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

Diagnosis: Dementia
Treatment: Increase in personal care services from 70 hours to 24 Hour(s) per Day (Split Shift) 
The insurer denied: Increase in personal care services from 70 hours to 24 Hour(s) per Day (Split Shift) 
The denial is: Upheld

The patient is a female with medical history notable for incontinence and dementia. The patient was approved for 56 hours per week of level 2 personal care services. The patient and her care team requested an increase to 24 hours per day split shift which was denied by the health plan. They approved an increase to 70 hours per week.

A Uniform Assessment System (UAS) was completed and was available for review. The assessment was completed via telemedicine with the patient's daughter present. The patient lives alone in her apartment. She was alert and oriented to person and place only. Her memory was minimally impaired and she had 0/3 recall at five minutes. She is not self-directing and not able to call for help in the case of emergency. For her Instrumental activities of daily living (IADLs), she requires total dependence for meal preparation, housework, shopping, and equipment management. She requires maximal assistance for finances, medications, and transportation. For her activities of daily living (ADLs), she requires total dependence for bathing and dressing lower body. She requires maximal assistance for dressing upper body, walking, locomotion, toilet transfer, and toilet use. She requires extensive assistance for hygiene and bed mobility. She is frequently incontinent of urine and uses pull-ups for incontinence care. She is continent of stool. The patient has a history of multiple falls over the previous year. She uses a wheelchair and relies on others for transport. No pressure ulcer was present at the time of evaluation, although the problem list does state that she has a history of sacral pressure ulcer. Compared with a prior UAS, she showed a decline in functional cross multiple domains. A task tool associated with the assessment recommended 51.3 hours per week to address her personal care needs, an increase from 46.1 hours on prior assessment.

The requested health service of increase in personal care services from 70 hours to 24 Hour(s) per Day (Split Shift) has not been clearly demonstrated to be medically necessary for this patient.
The patient has dementia, gait dysfunction, and incontinence. There are no medical records or letters of necessity which document unmet personal care needs at her current (recently increased) allotment of 70 hours per week. She does require hands on assistance for nearly all ADL's but is has not been clearly established that she would require split-shift 24 hour services. Split-shift care is warranted when patients have personal care needs that require continuous care throughout the day and night, such as turning and repositioning every 2 hours for pressure ulcers. There is no documentation to establish that medical need.
She is not capable of directing her own care or calling for help in an emergency, but safety monitoring is not a covered personal care service in the absence of another functional need.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Myopathy
Treatment: L2999 lower extremity orthoses, right ottobock C (cervical) brace
The insurer denied coverage for L2999 lower extremity orthoses, right ottobock C-brace
The denial is upheld

This is an adult with reported myopathy and difficulty walking.  Under review is the medical necessity of requested L2999 lower extremity orthoses, right ottobock C-brace.

The requested C-Brace is a microprocessor-controlled knee-ankle-foot (KAFO) orthosis that electronically controls the flexion and extension of the knee joint. The C-Brace attempts to control both swing and stance phases of gait during ambulation. The C-Brace holds promise for improving gait in individuals with lower extremity weakness due to neuropathy and/or myopathy. However, current literature studies tend to be small scale, poorly controlled and largely funded by the manufacturer.  In this particular case there is no documented evidence that a conventional KAFO with concurrent physical therapy would not meet the functional needs of this individual. 

The scientific evidence in peer-reviewed literature does not specifically support a result of improvement in health outcomes in this particular case.  

The L2999 lower extremity orthoses, right ottobock C-brace has approval from the appropriate regulatory bodies for this diagnosis. 

This patient is not proven to be a good candidate for L2999 lower extremity orthoses, right ottobock C-brace.

The L2999 lower extremity orthoses, right ottobock C-brace has not been proven as the best available treatment for this patient at this time.

There are no specific adverse risks increased over standard treatment/services.

The requested service has not been proven as likely to be more beneficial than any of the standard treatments/procedures for this patient.

In summary, the denial of L2999 lower extremity orthoses, right ottobock C-brace and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Myopathy
Treatment: L2999 lower extremity orthoses, right ottobock C-brace
The insurer denied coverage for L2999 lower extremity orthoses, right ottobock C-brace
The denial is upheld

According to the documentation submitted, this is a patient with a history of myopathy. The Progress Note stated that the patient's chief complaint was weakness, and difficulty walking. The note stated that the patient is at high risk for falling during ambulation due to poor control of the knee in extension related to the weakness, and the foot drop; The patient could hardly walk for 5 min without resting, and has been falling. The records show a diagnosis of myopathy, weakness and knee instability. The patient had an Orthotic evaluation and trial of a C-brace for the right lower extremity.

