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

Diagnosis: Atherosclerotic heart disease with angina; hyperlipidemia; cerebrovascular disease,

Treatment: Consumer Directed Personal Assistance Service- initial service

The insurer denied coverage for Consumer Directed Personal Assistance Service- initial service. The denial is reversed. 

This patient is a male with a history that included atherosclerotic heart disease with angina, hyperlipidemia, asthma, obstructive sleep apnea, cerebrovascular disease, muscle spasm, urinary calculi, depression and multiple medical conditions affecting physical and cognitive functioning. He applied for consumer directed personal assistance services (CDPAS) last year (assessment/UAS done). The request for CDPAS was denied by the insurer. 

The patient's medical history is noted for significant vascular disease; i.e. CAD/MI and multiple strokes.  There is no detailed neurologic exam with the available records, so specific neurologic deficits from the strokes are not known. However, the patient has significant cognitive impairment, and it is reasonable to consider that the patient's cerebrovascular disease has had an adverse effect on his cognitive function. MRI report was noted for microvascular ischemic white matter disease (which is associated with cognitive impairment/dementia); and also multiple areas of infarction.

The information in the UAS supported the patient's need for assistance with IADLs and ADLs, which was reflected in the UAS-ATSP Summary of Hours Recommended (20.72 hours). Comparing the earlier UAS with the information from the later neuropsychological evaluation, it is reasonable to conclude that by a specified time, the patient's functional status did not improve (poor balance, increased fatigue, weakness, falls, worsening cognition); and so the patient qualifies for at least the same amount of services that he needed earlier. The records provided for review support medical necessity for personal assistance services (in this case CDPAS) for the number of aide hours allocated in the earlier UAS-ATSP, i.e. 21 hours per week. This amount of services is an initial plan of care. An updated assessment (UAS) is needed to determine the patient's current functional status and whether additional aide hours are indicated.  

Based on the information from the earlier UAS and more recent information from the later neuropsychological evaluation, it is apparent that the patient has functional impairments requiring daily assistance with IADLs and ADLs as a result of cognitive deficits and physical symptoms/impairments associated with various medical conditions. Therefore, it is medically necessary for the patient to have assistance with IADLs and ADLs to help the patient complete daily activities effectively and safely.

Consumer Directed Personal Assistance Service 21 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

Based on the above, the medical necessity for the Consumer Directed Personal Assistance Service- initial service is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pulmonary/CAP
Treatment: Inpatient hospital stay
The health plan's determination is upheld in whole, inpatient stay was not medically necessary.

The pediatric patient  presents to the emergency department  due to worsening pneumonia despite outpatient antibiotic treatment. Patient started to have cough, fever and decreased by mouth (PO) intake 10 days prior to presentation. Patient finished the course of Azithromycin but continued to be symptomatic with persisting fevers, decreased PO intake and post tussive emesis with coughing. Then returned to PMD  with these complaints so  was sent  to the ER for further management and possible admission. Patient was placed on Augmentin. Upon discharge, the patient's pediatrician was concerned that the patient still had poor PO intake, persistent cough and fever (Tmax 101) and had only urinated once. Patient was sent to Urgent care where  a repeat CXR  revealed worsening left sided pneumonia and ptient was referred to the ED for likely admission.  In the ED patient was started on intravenous (IV) Ceftriaxone and lab work sent. Labs returned unremarkable. Patient was described to be in no apparent distress. Lung exam with diminished breath sounds to LLL, slight crackles and rest of lung fields clear. Plan was for admission for pneumonia refractory to outpatient treatment. Plan was for PO Amoxicillin on the floor and repeat imaging if no improvement. Reason for admission was worsening community acquired pneumonia. Patient improved overnight with no fevers but still with some productive cough. The nausea was improved. At the time of discharge patient with stable vital signs and tolerating PO. The patient did not have any laboratory evidence of dehydration nor  have any markedly elevated inflammatory markers or abnormal laboratory values. Patient did not require a high level of care or intense therapies. Patient did not meet criteria for inpatient stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Wisdom tooth eruption, early dental abscess, and periorbital cellulitis

Treatment: Emergency department services

The insurer denied coverage for emergency department services. The denial is reversed.

This patient is a male who presented to the Emergency Department (ED) with complaints of wisdom teeth pain, swelling, and abscess.  The patient's diagnoses included wisdom tooth eruption, early dental abscess, and periorbital cellulitis.  The patient's vital signs were: blood pressure of 145/75, temperature of 99.3 F, pulse of 73, respiration of 16, and oxygen saturation of 98% room air.  The patient was prescribed amoxicillin.  The patient was previously told by his orthodontist that he needed to get his wisdom teeth removed.  
Based on the review of the medical record, this patient had pericoronitis which is a severe inflammatory condition that can lead to a significant head and neck infection. As per Wehr et al (2019), "Pericoronitis is defined as an inflammation of the overlying gingiva associated with infection in the soft tissues surrounding a partially erupted tooth.  Mandibular third molars are most commonly affected.  This pathological condition is most prevalent in young adults, although patients of any age group may present with pericoronal inflammation." The medical records support that this patient had impacted wisdom teeth and pain and swelling around them, which is characterized as pericoronitis. 

