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

Diagnosis: Dementia

Treatment: PCA services of 24 hours per day, 7 days per week (split shift)  

The insurer is denied coverage for PCA services of 24 hours per day, 7 days per week (split shift).  

The denial is overturned. 

This male patient has a history of advanced dementia, insomnia, anterior myocardial infarction, hypertension, hyperlipidemia, cerebrovascular accident, cardiomyopathy, cardiac defibrillator in situ, non-sustained ventricular tachycardia, congestive heart failure, apical aneurism, back and leg arthritis, prostate cancer, chronic kidney disease, urinary urgency, bladder and bowel incontinence, muscle weakness, spinal stenosis and lumbosacral spine with bilateral sciatica.

This case involves a male who has multiple medical conditions that include dementia as well as prior myocardial infarction, hypertension, hyperlipidemia, cerebral vascular accident (CVA), cardiomyopathy, cardiac defibrillator, non-sustained ventricular tachycardia, congestive heart failure, spinal stenosis, arthritis, prostate cancer, weakness, incontinence of urine, urine frequency, and apical aneurysm. The documentation indicated the above conditions cause severe weakness and balance as well as gait disorders. He is unstable, which causes serious functional deficit. He is mostly wheelchair-bound, requiring maximum assistance. The documentation indicated he does utilize furosemide as well as warfarin, which cause urinary frequency and placing him at a high risk for bleeding in the event of a fall. The documentation does indicate he is receiving 7 days of 24-hour care. The documentation indicated however they are not able to function without an adequate nightly sleep. The documentation detailed due to the patient's deteriorating medical condition it has been requested that they increase services to 7 days a week, 24 hours a day split shift.

There does need to be two caretakers on 12 hour shifts for this male with dementia and multiple co-morbidities on high-risk medications (warfarin and furosemide in this case). These patients are very challenging to care for and notoriously do not sleep well at night even with appropriate medication. They are at high risk for falls and other adverse events such as fractures and intracranial bleeds if they fall. They are especially likely to fall at night when they are half asleep and usually delirious. The caretaker for these types of patients needs to be vigilant and always quick to intervene. Therefore, the caretaker will probably need to stay awake all night and this is impossible if they have had no rest during the day.

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

The carrier's denial of coverage for the inpatient hospital admission is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Neck Sprain/Strain.

Treatment: Physical therapy with proposed procedure codes 97110 (therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) and 97140 (manual therapy techniques, 1 or more regions, each 15 minutes).

The insurer denied coverage for physical therapy with proposed procedure codes 97110 (therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) and 97140 (manual therapy techniques, 1 or more regions, each 15 minutes).

The denial is upheld.

The patient has neck pain diagnosed as a sprain/strain. Treatment included physical therapy that began and was paid by the insurer. Currently under review is the medical necessity of physical therapy with proposed procedure codes 97110 and 97140.

The physical therapy treatment notes provide insufficient objective clinical information to support the medical necessity of the services provided for the treatment dates under review. The physical therapy treatment notes also fail to provide evidence of specific significant improvement that supports the medical necessity of continuing a structured physical therapy program. For example, neck range of motion was "25% (percent) w/neck pain" and unchanged compared to the initial visit. Her current pain level was also not significantly improved (5/10 compared to 6/10 at the initial visit). The physical therapy treatment provided without evidence of significant improvement is consistent with maintenance therapy, rendering additional therapy not medically necessary.

There was not sufficient evidence to support that physical therapy with proposed procedure codes 97110 (therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) and 97140 (manual therapy techniques, 1 or more regions, each 15 minutes) was considered medically necessary.

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient. Taken into consideration were the clinical standards of the plan, information provided concerning the patient, attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board and associations. All decisions are evidence-based.

The insurer's denial of coverage for physical therapy with proposed procedure codes 97110 (therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) and 97140 (manual therapy techniques, 1 or more regions, each 15 minutes) is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left arm wound with drainage and odor.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is overturned.

