain his current health and to prevent the patient from progressing and to provide the  necessary assistance and supervision medically required at this time.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteomyelitis, Decubitus ulcer
Treatment: Acute inpatient stay
The insurer denied coverage for the acute inpatient stay.
The denial is overturned.

This is a male patient with past medical history significant for paraplegia due to a motor vehicle accident who presented to the Emergency Department (ED) with complaints of a chronic stage 4 sacral decubitus. The patient's vital signs on ED presentation were: Temperature 98.7 F, Blood Pressure 115/70, Pulse 70, Respiratory Rate 16, and Oxygen Saturation 99% on room air. The patient's laboratory results included the following: white blood cell count of 9.8, hemoglobin of 11.7, hematocrit of 35.9, and creatinine of 0.92. The patient was started empirically on intravenous (IV) fluids and antibiotics (i.e., vancomycin and Zosyn) for a urinary tract infection and possible infected sacral decubitus ulcer. The patient's pelvic electromagnetic radiation (x-ray) imaging showed no evidence of fractures. The patient's wound cultures grew Staphylococcus epidermidis. General Surgery was consulted and their impression was 3 centimeters (cm) clean decubitus ulcer without overt infection around the surrounding tissues. They deemed that no surgical intervention was required. The patient remained afebrile, hemodynamically stable, and was discharged home with instructions to continue oral antibiotics as an outpatient.

According to documentation, the patient presented to the hospital with worsening stage 4 sacral decubitus ulcer that was refractory to outpatient management. The patient had low-grade fevers and on physical examination purulent drainage with "probe to the bone" strongly suggestive of osteomyelitis. The patient's magnetic resonance imaging (MRI) and wound cultures that were positive for Staphylococcus epidermidis were both supportive of the diagnosis of osteomyelitis. Due to this patient's underlying co-morbid conditions (i.e., paraplegia), decision for conservative management including daily IV antibiotics and wound care was medically appropriate. This determination is supported by literature and Milliman Care Guidelines (MCG) for osteomyelitis (M-600). Based on these findings, acute care hospital admission was medically necessary for this high-risk patient.   

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

Based on the above, the medical necessity for the acute inpatient stay is substantiated. The insurer's denial should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Glioblastoma, weakness, general debility.
Treatment:  Continued stay in Skilled Nursing Facility.

The insurer denied the Continued stay in Skilled Nursing Facility.  The denial is upheld. 

The patient is a male with history of glioblastoma s/p (status post) cranioplasty with dysarthria, bilateral leg weakness and general debility requiring extensive assistance with ADLs (activities of daily living).  He was admitted to SNF (skilled nursing facility).

The patient's relevant past medical history includes hypertension, hypercholesterolemia, diabetes mellitus, diabetic nephropathy, epileptic seizures, GERD (gastroesophageal reflux disease), esophagitis, TIAs (transient ischemic attacks), prostatitis, CVA (cerebrovascular accident), etc.

Prior to admission, the patient was living at home with spouse and requiring home health aide.  The desire is to be discharged home to an apartment, with friends promising to be with him 24/7, as the wife did not want him to return home.

No, the skilled nursing facility was not medically necessary.

The patient was confused with total dependence and showing less participation in rehabilitation with no tangible progress in rehabilitation.  The plan was to discharge him, but the nephew said he was unable to take the patient home, since he has nowhere to go and was willing to pay for the extra days in rehabilitation.  Therefore, continued stay in SNF (skilled nursing facility) was not medically necessary.  The patient remained totally dependent with no tangible improvement in rehabilitation, and his needs can be met at a lower level of care such as home therapy or custodial care.

As stated above, the continued stay in SNF was not medically necessary.  The clinical evidence indicates that further stay in SNF is not reasonably expected to be health beneficial for the patient, and/or withholding it in whole or in part, is not reasonably expected to affect the patient's health adversely, as the patient did not show tangible improvement in rehabilitation with state of confusion and a terminal cancer.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Immune deficiency
Treatment: HyQvia

The insurer denied coverage for HyQvia.
The denial is overturned.

This is a female patient with a medical history of immune deficiency. The patient has been on HyQvia since its clinical trial. Prior to this, she tried and failed intravenous gamma-globulin. The insurer has approved HyQvia since then and the patient has done extremely well. The patient is due for treatment; however, the insurer has denied coverage for HyQvia as not medically necessary. Since changing their formulary, the insurer requests that the patient try formulary alternatives before being able to approve HyQvia.  

This patient has been treated with HyQvia for years and has done well. The type of immune deficiency is not detailed and there is no description of any comorbidities, prior infections or concurrent medications. The health care plan did not act reasonably as the alternative drug options have very different properties from HyQvia in terms of mode of administration, side effect profile and convenience factors. Intravenous immunoglobulin has more side effects than subcutaneous immunoglobulin in general. 

