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

Diagnosis: dementia

Treatment: personal care aide (PCA) Level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week

The insurer is denied coverage for personal care aide (PCA) Level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week

The denial is overturned. 

This female patient has a history of dementia, hypertension, coronary artery disease, congestive heart failure, glucose intolerance, osteoarthritis, spondyloarthritis, glaucoma, depression, vestibulopathy, incontinence and impaired imbalance.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; 07/06/2016 notes:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."

Also:

"...As previously advised, social services districts are NOT required to allot time for safety monitoring as a separate task as part of the total personal care services hours authorized (see GIS 99 MA/013, GIS 99 MA/036). However, districts are reminded that a clear and legitimate distinction exists between "safety monitoring" as a non-required independent stand alone function while no Level II personal care services task is being provided, and the appropriate monitoring of the patient while providing assistance with the performance of a Level II personal care services task, such as transferring, toileting, or walking, to assure the task is being safely completed." 

The patient has extensive physical needs, needing assistance with all functions. She has cognitive impairment and incontinence. Serial UAS as well as MD letters document physical and mental decline. 

While she does have physical aids such as pull-ups, this does not replace assistance with toileting. The provision of diapers and DME such as alternate pressure beds is not by itself adequate for prevention of pressure sores, changing diapers regularly and positioning are also necessary.

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 personal care aide (PCA) Level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week is overturned.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease. 
Treatment: Home Care / Personal Care (HHC - Level 2 Personal Care Services, per 15 minutes) Increase to 70Hour(s) per Week  (Health plan approved 49 Hour per week: Mon 7 Tue 7 Wed 7 Thu 7 Fri 7 Sat 7 Sun 7). 

The insurer denied the Home Care / Personal Care (HHC - Level 2 Personal Care Services, per 15 minutes) Increase to 70 Hour(s) per Week  (Health plan approved 49 Hour per week: Mon 7 Tue 7 Wed 7 Thu 7 Fri 7 Sat 7 Sun 7). 

The denial is upheld. 

This male has medical conditions including COPD (chronic obstructive pulmonary disease), age-related decline, anemia and weakness.  This patient is appealing denial of increase in PCA (personal care assistant) services from 49 hours per week to 70 hours per week.  The denial notice shows the member needs assistance with chores.  There is no change in ADLs (activities of daily living) in last 90 days; no change in clinical conditions; and no change in social circumstances. 

UAS (Uniform Assessment System) evaluation completed shows minimally impaired cognition and functional status: total dependence with meal preparation, housework, managing finances, and shopping; maximal assistance with managing medications, bathing, personal hygiene, dressing, and toileting; extensive assistance with phone use, and walking; limited assistance with bed mobility; and supervision with eating.  The patient is frequently incontinent of bowel and bladder. He had a fall in the last 90 days when getting out of bed. 

No. The proposed treatment is not medically necessary. 

Personal Assistance Services provide hands-on assistance to individuals to include: assistance with activities of daily living (ADLs); health maintenance activities; and routine support services.  This patient has multiple chronic conditions. This patient is appealing denial of increase in PCA (personal care assistant) services from 49 hours per week to 70 hours per week.  UAS (Uniform Assessment System) evaluation completed shows the patient requires assistance with all activities of daily living except eating.  The patient is incontinent of bowel and bladder.  There has been no change in the patient's clinical condition or ADLs (activities of daily living). The documentation does not support an increase in PCA (personal care assistant) hours.  The approved PCA  (personal care assistant) 49 hours per week is sufficient to meet this patient's needs for assistance with (activities of daily livings).  The proposed increase to 70 hours per week is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Epididymitis

Treatment: Inpatient hospital stay

The insurer denied coverage for inpatient hospital stay.

The denial is upheld.

This is the case of an adult male with past medical history of lung cancer, hypertension (HTN), chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), Peyronie's disease, recurrent epididymitis. The patient presented to the Emergency Department (ED) with 4-day history of left testicular pain. He was afebrile with stable vitals. He had recently been on a 14-day course of oral Levaquin and the testicular pain improved. Scrotal ultrasound in ED revealed left epididymitis. The patient was then admitted for this. He was treated with intravenous (IV) Zosyn every 6 hours and analgesia as needed. Symptoms improved and he was discharged to home. 