The orthosis has been shown to be effective for certain clinical conditions. 

The device has approval from the Food and Drug Administration (FDA).

A search was performed utilizing the National Library of Medicine. The key word was microprocessor knee prosthesis. There were several references. The scientific literature has demonstrated benefit of the prosthesis for a select group of individuals. These include physiologic young working people who require the device for uneven surfaces and need to decrease their oxygen requirement due to high demand. (The K4 ambulator). The prosthesis is accepted and utilized by the practicing medical community for these individuals. The records show no evidence of amputation. The employment status and general activity were not reported. There was no documentation to him being a K4 ambulator .There was no reason why a standard KAFO ()with knee lock could not be provided. 

Is L2999 lower extremity orthoses, right ottobock C-brace is not the best available treatment for this patient at this time. 

The reported problems are compliance, breakdown and weight. 

In summary, the denial of L2999 lower extremity orthoses, right ottobock C-brace and coverage for the requested treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not  substantially increased over standard treatments.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Migraines
Treatment: Botox injections
The insurer denied coverage for Botox injections
The denial is upheld

 
This case involves a teenager under review for Botox injections. Neurologic reevaluation reported the patient presented regarding headaches that started years ago. Past treatment included naproxen, amitriptyline, magnesium, vitamin B2, and infusions. It was noted prior magnetic resonance imaging (MRI) of the brain was unremarkable. The treatment plan included a Botox injection.  A Botox injection was performed. Follow-up reported the patient continued to do poorly. Follow-up reported the patient did not notice any relief from Botox therapy. The clinical note reported an increase in frequency and intensity of headaches since discontinuing Botox. The patient had over 17 severe headaches a month. The procedure report reported the patient was given Botox injections. A letter reported the patient had at least 50% (percent) improvement in symptoms after a second round of injections.

Botox is not considered medically necessary for the patient. This patient is a teenager. Current scientific literature does support Botox for treatment of migraines. The practice guideline for pediatric migraine prevention notes that there are insufficient data to determine whether Botox is superior to placebo in adolescents. Up to Date similarly states, "there is evidence from randomized controlled trials that botulinum toxin injections with onabotulinumtoxinA decrease the number of headache days in adult patients with chronic migraine, as reviewed separately (see "Chronic migraine", section on 'Botulinum toxin'). However, the benefit in children is unclear. A systematic review of seven studies involving 110 children showed modest reductions in headache frequency, duration, and intensity among responders. However, the quality of the evidence was low, and the results of the lone randomized trial included showed no benefit over placebo." In addition, the patient reported inconsistent results with Botox injection. As such, ongoing use of Botox would not be considered medically necessary for this patient.

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for Botox services is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
treatment: Wegovy
The insurer denied Wegovy. The health plan's determination is upheld. 

This is a female patient who has been prescribed Wegovy. The patient's weight is 278 lbs (pounds). No other clinical information was provided. No medical records were provided for review.

A formulary exception is not indicated in this case. There are no medical records available to review. There is no documentation to prove that the patient has tried non-medical methods to lose weight for at least 3 months. Also, there is no documentation of the patient's body mass index (BMI). Wegovy is not indicated for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Heart failure, hypertension, and coronary artery disease.
Treatment: Increase Home Care/Personal Care (HHC) Level II per 15 Minutes to 84 Hours per Week.
The insurer denied: Increase Home Care/Personal Care (HHC) Level II per 15 Minutes to 84 Hours per Week.
The denial is overturned.

This elderly male patient has conditions including heart failure, hypertension, and coronary artery disease. The denial of an increase in personal care to 84 hours per week is being appealed. The health plan approved 42 hours per week.
Uniform Assessment System (UAS) evaluation completed last month shows modified independent cognition and functional status: total dependence with housework; maximal assistance with shopping and transportation; extensive assistance with meal preparation, managing finances and medications, phone use, bathing, lower body dressing, and locomotion; limited assistance with upper body dressing, personal hygiene, and toileting; and supervision with eating. The patient has infrequent bladder incontinence. He has had one fall in past 30 days. Compared to Uniform Assessment System evaluation performed last year, there has been a decline with housework, locomotion, and toileting. A letter from the Provider notes the patient is homebound. He is frequently confused, disoriented and incontinent. He is unable to stand or ambulate without assistance and he needs assistance with activities of daily living (ADLs). He recently had COVID(Coronavirus disease) and has deteriorated since. He lives alone. The provider is recommending split shift care.