The patient is a male with extensive intravenous (IV) heroin use and a four-month history of a left arm wound who presented to the Emergency Department from a rehabilitation unit due to drainage and odor. He previously had an abscess that was drained and he has noted his wound was worsening.  An x-ray of the arm indicated gas without foreign body.  The left arm wound measured 12.0 by 5.0 centimeters with extension to the tendon, but without erythema. White blood cell (WBC) count was 6.8. The arm had good range of motion without crepitus.

The patient was admitted and treated with empiric intravenous (IV) antibiotics and had undergone a series of labs and wound cultures. Initial orthopedic and surgical consultations indicated that surgical management was not their responsibility.  Further surgical consultation indicated a plan for debridement once COVID testing was negative. The patient underwent a detoxification protocol while in the hospital. He left against medical advice without surgery.

Yes, the proposed acute inpatient admission was medically necessary.
This was a high risk patient with a history of intravenous (IV) drug use, prior arm abscesses and worsening wound size with erythema and odor. According to one study (reference 2), over 40% of patients with similar risks have required up to three days of hospital admission. Although he did not present with an elevated white count or fevers, his x-ray indicated gas in the area of the wound suggesting risk of infection and need for antibiotics and possible surgery. Since the patient required consultations and labs while awaiting his COVID status, an inpatient stay for management and surgical consultations was required. The patient's degree of risk and need for close monitoring were more intensive than the scope of an observation level of care.

Based on the above, this high risk patient with the aforementioned history and reasoning above required admission.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Thrombophilia. 
Treatment: Formulary exception for Pradaxa (dabigatran). 

The insurer denied the Formulary exception for Pradaxa (dabigatran). 
The denial is overturned. 

The patient in this case is a woman. She has a prior history of DVT (deep venous thrombosis) and pulmonary embolism.  She has been found to have a heterozygous prothrombin gene mutation.  The DVT (deep venous thrombosis) and pulmonary embolism occurred after surgery for a varicose vein and while she was taking Eliquis.  She was treated with Pradaxa, and has been on that medication since that time.  The request in this case is for continued use of Pradaxa.  She is noted to have tolerated this medication well and has not had any recurrent venous thrombosis while taking Pradaxa.  The formulary alternatives in this case are warfarin and Xarelto. 

Yes, the health plan should cover the Formulary exception for Pradaxa (dabigatran). 

This patient was diagnosed with deep venous thrombosis and pulmonary embolism in the past while taking Eliquis. She has been treated with Pradaxa without recurrent venous thrombosis. Xarelto and warfarin are the formulary alternatives.  Xarelto has the same mechanism as Eliquis (Factor Xa inhibitor), while Pradaxa has a different mechanism of action (direct thrombin inhibitor). This patient already failed Eliquis, and that raises the risk that she would also fail Xarelto.  Warfarin has a different mechanism of action, but is associated with increased bleeding risk and reduced efficacy compared to Pradaxa.  Furthermore, the patient has done well while taking Pradaxa, as noted above. There is sufficient grounds for concluding that the formulary drugs could be ineffective for this patient based on her prior history of venous thrombosis while taking the related drug Eliquis. They therefore have the potential to be less effective than Pradaxa. They are also associated with a higher risk of major bleeding than Pradaxa. Given these considerations, it should be considered medically necessary for this patient to continue treatment with Pradaxa.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: left breast cellulitis

Treatment: acute inpatient level of care

The insurer is denied coverage for acute inpatient level of care

The denial is upheld. 

This female patient has no prior medical history.

The patient was treated with empiric antibiotics (Clindamycin) for possible breast cellulitis. Following review of the breast ultrasound, it was determined that no surgical intervention was required- "really no collection to drain." The patient remained afebrile, hemodynamically stable and was discharged to continue outpatient management.

According to documentation, the patient presented to the Emergency department (ED) with complaints left breast erythema. She was afebrile, hemodynamically stable with unremarkable laboratory results including a normal WBC. There was no evidence for a systemic infection and no surgical intervention was required. The patient had no co-morbid conditions or risk factors. Based on above findings, patient was stable for outpatient management following observation in the ED.

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 the acute inpatient level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Bronchiectasis

Treatment: Airway clearance device (E0483RR x 3)

The insurer denied coverage for airway clearance device (E0483RR x 3).

