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

Diagnosis:  Dementia, osteoarthritis, glaucoma.
Treatment:  Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week.

The insurer denied: Personal Care Aide (PCA) Level 2: 12 hours per day - 7 day(s) per week - for a total of 84 hours per week.  The denial is upheld.

This is an elderly female patient who has medical conditions that include dementia, hypothyroidism, osteoarthritis, glaucoma, and reflux. The denial of personal care aide (PCA) level 2: 12 hours per day - 7 days per week - for a total of 84 hours per week is being appealed. The health plan approved personal care aide 5.5 hours per day - 7 days per week - for a total of 38.5 hours per week. Uniform Assessment System (UAS) evaluation completed 2 months ago shows moderately impaired cognition and functional status: total assistance with housework; maximal assistance with meal preparation, managing medications and finances, shopping, bathing, and lower body dressing; extensive assistance with personal hygiene, upper body dressing, walking, locomotion, toileting, and bed mobility; limited assistance with phone use; and independent with eating. The patient has frequent bladder incontinence. Compared to Uniform Assessment System evaluation completed 4 months ago, there has been a decline with cognition and toilet use. A letter from the Provider reports the patient has moderate cognitive deficit. She has poor judgment and insight. She has difficulty functioning alone and needs to be cared for 12 hours a day.

The requested health service 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 as well as progressive dementia. The denial of personal care aide (PCA) level 2: 12 hours per day- 7 days per week- for a total of 84 hours per week is being appealed. The health plan approved personal care aide 5.5 hours per day- 7 days per week - for a total of 38.5 hours per week. Uniform Assessment System (UAS) evaluation completed 2 months ago shows the patient requires assistance with all activities of daily living, except eating. Compared to Uniform Assessment System evaluation completed 4 months ago, there has been a decline with cognition and toilet use. The appeal statement reports the patient has poor judgment and insight and has difficulty functioning alone and needs to be cared for 12 hours a day. The evaluation is remarkable for progressive cognitive decline. There has been no significant change in functioning compared to Uniform Assessment System evaluation completed. Personal care aide is not indicated for supervision or when no tasks are being performed. The information provided does not support a significant change in functional needs requiring an increase in personal care aide to 84 hours per week. The proposed increased personal care aide to 12 hours per day - 7 days per week - for a total of 84 hours per week is not indicated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Neck injury

Treatment: pain management: pain injection (62321 x [times] 1)

The insurer denied coverage for pain management pain injection (62321 x 1).

The denial is overturned.

This patient was involved in a motor vehicle accident.  The patient had a cervical epidural steroid injection (ESI) and had 50% (percent) pain relief which gradually improved to complete resolution. The patient sustained another neck injury 4 months ago.  The patient's medication trials have included Voltaren, Cyclobenzaprine, Ibuprofen and Ultracet.  The patient has had physical therapy. An electromyelogram (EMG) shows cervical (C)5-C6 radiculopathy. A magnetic resonance imaging (MRI) shows C6-C7 anterior disc bulge. The request was for a cervical epidural steroid injection.  The health plan turned down the Epidural steroid injection stating that therapy was not indicated beyond one year.

This is a new injury. Evidence-based clinical practice guidelines (1) support the use of epidural steroid injections without a one-year limitation.  Similarly, the utility of Epidural Steroid Injections is supported by a Cochrane review (2).  There is no evidence-based guideline that limits therapy to 12 months.

The injection is medically reasonable and necessary.

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

The medical necessity for pain management: pain injection (62321 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: CVA (cerebrovascular accident) with left hemiparesis, diabetes mellitus, hypertension, hyperlipidemia, and sacral decubitus ulcer
Treatment: Increase in home/personal care level 2 to 24 hours/day (split shift)
The insurer denied an increase in home/personal care level 2 to 24 hours/day (split shift).
The denial is overturned.

The patient is an adult female with a previous history of CVA (cerebrovascular accident) with left hemiparesis, diabetes mellitus, hypertension, hyperlipidemia, and sacral decubitus ulcer. Her level of functioning was noted as being bed-bound. It was also noted that she had frequent urinary incontinence and frequent UTIs (urinary tract infections). A final adverse determination denial was reviewed. At the time, the patient was receiving 84 hours/week. The request was for 24 hour/day (split shift). It was noted that the patient had bladder and bowel incontinence. She was totally dependent with meal preparation, housework, stairs, shopping, transportation, bathing, lower body dressing, locomotion, toilet transfer, toilet use. She had maximum assistance need for medication management, personal hygiene, and upper body dressing.