According to Sanders & Houck (2019), "Dental infections, while relatively straightforward regarding diagnosis and access, can be challenging to manage acutely. Dental abscesses or periapical infections typically arise secondary to dental caries (tooth rot related to poor dental hygiene), trauma, or failed dental root canal treatment.  Left untreated these infections can be not only extremely painful but also pose a significant risk of descending into the deep neck space or ascending to intracranial sinuses.  Identifying, treating and educating patients about a dental abscess will not only grant symptomatic relief but can also prevent dangerous complications.[1][2]"

Based on literature review, this patient presented to the ED with a significant inflammatory, dental condition that can lead to a severe fascial space infection. Thus, emergency care services were medically necessary to assess this patient's medical condition and determine if inpatient level of care was indicated or not. 

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

The carrier's denial of coverage for the emergency department services should be reversed.  The medical necessity is substantiated.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis:  Skin Disorders - Psoriasis.
Treatment:  Pharmacy/Prescription Drugs.

The health plan denied the Taltz.  The denial is upheld.

The patient is an adult male with moderate to severe psoriasis (45% body surface area involvement).  The patient has tried and failed topical steroids and the biologic agent Stelara.  The health plan has denied the Stelara as not medically necessary.

The health plan's determination is upheld. 

The patient's health plan covers Humira, Tremfya, Cimzia, Skyrizi, and Cosentyx [1], which are all appropriate for this patient's particular clinical scenario.  They are not contraindicated or likely to cause an adverse reaction by or physical or mental harm to the patient.  Modern dermatology literature [2-5] supports use of the health plan-covered and preferred medications as similarly efficacious to the requested Taltz, particularly for a patient with relatively little history of systemic psoriasis therapy previously utilized, and recommend use of these preferred agents as appropriate for this patient's clinical scenario.  Therefore, as per current medical standards of care, Taltz is not medically necessary.

The health plan-preferred alternative biologic agents are all appropriate and anticipated to benefit this patient's psoriasis, based on the patient's clinical history and scenario.  The patient's past treatment and health coverage history does not show treatment failure or medical likelihood of either treatment failure or contraindication, of the health plan-covered and preferred alternative biologic medications. 

The patient is not stable on Taltz after multiple failures on alternative systemic therapies and has not been on it so long that discontinuation of Taltz would pose any significant health problems for this patient.

The patient's health plan-preferred and covered biologic alternatives (Humira, Tremfya, Cimzia, Skyrizi, and Cosentyx) are all appropriate for this patient with moderate to severe psoriasis, who has failed only topical medications and Stelara.  These agents are all easily-adhered to with minimal side effects compared to the requested Taltz and are likely to improve the patient's psoriasis and any associated quality of life issues.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Endocrine/hypogonadism 
Treatment: Prescription medication 

The health plan's determination is upheld in whole. The formulary preferred testosterone preparations would not be less effective or have more side effects than the requested testosterone preparation. The patient has a history of hypogonadism. Patient also has Cushing's disease status post transsphenoidal resection and hypopituitarism. The coverage request is for testosterone gel 1% (50mg/5gm). The patient has tried and failed testosterone cypionate - there was swelling at injection site and mood swings. Hypogonadism treatment in symptomatic men is recommended by the Endocrine Society 2018 guidelines, and the society does not differentiate between different types of testosterone preparations in terms of efficacy in treating hypogonadism and its symptoms. Similarly, the 2018 American Urological Association (AUA) guidelines on the topic also do not differentiate between different types of testosterone preparations in terms of treatment efficacy. Additionally, there are no high-quality clinical studies showing one preparation results in improved patient outcomes versus another testosterone preparation. Additionally, all testosterone preparations have similar side effect profiles in terms of adverse effects from the active testosterone hormone (prostate enlargement, increased prostate-specific antigen (PSA), hypertension, emotional liability, increased hematocrit, increased cardiovascular and stroke risk, worsening of sleep apnea, etc.). Intramuscular testosterone preparations have increased risk of pulmonary oil microembolism and local injection pain/reactions, while gel preparations have higher risk of skin irritation and transfer to other persons, however these risks may be mitigated with administration protocol precautions. The provider notes the patient has tried and failed testosterone cypionate - however the other formulary testosterone drugs, testosterone transdermal gel 25mg/2.5 gm (1%); testosterone transdermal gel 10mg/actuation (2%); and testosterone enanthate are appropriate alternatives. Thus, the patient can use formulary preferred drugs first, before requesting non-preferred agents such as testosterone gel 1% (50mg/5gm).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Cervical myelopathy, avascular necrosis of bilateral hips, and CRPS.
Treatment:  Personal Care Services, ten to 12 hours/day, seven days/week, for a total of 70-84 hours.