The insurer has denied coverage for the inpatient hospital stay as not medical necessary. They stated that the patient could have been placed in observation area with monitoring as alternative. They noted a lack of hemodynamic, pulmonary, metabolic, or neurologic reason to treat the patient at an acute level of care (LOC). The appeal on behalf of the hospital is noted and read in detail. 

Per Milliman Care Guidelines (MCG) Health (24th) Urologic Disease, the patient fails to meet clinical indications for admission to inpatient care for "Scrotal testicular or epididymitis disorder requiring inpatient care." In ED, the patient was afebrile, no increased white blood cell (WBC) count, stable vitals, and ultrasound findings were consistent with left epididymitis.

The healthcare plan acted reasonably and with sound medical judgement and in the best interest of the patient.

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

Diagnosis: Cholecystitis

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

As per the Emergency Room (ER) note, the patient was afebrile with stable vital signs. She complained of pain but denied fever, nausea, or vomiting. On exam the patient had moderate right upper quadrant (RUQ) tenderness without rebound or guarding. A sonogram revealed gall stones in the gallbladder neck with no evidence of thickened gallbladder or pericholecystic fluid. Lab results were as follows: white blood cell (WBC) count was 7.78; aspartate aminotransferase (AST) was 130; alanine aminotransferase (ALT) was 89 and alkaline phosphatase (ALP) was 121. The diagnosis was cholecystitis, and the plan was for nothing by mouth (NPO) and surgery. Surgery saw the patient and noted that on computed tomography (CT) of the abdomen, the gallbladder was distended with a suggestion of mild wall thickening/pericholecystic fluid. No calcified gallstones were noted. The patient was admitted and underwent an uneventful laparoscopic cholecystectomy. The pathology revealed chronic calculous cholecystitis. Progress notes indicated the patient was resting comfortably, was tolerating a clear liquid diet, and felt hungry. The patient was discharged with instruction to follow up with the surgeon on an outpatient basis. 

According to the guidelines of MCG Health Inpatient and Surgical care - 25th edition Gall bladder or bile duct inflammation or stone), the goal length of stay is ambulatory or 2 days and assumes optimal recovery, decision making, and care. Patients may be discharged to a lower level of care (either later than or sooner than the goal) when it is appropriate for their clinical status and care needs. 

Furthermore, according to MCG Inpatient and Surgical Care 25th Edition Cholecystectomy by laparoscopy, the operative status criteria is ambulatory. Thus, this patient could have been managed without an inpatient acute admission for this procedure.

This patient did not have signs and symptoms for acute cholecystitis as she did not have elevated WBCs, fever, nausea, vomiting or confirmatory tests to show acute cholecystitis. Her initial liver function tests (LFT's) were slightly abnormal but did not warrant inpatient admission. She did have right upper quadrant tenderness and she underwent an uneventful laparoscopic cholecystectomy and was discharged. Based upon these findings the inpatient admission was not medically necessary treatment for the patient's condition.

The health care plan did act reasonably and with sound medical judgment and in the best interest of this patient.

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

Diagnosis: Herniated Discs

Treatment inpatient hospital admission

The insurer denied coverage for inpatient hospital admission

The denial is upheld

This is a female with a history of hypertension, herniated discs, and a laminectomy. She presented to the hospital for a scheduled lumbar (L) 4-L5 microdiscectomy. After surgery, she was admitted for postoperative care. Pain was rated at a level of 5 out of 10. Her pain was adequately managed with the prescribed pain medications. She was seen by physical therapy (PT). The patient was able to ambulate with tolerable pain control. She was able to tolerate an oral (PO) diet. She was discharged with instructions to follow up with the Neurosurgeon within 7-10 days of discharge. 

The medical records demonstrate a non-complicated surgical procedure was completed. The physician performed a tubular discectomy. Ie (for example). Limited incision and exposure. There was minimal blood loss.  The post-operative records showed pain was tolerated with oral analgesia. There were no problems with the wound. There was no evidence of infection nor fever. Vital signs were stable. The patient did not require treatment for other underlying medical conditions. She demonstrated independence with PT services. There were no extenuating conditions to substantiate the admission and length of stay as provided. Services could have been completed at a lower level of care. 