The requested increase in home/personal care level 2 to 24 hours/day (split shift) is medically necessary.

In this instance, the requested service increase is appropriate based on the severity of illness and intensity of services. This patient is bed-bound. This patient has sacral decubitus ulcers. She is hemiplegic. She has frequent urinary incontinence. She has frequent UTIs, thus, further increasing her urinary output and increasing her likelihood of skin breakdown. The increased hours are appropriate for the management of her chronic illnesses, and they will not be adequately managed if she remains at the current 84 hours/week schedule. She is at an increased risk for adverse clinical outcomes. The medical necessity is established.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Low Back Pain

Treatment: Pain injections (64483 x 1, 64484 x 1)

The insurer denied coverage for pain injections (64483 x 1, 64484 x 1)

The denial is overturned.

This patient has chronic low back pain.  The patient has had 3 prior spine surgeries. The patient has tried non-steroidal anti-inflammatory drugs (NSAIDs), Physical Therapy (PT) and activity modification. The patient had a Transforaminal Epidural steroid injection (ESI) in the Spring of this year, with good effect for 3 months.  The request is to repeat the ESI.  The health plan states that ESI are not indicated after 12 months.

Clinical practice guidelines (1) support the performance of Epidural steroids in post laminectomy patients. The policy cited by the health care plan misquotes the Veterans Administration (VA)/Department of Defense (DoD) guideline and Neurology guidelines.

The American Society of Interventional Pain Physicians (ASIPP) Clinical practice guideline states: "Post-surgery syndrome: The evidence for lumbar and cervical post-surgery syndrome based on one relevant, high-quality randomized controlled trial (RCT) with fluoroscopic guidance for caudal and cervical interlaminar epidural injections, with or without steroids, is Level II with moderate to strong recommendation for long-term improvement."  There is no one year time limit.

Both the VA/DoD guideline and the Neurology guidelines do not support the use of epidural steroids except for acute pain.  They do NOT address the use of ESI in chronic or post-laminectomy patients.  They also do NOT state that only one year of steroid is acceptable.

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

The medical necessity for pain injections (64483 x 1, 64484 x 1) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Cavitary mycobacterium avium pulmonary infection (MAC)
Treatment: Inhaled Liposomal Amikacin (Arikayce)
The insurer denied coverage for Inhaled Liposomal Amikacin (Arikayce).
The denial is Overturned.

The patient is an adult who was diagnosed with cavitary mycobacterium avium pulmonary infection (MAC). The patient had positive cultures on the bronchoalveolar lavage (BAL) specimen. Sensitivities revealed that this patient's MAC was sensitive to Clarithromycin, intermediate sensitivity to intravenous (IV) Amikacin and sensitive to Liposomal inhaled Amikacin (Arikayce). Generally, for MAC infections a triple therapy regimen which includes a Macrolide and Ethambutol and Rifampin/Rifabutin is recommended. However, for patients with cavitary MAC infection such as this patient it is recommended that Amikacin be included as initial therapy for the first few months.

In this patient, her MAC was sensitive to Inhaled Liposomal Amikacin and the organism was intermediate Sensitive to IV Amikacin.

Based on above it was appropriate to treat this patient with Inhaled Liposomal Amikacin (Arikayce).

Prior Denial is reversed.

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

Diagnosis: Chronic Urticaria

Treatment: Xolair 150 mg (milligrams) /ml (milliliters) syringe (procedure code J2357)

The insurer denied coverage for Xolair 150 mg (milligrams) /ml (milliliters) syringe (procedure code J2357)

The denial is overturned

The patient has been treated for chronic urticaria. The denial letter states that documents showing that leukotriene receptor antagonists (LRA) have been tried and failed. The appeal letter written by the patient's provider states that LRA are not approved by the Food and Drug Administration (FDA) for treatment of urticaria and that the patient has failed H1/H2 antagonists and has been treated with systemic corticosteroids over several months. The clinical narrative also states that the patient has taken 40 milligrams (mg) per day of Zyrtec without relief. The patient's provider argues that since LRA are not approved for chronic urticaria (CU) treatment, it is unreasonable to request LRA failure as a prerequisite for approving Xolair. A telehealth visit progress note and two in-person visit progress notes included. Both urticaria and angioedema are described.