The denial is overturned.

This is a male with a diagnosis of moderate persistent asthma, bronchiectasis and dysphagia. He also has Dandy Walker syndrome and developmental delay. He has been treated with daily symbicort, montelukast and the Vest airway clearance device. Since his diagnosis of bronchiectasis was confirmed by computed tomography (CT) scan, his mother has attempted to perform manual chest physical therapy, but this has not been felt to be effective for this patient. In addition, positive expiratory pressure (PEP) devices have been attempted to help mobilize his secretions but because of his developmental delay he has not been able to benefit from these devices. The patient is scheduled to have a modified barium swallow performed to evaluate his swallowing and assess his risk of aspiration of oral feedings. He is currently fed with a thickening agent to minimize the risk for aspiration. The patient's Pediatric Pulmonologist has ordered the InCourage high frequency vest to perform chest vest therapy to prevent worsening of his bronchiectasis. 

The insurer has denied the InCourage Vest and indicated that manual chest physical therapy and PEP devices should be used for this patient.

Bronchiectasis results in airway damage and pooling of secretions which lead to recurrent lower airway infections. Airway clearance is an essential treatment that improves the quality of life and long-term outcome for children with bronchiectasis. Patients with bronchiectasis benefit from daily chest physical therapy to help mobilize secretions and avoid recurrence of respiratory infections. The InCourage Vest therapy is considered the most appropriate level of service; it is known to be an effective therapy which has been shown to decrease airway infections and hospitalizations and to improve health outcomes for children with bronchiectasis.

According to UpToDate article Respiratory muscle weakness due to neuromuscular disease: Management, "Secretion mobilization techniques - High frequency chest-wall oscillation and intrapulmonary percussive ventilation are two techniques that can mobilize secretions from the airways [34]." 

The patient has a history of developmental delay, dysphagia, asthma and bronchiectasis. 
The medical record indicates that the mother has been unsuccessful in performing adequate daily chest physical therapy and that this patient cannot adequately perform airway clearance with a PEP device. The medical record does support the need for ongoing daily treatment with the Vest therapy and the InCourage Vest would be medically necessary treatment for this patient's condition.

The health care plan did not act reasonably, with sound clinical judgment, or in the best interest of the patient.

The insurer's denial of coverage for an airway clearance device (E0483RR x 3) is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shoulder Pain, Osteoarthritis

Treatment: consumer directed personal assistance services (CDPAS), a total of 37 hours per week

The insurer denied coverage for consumer directed personal assistance services (CDPAS), a total of 37 hours per week

The denial is upheld.

This case involves an adult female who was seen for a follow-up with complaints of shoulder pain. The documentation indicated objectively there was tenderness to the right shoulder. The physician indicated the patient should continue with multiple medications and undergo imaging to the shoulder. It was recommended she participate in regular exercise. Prior to this, she was seen complaining of ankle pain and to undergo an annual physical examination. The documentation indicated she subjectively did not have any significant findings. It was recommended at this visit she continue with medication use. The assessment indicated the patient does live alone. She does indicate she needs more help as she does currently receive personal care assistance 27 hours a week from her stepson. However, she indicated he no longer lives with her given he has a newborn. The request has been received for consumer directed personal assistant services for a total of 37 hours a week.

The documentation provided does not support the request for 37 hours a week of directed personal assistant services. Neither the diagnosis nor prognosis of her joint conditions was made available, so it is difficult to determine why she needs extra help. Therefore, given the above, the prior denial remains upheld.

The health plan acted 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), a total of 37 hours per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Severe crowding, and impacted canine (#6)

Treatment: D8080 (braces)

The insurer denied coverage for D8080 braces.

The denial is overturned.

Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, as well as narrative letters, it appears that this patient presented for evaluation for orthodontic care. The orthodontist recommended comprehensive orthodontics due to severe crowding, and impacted canine (number [#] 6). The orthodontist has completed the Handicapping labio-lingual deviation (HLD) index as required and has chosen the automatically qualifying condition of impacted permanent anterior where extraction is not indicated. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements, attaining only 13 points on the HLD index. The patient's mother is appealing the decision on behalf of the patient.