The proposed treatment is 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. The denial of an increase in personal care to 84 hours per week is being appealed. The health plan approved 42 hours per week. Uniform 
Assessment System (UAS) evaluation completed last month shows the patient requires assistance with all activities of daily living, except eating. He has infrequent bladder incontinence. Compared to Uniform Assessment System evaluation performed last year, there has been a decline with housework, locomotion, and toileting. An appeal statement from the patient's provider supports the need for assistance with all activities of daily living and indicates that the patient's function deteriorated since being diagnosed with COVID. The information provide show that this patient has significant limitations in functioning. The approved personal care services of 42 hours per week is insufficient to meet this patient's needs for assistance with activities of daily living. The proposed increase to 84 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  History of Mild Aortic Stenosis.
Treatment: Transthoracic Echocardiogram.
The insurer denied the Transthoracic Echocardiogram.
The determination is overturned.

This is a male patient with a history of hypertension, hyperlipidemia, type 2 diabetes, peripheral arterial disease, duodenal ulcers, gastrointestinal bleed and a bilateral below the knee amputation. When evaluated, a systolic murmur suggestive of aortic stenosis was auscultated. An electrocardiogram showed sinus tachycardia with nonspecific repolarization abnormalities. A transthoracic echocardiogram was recommended. A note from the office nurse documented that she had spoken with the patient's daughter and confirmed that the patient had not had any prior echocardiograms. It also indicated that he has been experiencing intermittent chest pain and dyspnea. The medical necessity of the echocardiogram is under review.
Based on the documentation provided a transthoracic echocardiogram is medically necessary.
This patient has a systolic murmur consistent with aortic stenosis. He has not had a prior echocardiogram. Per the 2020 American College of Cardiology (ACC) / American Heart Association (AHA) Guideline for the Management of Patients With Valvular Heart Disease, " A comprehensive transthoracic echocardiogram with 2-dimensional (2D) imaging and Doppler interrogation should be performed for diagnosis and evaluation of known or suspected valvular heart disease." In patients with signs or symptoms suggestive of aortic stenosis transthoracic echocardiography (TTE) allows for assessment of the severity of stenosis as well as valvular anatomy, measurement of left ventricular size and function, and is useful in determining prognosis and guiding therapy. Moreover, this patient has complaints of chest pain and dyspnea. Particularly given his multiple risk factors there is concern for a potential cardiac etiology for these symptoms. Per the American College of Cardiology Foundation (ACCF) / American Society of Echocardiography (ASE) / American Heart Association (AHA) / American Society of Nuclear Cardiology (ASNC) / Heart Failure Society of America (HFSA) / Heart Rhythm Society (HRS) / Society for Cardiovascular Angiography and Interventions (SCAI) / Society of Critical Care Medicine (SCCM) / Society of Cardiovascular Computed Tomography (SCCT) / Society for Cardiovascular Magnetic Resonance (SCMR) 2011 Appropriate Use Criteria for Echocardiography, a transthoracic echocardiogram (TTE) is recommended and appropriate in this situation-symptoms or conditions potentially related to suspected cardiac etiology including but not limited to chest pain, shortness of breath, palpitations, transient ischemic attack (TIA), stroke, or peripheral embolic event.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Sarcoidosis
Treatment: Xeljanz
The insurer denied Xeljanz.
The determination is upheld.

This is a patient with a request for Xeljanz. The patient has sarcoidosis. She has tried Remicade, Cellcept, Methotrexate, Imuran and Prednisone. At issue is whether Xeljanz 11 milligrams (mg) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Xeljanz is not more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease. Other standard therapies include tumor necrosis factor (TNF) alpha agents such as Humira.