The type of gamma-globulin suited for any given patient depends on a number of factors. Given that the patient has done well with HyQvia, it would support that this preparation is appropriate to continue.

Based on the above, the medical necessity for HyQvia is substantiated. The insurer's denial is overturned.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Rosacea
Treatment: Noritate Cream, Pre-service
The insurer denied the Noritate Cream, Pre-service.
The denial is upheld.

The patient is a female with acne. She has been treated with topicals, oral antibiotics and spironolactone.  Her provider is requesting Noritate.

The health plan should not cover the Formulary exception for Noritate cream (metronidazole).

Topical metronidazole is not commonly used for acne.  It is more commonly used for rosacea. Use of Noritate is not considered medically necessary over the formulary agents, generic metronidazole, azelaic acid, doxycycline and Soolantra. The patient does not have any documented contraindications to the health plan's preferred formulary agents.  These would be appropriate alternatives to Noritate, as they are reasonably expected to be at least as efficacious as Noritate in the treatment of the patient's condition.

Therefore, given the above, the health plan should not cover the Formulary exception for Noritate cream (metronidazole).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Endocrine/Metabolic/Nutritional. 
Treatment: Diabetic Equipment, Supplies and Self-Management Education. 
The insurer denied the continuous glucose monitor. 
The denial was overturned. 

The patient has  glycogen storage disease type IX (phosphorylase kinase deficiency). He has a history of hypoglycemia with ketosis as part of this disorder and receives a high protein complex carbohydrate diet. He was admitted to the hospital and was found to be in poor metabolic control with frequent hypoglycemia with fluctuations in blood glucose values from 59-99 nanograms (ng)/deciliter (dL). He has hypoglycemia unawareness. He has been prescribed a DexCom G6 for continuous blood glucose monitoring. 
At issue is the medical necessity of the continuous glucose monitor. 

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

The requested health service/treatment of a continuous glucose monitor is medically necessary for this patient. 

Continuous glucose monitoring is medically necessary to decrease risk of hospitalization and both short- term and long-term sequelae of the patient's metabolic disease. The patient has a metabolic disorder resulting in hypoglycemia and has been hospitalized with dangerously low blood sugars. He is at risk of experiencing ongoing life-threatening hypoglycemia and seizures and is unable to recognize signs and symptoms of hypoglycemia. 
Use of a continuous glucose monitor (CGM) in the setting of glycogen storage disease (GSD) has been studied and is a reliable tool in monitoring glucose trends with good concordance with finger stick glucose values. The CGM device has alarms that can alert him and his caregivers to hypoglycemia. The CGM can uncover previously undetected, subclinical low glucose levels resulting in actionable interventions. 
Moreover, CGM has been demonstrated to improve biochemical control in patients with GSD. Improvement of metabolic control in GSD can mitigate complications such as hyperlipidemia, hepatomegaly, hyperuricemia, and poor growth.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension/ High Blood Pressure
Treatment: Home Health Care
The health plan denied the request for an increase in home health care. 
The health plan's determination is upheld.

The patient is a female with a past medical history for multiple medical problems. The patient is requesting personal care services 12 hours a day 7 days a week for a total of 84 hours a week. She is currently receiving 56 hours a week of services. The services were denied based upon medical necessity. The plan partially approved an increase in services to 9 hours a day 7 days a week for a total of 63 hours a week. 
At issue is the medical necessity of the requested services.

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

No, the requested health service is not medically necessary for this patient.
Upholding the previous decision based upon the following rationale is recommended. Services which are being provided, 63 hours a week are adequate to meet the patient's medical needs. Additional services are not medically necessary.
The patient is a female with a past medical history significant for hypertension, coronary artery disease, congestive heart failure, and the toward dysfunction, dizziness, memory impairment, osteoarthritis, urinary incontinence, generalized weakness, hypothyroidism and atrial fibrillation.
The appeal was denied stating that New York State law does not allow health plans to provide aid services for safety and/or supervision alone.
A Uniform Assessment System (UAS) performed noted the patient required a total of 36.3 hours per week for an average of 4-6 hours a day. Services were distributed between level 1 and level 2 services. Service aide hours are noted to be 63 hours a week which are above the recommended 36.3 hours which were documented in a UAS.
The physician's letter of appeal stated the patient's health status was declining and that she fell and had a skin wound. In the progress note there was mention of a skin wound, however there is a limited description. There is no mention of any specific recommendations regarding treatment plans for the skin wound such as nursing services or the need for frequent changes of dressings. There is no notation that the patient cannot reposition herself in bed by herself. There is also notation that the patient has been falling, however stand-alone services for monitoring and safety supervision without providing functional services such as activities of daily living (ADLs) or Instrumental activities of daily living (IADLs) are not considered in the terms of the plan.
In conclusion, the amount of services provided were adequate to meet the patient's medical needs. Additional service hours are not medically necessary.