The insurer denied the Personal Care Services, ten to 12 hours/day, seven days/week, for a total of 70-84 hours.  The denial is overturned.

The proposed treatment of an increase in Personal Care Services, to ten to 12 hours/day, seven days/week, for a total of 70-84 hours is deemed medically necessary. 

The patient is a female with a history of cervical myelopathy, avascular necrosis of bilateral hips and CRPS (complex regional pain syndrome) of bilateral feet.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  An appeal review requested for potential approval of an increase in Personal Care Services, to ten to 12 hours/day, seven days/week, for a total of 70-84 hours to offer improved ADL assistance. 

The patient is a female with a history of cervical myelopathy, avascular necrosis of bilateral hips and CRPS of bilateral feet.  Due to impairments related to these conditions, she requires assistance for completion of the majority of her activities of daily living (ADLs).  Recent documentation from the patient's provider indicates that the patient has demonstrated progressive functional decline, rendering her with limited strength and mobility.  For these reasons, she is wheelchair dependent and requires assistance with the majority of her ADLs.  For these reasons, the currently approved plan of 56 hours/week Personal Care Services is insufficient to meet the patient's current needs.  Hence, the proposed treatment of an increase in Personal Care Services, to ten to 12 hours/day, seven days/week, for a total of 70-84 hours is deemed medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma 
Treatment: Inpatient admission 

The inpatient admission was not medically necessary. 

Summary: The patient is a female child.  She was admitted through the ED for asthma.  She was given two duo nebulizer treatments, magnesium sulfate, albuterol and IV steroids.  She was administered IV fluids.  Chest x-ray showed peribronchial cuffing.  Her vital signs were stable.  The patient was weaned successfully and sent home on asthma medications.  

The patient's vital signs were stable.  She was administered IV fluids.  The treatment that was provided to the patient meets criteria for observation outpatient management rather than admission to the hospital.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Polycystic ovarian syndrome (PCOS).  
Treatment:  Victoza 0.6 mg/0.1 ml, quantity per 72 days

The insurer denied coverage for Victoza 0.6 mg/0.1 ml, quantity per 72 days.  The denial is upheld.

This patient is a female with a history of polycystic ovarian syndrome (PCOS).  Initially, the patient was treated with Metformin and Spironolactone; there was no indication of the patient's response to these medications.  The patient was noted to have elevated testosterone levels, but there was no mention of glucose levels, insulin levels, Hemoglobin A1c, or gonadotropins.  The medical record mentioned that the patient had hirsutism.  The patient was noted to have started on Victoza (liraglutide) 0.6 mg daily, and her weight decreased from a body mass index (BMI) of 30.8 to a BMI of 28.5.  It was stated that her insulin sensitivity increased and the patient lost a significant amount of body weight.

As per UpToDate, the limited data in women with PCOS on liraglutide states, "Though not specifically approved for PCOS, liraglutide is approved for individuals with a BMI of 30 kg/m2 or greater."  While there is support for liraglutide medication use for weight loss for individuals with a BMI of 30 kg/m2 or greater, there is lack of literature evidence to support that this medication increases insulin sensitivity and is medically indicated for patients with PCOS below the threshold BMI of 30 kg/m2. 

Based on the review of the medical records provided, there is lack of objective clinical data for review, such as the patient's weight changes or the effects of the medication use on the patient's lab values, such as glucose levels, insulin levels, Hemoglobin A1c, or gonadotropins.  This lack of data accompanying the patient's records, and the fact that the patient's BMI is now down to 28.5 (below the threshold BMI of 30 kg/m2 for liraglutide use), the continuation of liraglutide (Victoza) as currently prescribed is not medically necessary to treat this patient's medical condition. 

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

The carrier's denial of coverage for the preservice request for Victoza 0.6 mg/0.1 ml, quantity per 72 days is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Recurrent cellulitis.
Treatment:  Acute inpatient hospital stay.
The insurer denied coverage for acute inpatient hospital stay.  The denial is upheld. 