Damsey et al describes a small study of 10 patients only: "Sarcoidosis is an idiopathic inflammatory disorder that is commonly treated with glucocorticoids. An imprecise understanding of the immunologic changes underlying sarcoidosis has limited therapeutic progress. Here in this open-label trial (National Clinical Trial (NCT) 03910543), 10 patients with cutaneous sarcoidosis are treated with tofacitinib, a Janus kinase inhibitor. The primary outcome is the change in the cutaneous sarcoidosis activity and morphology instrument (CSAMI) activity score after 6 months of treatment. Secondary outcomes included change in internal organ involvement, molecular parameters, and safety. All patients experience improvement in their skin with 6 patients showing a complete response. Improvement in internal organ involvement is also observed. Custer of differention (CD4) + T cell-derived interferon gamma (IFN-) is identified as a central cytokine mediator of macrophage activation in sarcoidosis. Additional type 1 cytokines produced by distinct cell types, including interleukin (IL)-6, IL-12, IL-15 and granulocyte-macrophage colony-stimulating factor (GM-CSF), also associate with pathogenesis. Suppression of the activity of these cytokines, especially IFN-, correlates with clinical improvement. Our results thus show that tofacitinib treatment is associated with improved sarcoidosis symptoms, and predominantly acts by inhibiting type 1 immunity." In this case, there are not head to head studies to show that Xeljanz is more effective than more established therapies.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Sarcoidosis
Treatment: Xeljanz
The insurer denied Xeljanz.
The determination is upheld.

This is a female patient with sarcoidosis who had previously tried and failed Cellcept, methotrexate, Imuran, prednisone, and Remicade. She continues to have enlarged lymph nodes, pulmonary symptoms, and arthritis. At issue is whether Xeljanz 11 milligrams (mg) is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

The proposed health service or treatment Xeljanz 11 mg is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

This patient has sarcoidosis and had previously tried and failed Cellcept, methotrexate, Imuran, prednisone, and Remicade. She continues to have enlarged lymph nodes, pulmonary symptoms, and arthritis. However, although there are case reports of using Xeljanz for sarcoidosis, there is no high-quality study demonstrating that it is effective and safe for the treatment of sarcoidosis.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Obstructive Sleep Apnea
Treatment: Sleep Study
The insurer denied the sleep study.
The health plan's determination is overturned.

The patient is a female who is seeking approval for a sleep study. This was originally denied due to lack of symptoms. From the visit with her provider, it noted asthma, obstructive sleep apnea (OSA) history and bariatric surgery. 

The health plan did not act reasonably in its decision and did not practice sound medical judgment.

The requested health service is medically necessary. The patient needs to be evaluated with the sleep study and Multiple Sleep Latency Test (MSLT) due to sleepiness work up. She lost weight and may have idiopathic hypersomnia, but her symptoms are well documented and the testing is appropriate. She has a 10 year history of excessive daytime sleepiness. She was on continuous positive airway pressure (CPAP) previously but was having issues with it. She had an Epworth score of 13. A sleep study and follow up MSLT were ordered to assess sleepiness. She was stopped on medications which would make her sleepy.

The health plan's determination is overturned in whole.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraines
Treatment: Nurtec 75 mg (milligram) oral disintegrating tablet
The insurer denied Nurtec 75 mg oral disintegrating tablet.
The determination is overturned.

The patient is a female with chronic migraines. Treatment with Nurtec oral disintegrating tablet (ODT) is requested for acute migraines. The member has tried and failed Ubrelvy, Imitrex, and Relpax. Nurtec ODT was denied because the patient has not tried and failed Ubrelvy. The provider appealed the determination.
The health plan's determination in overturned in whole.
The requested Ubrelvy has been ineffective. The progress notes submitted for review indicate that the member has tried and failed Ubrelvy, Imitrex, and Relpax for treatment of acute migraine.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Congestive Heart Failure
Treatment: Long term acute care
The health plan denied Long term acute care. The denial is upheld.

The patient is an adult male with history of chronic respiratory failure on supplemental oxygen, atrial fibrillation on Eliquis, CHF (congestive heart failure), endocarditis status post tricuspid valve replacement with acute on chronic hypoxic respiratory failure who is being treated for CHF (congestive heart failure). The patient is on supplemental oxygen. The patient is being optimized from CHF (congestive heart failure) as well, as other home medications are resumed. The request is for LTACH (long term acute care hospital). This was denied coverage by the health plan due to lack of medical necessity. This denial is being appealed.

The patient has acute on chronic hypoxic respiratory failure, and he is on high flow oxygen. The patient also has chronic pain syndrome and is on chronic pain medications. The patient is able to tolerate oral diet. The patient is able to participate in physical therapy and occupational therapy. The patient is being diuresed with IV (intravenous) Lasix as needed. The patient is not on any invasive drips. The oxygen levels are above 92%. The patient is not receiving any treatment that could not be safely provided at a lower level of care. The requested long term acute care is not medically necessary.