While there have been some trials showing efficacy of montelukast in randomized control trials (RCT), no meta-analysis (Reference 2) has been performed to provide a strong evidence-based medicine basis for the use of montelukast in refractory chronic urticaria. In fact, European guidelines do not advise using LRA prior to proceeding with Xolair. The up-dosed antihistamine failure for this patient also suggests that the patient should proceed with Xolair treatment according to the European Association of Allergy & Immunology (EAACI)/World Allergy Organization (WAO) guidelines (2021).

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

The medical necessity for prescription drug Xolair 150 mg /ml syringe (procedure code J2357) to be filled by a specialty pharmacy on a date yet to be determined is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, Congestive Heart Failure, Coronary Artery Disease.

Treatment: for Personal Care Assistance services, 8 hours per day, 7 days per week (Monday through Sunday), a total of 56 hours per week.

The insurer denied coverage for Personal Care Assistance services, 8 hours per day, 7 days per week (Monday through Sunday), a total of 56 hours per week.

The denial is overturned.

This is a patient with chronic medical problems including diabetes, congestive heart failure, and coronary artery disease. The patient lives alone in a 1-bedroom apartment. The insurer approved Personal Care Assistance (PCA) services 27 hours/week. The request is for PCA services 56 hours per week, 8 hours per day, 7 days per week, leading to an external review. 
 
According to the Uniform Assessment System (UAS) report, the patient's cognition is described as moderately impaired. The patient reportedly requires maximal assistance for completing much of their Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. The patient reportedly requires maximal assistance for bathing. Extensive assistance is reportedly needed for personal hygiene, lower body dressing, locomotion, and toilet use. Limited assistance is reportedly needed for upper body dressing, toilet transfer, and ambulation. The patient is independent in bed mobility and eating. The patient is occasionally incontinent of the bladder and continent of the bowel. There have been no reported falls over the prior 90 days. 

The patient's ability to perform Activities of Daily Living (ADL) tasks and their self-sufficiency have reportedly declined and deteriorated, respectively, particularly since the patient's recent hospitalization. The patient's cognitive and functional abilities have declined when compared to the UAS report. Based on the records reviewed, the patient's cognitive and functional ability have significantly declined, which supports increasing PCA services to 56 hours/week. 

The healthcare plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. (Taken into consideration were the clinical standards of the plan, the information provided concerning the patient, the 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). 

From a physical medicine and rehabilitation perspective, PCA services, 8 hours per day, 7 days per week, a total of 56 hours per week is medically necessary.

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

The medical necessity for Personal Care Assistance services, 8 hours per day, 7 days per week (Monday through Sunday), a total of 56 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stage IV (4) Bulky Follicular Lymphoma
Treatment: Whole Body magnetic resonance imaging
The insurer denied Whole Body magnetic resonance imaging.
The denial is upheld.

The patient is an adult male with stage IV (4) Bulky Follicular Lymphoma. The attending physician has requested a total body MRI (magnetic resonance imaging) for surveillance purposes. Based on the physician's letter of medical necessity, a whole body MRI (magnetic resonance imaging) will decrease the patient's radiation exposure.

The requested health service is not medically necessary.

The standard assessment for NHL (Non-Hodgkin lymphoma) remains CT (computed tomography) scans. MRI (magnetic resonance imaging) is not supported for routine use of surveillance of treated non-Hodgkin lymphoma by the NCCN (National Comprehensive Cancer Network). The use of MRI (magnetic resonance imaging) for surveillance of treated lymphoma is not in line with accepted standards of practice as outlined by the NCCN (National Comprehensive Cancer Network. There is no documented reason that standard CT (computed tomography) scans cannot be used in this setting.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia. 
Treatment: Personal Care Assistance Service, a total of 70 hours per week. 
The insurer denied Personal Care Assistance Service, a total of 70 hours per week. 
The health plan's determination is overturned. 

This is a case review for a female with medical history notable for dementia and chronic low back pain. The patient's physician provided a letter of support for this appeal. The letter states that the patient's mobility has been significantly compromised due to lumbar disease. She is having difficulty with walking even short distances due to pain. This has impacted her ability to complete activities of daily living. 