This patient is a female with past medical history significant for diabetes mellitus, gastroesophageal reflux disease (GERD), obesity, chronic obstructive pulmonary disease (COPD), lymphedema, and venous stasis who presented to the Emergency Department (ED) with complaints of left lower extremity pain and ulceration.  As per the ID consult, the patient has history of recurrent cellulitis and came to ED with pain/itching for digital cleft great and 2nd toe for a month and pain swelling redness around the LLE ulcer for a week.  The patient was diagnosed with dermatomycosis on antifungal cream but since then several weeks itching worse and then with mild purulence in previously healing LLE ulcer.  Recently seen by dermatologist who did culture showing staph susceptible only to vancomycin and linezolid but was started on Bactrim.  The patient's vitals on ED presentation included:  Temperature-98.2 F, Blood Pressure-155/85, Pulse-86, Respiratory Rate-20, and Oxygen saturation-99%.  A note with a more detailed description -LLE ulcer 10cmX10cm healing no pus, surrounding area erythematous, mild tenderness.  The Infectious Disease service was consulted for outpatient antibiotic management. 

The Vascular Surgery service was also consulted, and they recommended local wound care for the patient.  The patient remained afebrile, hemodynamically stable and clinically improved.  The patient was discharged to continue management as an outpatient.

According to the review of the medical documentation, the patient history of chronic ulcer with recent increase in symptoms was admitted with a possible left lower extremity cellulitis and venous stasis ulcer.  Otherwise, the patient was afebrile, hemodynamically stable with normal white blood cell count.  

There was no evidence of a disseminated infection and no surgical intervention was required.  According to the practice guidelines for the diagnosis and management of skin and soft tissue infections, outpatient therapy is recommended for patients who do not have systemic inflammatory response syndrome (SIRS), altered mental status, or hemodynamic instability, and hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient, or if outpatient treatment is failing (Stevens et al., 2014).  The patient did not meet criteria for acute care hospitalization.

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

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

Diagnosis:  Atrial fibrillation.
Treatment:  Inpatient hospital admission.
The insurer denied coverage for Inpatient hospital admission.  The denial is upheld. 

This patient is a male with a past medical history notable for gout and hyperlipidemia.  The patient presented to the Emergency Room (ER) with complaints of abdominal pain, bloating, and shortness of breath.  The patient was found to have an irregular heart rhythm at an Urgent Care clinic; therefore, was sent to the ER.  The patient was noted to have heart rates in the 30s in the ER; troponin was negative.  The patient's vital and clinical signs were stable.  Upon Cardiology consultation, the patient was noted to have atrial fibrillation.  The patient was noted to have known about his irregular heart beat for several years prior to this presentation.  The patient was started on heparin infusion and admitted for new onset atrial fibrillation, with the understanding that the patient had this irregular heart beat in the past.  The patient's echocardiography showed normal left ventricular systolic function.  The patient was discharged home.

Based on the review of the medical record, the patient presented with atrial fibrillation.  However, the remainder of the patient's cardiac workup was unremarkable, including the patient's cardiac troponin level.  The patient remained clinically and hemodynamically stable throughout the hospitalization.  In the absence of evidence of myocardial ischemia, hypoxemia, hemodynamic instability, or other end-organ dysfunction, the patient's care could have been provided in the observational setting, allowing for additional cardiac testing.  Based on the clinical guidelines, the patient did not meet inpatient admission, and inpatient admission was not medically necessary to treat this patient's medical condition.  Although the patient had new onset symptoms, this did not meet the medical policy criteria for any other additional extenuating circumstances. 

The health plan allows for initial evaluation and subsequent monitoring in the hospital under both inpatient and observational levels of care.  Thus, the health plan acted reasonably with sound medical judgment and in the best interest of the patient.

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

Substance abuse/Addiction 
Substance Abuse: Inpatient

Diagnosis: Substance abuse. Treatment: Inpatient rehab. The insurer denied inpatient rehab. The health plan's determination is upheld.

The patient is a male who presented for inpatient rehabilitation substance use disorder treatment to address substance use disorder for alcohol abuse. The patient had no history of withdrawal seizures, delirium tremens or other episodes of severe withdrawal symptoms. He had a ten-year history of alcohol use. He reported intermittent use of alcohol with up to one pint of tequila up to three times per month. 

Inpatient Substance Use Rehabilitation Treatment is not medically necessary for this patient.
The patient presented with alcohol use disorder with the request for treatment. He was admitted and received inpatient level rehabilitation treatment. He readily engaged in treatment with evidence-based psychosocial treatments. During the brief time interval under review, the patient was noted to be in no apparent distress with satisfactory functioning and active participation in treatment including positive interactions with staff and peers. Throughout his brief stay, there were no complicating treatment issues or biomedical or co-occurring psychiatric issues that would have warranted inpatient level of care. The application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) Criteria did indicate that the patient was clinically appropriate for treatment with lower level care in a less restrictive treatment setting.