It is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, a Handicapping Labio-Lingual Deviation Index is utilized. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used, utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.

In this case, the treating orthodontist claims an automatic qualifying condition of impacted permanent anteriors where extraction is not indicated. This reviewer finds that this automatically qualifying condition criterion is met and does support comprehensive orthodontic care. In this case, the clinical circumstance does meet insurer and plan criteria to justify orthodontic care.

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

D8080 braces considered is medically necessary for this patient.

The insurer's denial of coverage for D8080 braces is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pelvic pain, abdominal myomectomy and left ovarian cystectomy
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female [gravida-1, para-1 (G1 P1)] with a history of uterine fibroids and menorrhagia. She presented to the emergency room with pelvic pain. Her vital signs were normal. According to the medical records, her pelvic examination revealed no vaginal bleeding, and she was afebrile.

The patient was seen by the gynecology service for a preoperative discussion. The patient's vital signs were normal and she was afebrile. Her abdominal examination revealed no tenderness, rebound or guarding. An abdominal myomectomy and left ovarian cystectomy with lysis of adhesions was performed. The procedure was performed without complications and 200 milliliter blood loss. The patient was taken to the Post Anesthesia Care Unit (PACU) and recovered without incident. The patient was transferred to the inpatient service. Her vital signs were stable and she was afebrile. The incision was stable and her pain was well-controlled. The abdominal examination was non-tender and normal. She recovered without incident on the inpatient floor. The Health Plan has denied the inpatient admission on the basis of lack of co-morbidities and a stable postoperative course.

No, the proposed inpatient hospital admission was not medically necessary.

According to the medical records, the patient was afebrile in the Post Anesthesia Care Unit (PACU). Her vital signs were normal and stable during the PACU stay. The patient required intravenous (IV) pain medications for a short period of time, and her pain was satisfactorily controlled with oral pain medications on the first postoperative day. According to the inpatient records, the patient had progressed to a normal diet, was ambulating without difficulty, had normal bowel sounds and a nontender abdomen by the first postoperative day. She was voiding normally. The patient underwent an uncomplicated laparoscopic myomectomy. The procedure time was not longer than expected and the blood loss was as expected at 200 milliliters. The postoperative period in the PACU was not significantly complicated and the patient's condition was stable, with stable vital signs on discharge to the inpatient service. The patient did not have serious co-morbidities to be a complicating factor in her preoperative and postoperative care plans. The patient was likewise stable on admission from the PACU. Stable postoperative patients who have undergone uncomplicated procedures such as laparoscopic myomectomy do not require acute inpatient admission after their discharge from the PACU. They may be reliably observed, by the standard of care, in a lesser level of care prior to their eventual discharge. Therefore, the patient could have been reliably discharged from the PACU to a lesser level of care rather than the acute inpatient service. Therefore, the treatment did not have to be provided in an acute inpatient setting and was not medically necessary.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: esophageal reflux disease.

Treatment: Esomeprazole Capsules.

The insurer is denied coverage for Esomeprazole Capsules.

The denial is overturned. 

This male patient has a history of asthma, esophageal reflux, hiatal hernia, heartburn, gastric ulcer, and hemorrhoids.

UpToDate has an article titled "Proton Pump Inhibitor: Overview of use and adverse effect in the treatment of acid related disorders." The article states that switching of proton pump inhibitor (PPI) is a reasonable strategy in patient with side effect to an individual PPI. There is significant variability in intragastric PH (acid/base) control between PPIs, although no consistent difference was found in symptom resolution or esophagitis healing rates.

This patient has extensive GERD (Gastroesophageal Reflux Disease) and requires PPI therapy. The insurer has denied esomeprazole because the formulary alternatives have not been tried. However, the records that were submitted for review state that omeprazole, lansoprazole, and pantoprazole have all been tried and failed. He has achieved symptom relief with esomeprazole. Since he has tried and failed 3 formulary alternatives. The denial of esomeprazole is more effective than the formulary options.

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 Esomeprazole Capsules  is overturned.  The medical necessity is substantiated.