Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

This is a male patient with chronic low back pain. His pain was described to be constant, aching, and throbbing discomfort that worsened with increased physical activity, including bending, and walking. The patient described the pain to negatively impacting his activities of daily living (ADLs). A magnetic resonance imaging (MRI) was performed that revealed Modic changes in the vertebral end plates. A request for an Intracept procedure was made.

Based on the review of the literature on Intracept Procedure of the treatment of chronic low back pain, currently there are no large long-term studies that show evidence of the benefit of this procedure for this patient. The patient had no clear Modic changes noted at vertebral levels L4-L5 on the magnetic resonance imaging (MRI). And while the patient had Modic changes noted at vertebral levels L5-S1, there was not indication that that patient's pain was stemming from L5-S1 segment. Becker et al. (2017) noted in their study of patients with Modic changes confirmed by discography to determine the affected levels. For those who had Modic type I or II changes and positive confirmatory discography, the study showed that the ablation of the basivertebral nerve (BVN) for the treatment of chronic lumbar back pain significantly improved patients' self-reported outcome early in the follow-up period, and this improvement persisted throughout the 1-year study period."  

In this case, the patient did not have a discography confirmation that the L4-S1 levels were the affected, pain generators. Without this confirmation, this patient was not a good candidate for the Intracept Procedure. In addition, the Intracept Procedure does not have final approval from the appropriate regulatory bodies for this diagnosis. As noted above, not for this particular cohort. 

The Intracept Procedure is not likely to be more beneficial than any of the standard treatments/procedure for this patient.

The carrier's denial of coverage for the Intracept Procedure should be upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Digestive System/Gastrointestinal
Treatment: Inpatient Hospital
The insurer denied: Inpatient Stay
The denial is: Upheld in whole

The patient is a female who presented to the emergency room (ER) with severe abdominal pain and decreased ostomy output and no flatus in the ostomy bag. A computed tomography (CT) scan was obtained which did not demonstrate "acute gastrointestinal (GI) related changes." Vitals were within normal limits with the exception of high blood pressure. The patient was hospitalized and given GoLYTELY and had a large bowel movement several hours later and was discharged home.
The subject under review is the medically necessity of the inpatient stay.

The health plan's determination is upheld in whole. 

No, the requested health service/treatment of inpatient stay is not medically necessary for this patient. The patient was only briefly admitted to the hospital and given laxatives to induce a bowel movement and then discharged. The patient did not have a severity of illness that required the intensity of service for inpatient admission. No high acuity services appear to have been rendered to the patient. The patient did not require complex testing or intense monitoring. There is no evidence that the treating team identified any conditions or problems that in their judgement would have made an observation level of care inappropriate. There is no documentation of complicating events or special circumstances that would have made care at a lower level status unsafe.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis Cerebral Palsy
Treatment Sprint Plus APS car seat
The insurer denied the Sprint Plus APS car seat
The determination is upheld

The patient  has a diagnosis of cerebral palsy and is non-ambulatory. She uses a wheelchair for ambulation, increased muscle tone. Her height is documented at 43 inches (") and her weight at 43.5 pounds (lbs) According to the appeal information submitted by the patient's mother, the patient "cannot move at all and cannot support her own weight and putting her in a car without a car seat would be putting her life in danger."
Available records include the New York State Medicaid Program Durable Medical Equipment, orthotics, prosthetics, and supplies procedure codes and coverage guidelines, appeal request for review from 4/6/20 by People First Mobility, documentation regarding the requested piece of equipment which is the Sprint APS [all positioning system] Plus, vehicle restraint system, letters documenting the denial notice sent to patient's parent, adaptive equipment assessment and prescription services from Elmwood Health Center  which documents the patient's height/weight/physical exam and the parent's current system of holding the patient in the back seat while driving without using a car seat. At issue is the medical necessity of the Spirit plus all positioning system (car seat).