The requested Personal Care Assistance Services: Total of 70 Hours per Week is medically necessary for this patient. 
The patient is of advanced age and has multiple musculoskeletal conditions which contribute to age-related debility and limited ability to perform activities of daily living. Her functional status is complicated by dementia. Both conditions are progressive and likely to continue to worsen in the future. The patient has multiple documented falls when attempting to complete personal care tasks independently. These falls have resulted in emergency department visits and hospitalizations. These falls are evidence of unmet personal care needs. The task tool can be seen as a starting place for personal care assistance hours, but if a patient has evidence of unmet personal care needs, additional hours should be granted as medically necessary. Her true level of need is likely underestimated by the Uniform Assessment System (UAS). Therefore, the requested 70 hours per week is medically necessary for the patient. This will allow her to receive care for both her scheduled and unscheduled personal care needs throughout the day.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Neuromyelitis Optica.
Treatment: Enspryng.
The insurer denied Enspryng.
The determination is overturned.

The patient is a male with Neuromyelitis Optica and Crohn's disease. Treatment with Ensuring is the subject of this review. The drug was denied because documentation was lacking concerning details about the patient's diagnosis and laboratory studies. The provider appealed the determination. At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

The formulary drug will not be as effective as the requested nonformulary drug. The patient is requesting treatment with Ensuring for neuromyelitis optica. The drug was previously denied because there was no documentation that the patient has Neuromyelitis Optica spectrum disorder. However, the letter of appeal demonstrates that the patient is diagnosed with this demyelinating disorder. Additionally, the physician has confirmed that the patient has. anti-Aquaporin (AQP) 4 antibodies. The patient has also had a history of acute myelitis and optic neuritis. There is no documentation to suggest that the drug will be used in combination with her biologics. The patient has previously tried and failed oral immunosuppressive drugs, and biological agents for the treatment of Crohn's disease.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Multiple Sclerosis
Treatment: Formulary Exception for Kesimpta
The insurer denied: Formulary Exception for Kesimpta
The denial is overturned.

The patient is an adult female with multiple sclerosis. The provider wishes to prescribe Kesimpta. The patient is John Cunningham virus (JCV) positive with titer of 3.98. The request was previously denied as the patient has not tried formulary alternatives including Aubagio, Betaseron, Copaxone, dimethyl fumarate, fingolimod, glatiramer acetate, Glatopa or Tysabri.

The health plan should cover the proposed treatment.

The patient requires high efficacy treatment to prevent disease activity and progression. None of the disease modifying therapies (DMTs) on the preferred list, with the exception of Tysabri, are high efficacy. Tysabri would not be appropriate for this patient given the John Cunningham virus (JCV) positive status. Kesimpta is considered a high efficacy disease modifying therapy and it has been shown in the literature that early treatment with high efficacy disease modifying therapy increases the risk of having no evidence of disease activity (NEDA).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right knee/thigh pain. 
Treatment: Inpatient Hospital Stay. 
The insurer denied the Inpatient Hospital Stay. 
The determination is upheld. 

This is a male patient who presented to the emergency department (ED) with a complaint of worsening right knee/thigh pain. The records indicate that he had previously been hospitalized for a right thigh abscess and had been treated with interventional radiology drainage of the abscess and antibiotics. He was discharged from this prior admission. His past medical history includes human immunodeficiency virus (HIV) infection, diabetes, prior deep vein thrombosis (DVT), and chronic hepatitis B. The ED and orthopedic surgery history and physicals (H&Ps) indicate that the initial vital signs identified an elevated heart rate of 122/minute with normal blood pressure and oxygen saturation. At the time of surgical assessment, the right knee was swollen and tender. There was an existing drain in the right anterior thigh connected to a collection bag.A computed tomography (CT) scan showed a right knee fluid collection and a right thigh abscess that had been previously imaged. 
He was admitted to the hospital. He was treated with antibiotics. The orthopedic service evaluated the patient and he underwent interventional radiology (IR) drainage of the right knee fluid collection. His diet was advanced following this intervention. He was discharged from the hospital with instructions for short term outpatient orthopedic follow up and continued oral antibiotics. 
At issue is the medical necessity of an inpatient stay. 
Inpatient care was not medically necessary per the submitted Milliman Care Guidelines (MCG) or medical standards for this patient. 
The care and treatment provided during this time could have been rendered with a lower level of care. This patient presented to the ED having been sent from an outpatient clinic. He was hemodynamically stable at the time of presentation. While the heart rate was elevated at the time of presentation, this normalized on subsequent assessment. He was able to tolerate a diet. He was provided pain medications and antibiotics. He remained clinically stable throughout the period of monitoring. He underwent an IR aspiration of the right knee procedure  and responded favorably to this intervention such that he was considered stable for discharge following the procedure.