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

The inpatient hospital admission is not considered medically necessary for this patient.

The insurer's denial of coverage for the inpatient hospital admission is upheld. Medical Necessity is not substantiated.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Low back Pain with Lumbar Radiculopathy.

Treatment: the Intracept Procedure (procedure codes 22899 and C9752).

The insurer denied coverage for the Intracept Procedure (procedure codes 22899 and C9752).

The denial is overturned.

This case involves an adult female patient who has a history of low back pain for greater than 6 months. She has undergone multiple treatments that include physical therapy as well as acupuncture, massage therapy and medication management. The documentation indicated she has pain which has had a significant impact upon activities of daily living. She does utilize medications with minimal benefit. The physician indicated she has also undergone a magnetic resonance imaging (MRI) scan revealing Modic type II changes. The physician detailed her chronic low back pain most likely from the vertebrogenic changes at the L (lumbar) 5-S (sacral) 1 level. A chart note indicate she was seen complaining of ongoing low back pain. She did indicate she received 80% (percent) relief from an epidural steroid injection. She however continues to feel increasing pain with certain movements. The documentation indicated at this time she had not trialed chiropractic care or physical therapy. The examination revealed tenderness with palpation to the lumbar spine. There was 4/5 strength to the lower extremities with decreased sensation to the lateral left and right foot. The physician indicated she has trialed epidural steroid injections and trigger point injections. Noninterventional treatment has failed and therefore it was recommended she undergo the requested procedure.

The scientific evidence in peer reviewed literature does support a result of improvement.

This procedure does have final approval.

This patient is a good candidate. She has had a trial and failure of conservative care and has Modic type II changes on imaging. This is the most appropriate treatment at this time.

This is the best available treatment at this time. 

The adverse risks are not increased over other standard treatment.

The requested procedure is likely to be more beneficial than any other existing standard health service for this patient. 

The carrier's denial of the Intracept Procedure (procedure codes 22899 and C9752) should be overturned.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic Low back Pain with Lumbar Radiculopathy.

Treatment: the Intracept Procedure (procedure codes 22899 and C9752).

The insurer denied coverage for the Intracept Procedure (procedure codes 22899 and C9752).

The denial is overturned.

The patient is an adult female diagnosed with spondylosis without myelopathy or radiculopathy lumbosacral region and low back pain. The magnetic resonance imaging (MRI) scan of the lumbar spine noted there were no fractures, lytic or blastic disease. There was a 2 cm (centimeters) incidental benign hemangioma in the L (lumbar) 3 vertebral body that was unchanged since prior examination. There was moderate degenerative endplate reaction (Modic type II) apparent in the superior endplate of S (sacral)1. The office visit noted the patient had subjective complaints of low back pain and bilateral lower extremities left greater than right pain. The pain had not changed. The patient wanted to discuss pain control. She was status post lumbar epidural steroid injection twice and stated she was doing better but still had discomfort. The patient felt obtaining 80% (percent) relief but emphasizing quality of life and function did not further improve. She felt increased pain with certain movements. The patient had trialed multiple modalities of conservative treatment with no sustained relief. The pain on the average was 8/10 and was intermittent. The pain was improved by nothing. The patient had attempted injections, epidural injections, physical therapy, home stretching exercises, acupuncture, and massage. The patient had tried nonsteroidal anti-inflammatory drugs, and muscle relaxants. The request was received for the Intracept procedure at L5-S1. 

There is good evidence regarding the effectiveness of the Intracept procedure.

The procedure is approved by the Food and Drug Administration (FDA).

Based on MRI findings and clinical information provided, the patient appears to be an appropriate candidate for this procedure.

The patient has failed other conservative treatments, including injection therapy. This would be the next level of treatment.

The patient has failed previous treatment to this point. It is reasonable to consider this procedure as it has shown functional benefit in this patient group.

As in all treatment there are risks to proceed with interventions. All the usual risks for interventional pain treatments apply to this situation including but not limited to bleeding, infection, temporary or permanent nerve injury.

The requested procedure is likely to be more beneficial than any other existing standard health service for this patient.

The carrier's denial of the Intracept Procedure (procedure codes 22899 and C9752) should be overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain (atelectasis). 
Treatment: Inpatient Admission. 

The insurer denied the inpatient admission. 
The denial is upheld. 

The patient is a female with history of diverticulosis, anxiety, and IBS (irritable bowel syndrome). She presented to emergency room with worsening abdominal pain. The patient had tried and failed outpatient therapy with oral pain meds and oral antibiotics. The pain was severe and uncontrollable. 

The patient was admitted to hospital for the management of intractable abdominal pain as well as hypoxia. The patient received 2L (two liters) NC (nasal cannula), as well as pain medication, as needed. 

The admission was denied by the health plan for lack of medical necessity. This is being appealed. 

No, the Inpatient admission was not medically necessary. 

The patient was admitted to acute inpatient level of care for hypoxia and abdominal pain. The emergency room work up did not reveal any abdominal abnormalities. By day two, patient was not in any distress. The patient's oxygen levels remained above 90% on room air. The patient was tolerating oral diet and was capable of ambulation. The patient was not on any invasive drips. Thus, the entire admission from was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Atopic Dermatitis
Treatment: Dupixent SC Injection
The insurer denied the Dupixent SC injection.
The denial is overturned.

The patient is a male with a history of severe atopic dermatitis, multiple food allergies, and allergic rhinitis.  The request is for approval for Dupixent, which was denied for lack of trial with preferred agents such as cyclosporine, methotrexate and phototherapy.

Yes, the treatment with Dupixent is medically necessary.

The patient has severe generalized atopic dermatitis on abdomen, face, neck and legs.  Past medication tried and failed includes topical protopic, topical tacrolimus, antihistamines, topical steroids and Prednisone.  Continuing the use of topical therapies is not appropriate for this patient considering the severity of his condition and the body surface area affected.  Systemic immunosuppressants such as Methotrexate, Azathioprine, or Cyclosporine have many intolerable side-effects such as kidney damage, and frequent blood work for monitoring.  Furthermore, the use of phototherapy is time consuming and will interfere with the patient's schooling, and long-term use can lead to increased risk of photo aging and skin cancers.  Therefore, the patient has tried and failed conservative therapy. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: idiopathic short stature.

Treatment: Nutropin AQ injection 10 milligram (mg)/2 milliliter (ml).

The insurer is denied coverage for Nutropin AQ injection 10 milligram (mg)/2 milliliter (ml).

The denial is overturned. 

This female patient has a history of idiopathic short stature (ISS).

Classic growth hormone (GH) deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society [1], the Lawson Wilkins Pediatric Endocrinology Society [2, [3], and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists [4]. The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on height, height velocity, biochemical and sometimes radiological findings. The height and height velocity criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 Standard Deviation (SD) below the mean; 2) height more than 1.5 SD below the mid parental height SD; 3) height more than 2 SD below the mean and a height velocity over 1 year more than 1 SD below the mean for chronological age, or a decrease in height SD of more than 0.5 over 1 year in children over 2 years of age; 4) in the absence of short stature, a height velocity more than 2 SD below the mean over 1 year or more than 1.5 SD sustained over 2 years. The biochemical criteria include low insulin-like growth factor 1 or insulin like growth factor binding protein 3 or GH stimulation testing with a peak GH less than 10ng/ml.
The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. 
Growth hormone in the treatment of ISS is supported by randomized controlled trials and consensus guidelines [4, [5, [6, [7, [8, [9]. Food and Drug Administration (FDA) approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."
The patient had a pretreatment height less than or equal to -2.25 SD. The patient's height velocity is poor and would not allow the patient to reach a normal adult height. The request therefore meets ISS criteria. The request is consistent with generally accepted standards of medical practice and is therefore medically necessary.

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 Nutropin AQ injection 10 milligram (mg)/2 milliliter (ml) is overturned.  The medical necessity is substantiated.