The requested equipment of Sprint plus all positioning system (car seat) is not medically necessary for this patient. The patient's height is documented to be 43 inches (") and her weight is at 43.5 pounds (lbs). The request for the Sprint APS car seat states that the patient is too large for pediatric commercial car seats, however, the American Academy of Pediatrics recommends car seats for all children of this height/weight and there are commercially available car seats that can accommodate this height and weight. No clinical documentation regarding why a standard car seat with 5-point restraints is inadequate to meet the patient's needs. The patient's mother's statement that it is unsafe for the patient to be driven with no car seat is correct, however, there is no documentation that standard car seats have been trialed and found to be inadequate.
The use of a car seat in accordance with the American Academy of Pediatrics is necessary, however, this can be accomplished with a standard car seat.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Rh D Suppression
Treatment:  RhoGAM
The insurer denied the RhoGAM.  The denial is overturned.

The treatment with RhoGAM is medically necessary. 

The patient is a G1 female, known to be Rh (rhesus factor) negative.  She did not receive her antenatal Rh immune globulin on time at 28 weeks.  Her provider is requesting coverage of the antenatal Rh immune globulin at 37 weeks.  

The timing of administration of antenatal Rh immune globulin is arbitrary and was determined based on optimal cost effectiveness.  In other countries it is given multiple times during pregnancy.  The basis of its effectiveness is that it prevents antenatal sensitization of the mother from the small number of fetal cells that enter the maternal circulation during pregnancy.  It is not possible to establish efficacy at every single gestational age, but it becomes effective at this process as soon as it is administered.  Therefore, administration at any gestational age is likely to yield some degree of benefit.  The consequences of red cell alloimmunization, which is prevented by the antenatal use of Rh immune globulin, can be catastrophic and can lead to severe brain and other organ injury to fetuses in subsequent pregnancy, as well as fetal death and prematurity due to the severe intrauterine hemolysis.  Prevention of this process by antenatal and postnatal Rh immune globulin is a major public health victory of preventive medicine.  Therefore, this intervention is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Angioedema
Treatment: Inpatient Hospital  The insurer denied inpatient hospital stay
The determination is upheld.

The patient has a past medical history (PMH) of morbid obesity, idiopathic angioedema and hypertension (HTN) and admitted  with complaints of (c/o) lip swelling without shortness of breath (SOB), wheezing, chest pain, tongue swelling or a sensation of throat closing. Vital signs were remarkable for oxygenation 98%. The physical exam was notable for no apparent distress (NAD), lungs clear to auscultation bilaterally (CTAB), normal/unlabored respiratory effort, left-sided lip swelling without stridor. Lab work was unremarkable. The patient was diagnosed with angioedema and treated with SoluMedrol, Benadryl, and famotidine. There was no concern for airway compromise on admission. The patient was discharged in stable condition. At issue is the medical necessity of an inpatient stay.
The inpatient stay was not medically necessary. This patient with a known history of angioedema presented to the emergency department (ED) with complaints of (c/o) lip swelling. There was no actual or impending airway compromise, unstable vital signs, hypoxia, respiratory distress or respiratory failure, progression of allergic reaction/angioedema while undergoing treatment, hypotension, acute coronary syndrome (ACS), hoarseness or need for intravenous (IV) vasopressors. This patient was stable and was  treated with IV steroids and antihistamines, which could have been safely provided at a lower level of care, which is also consistent with the physician documentation provided.
Appeal type: Medical necessity
Decision: Overturned

Substance Abuse/Addiction
Substance Abuse: Residential
Diagnosis: Substance Abuse
Treatment: Inpatient Rehab. 
The insurer denied the inpatient rehab. 
The health plan's determination is overturned. 

The patient is a male who was admitted on for residential treatment of co-occurring substance use disorders with cannabis, cocaine and alcohol class substances of abuse, as well as an anxiety disorder with associated symptoms of depression and insomnia. The patient has a history of escalating use of substances with progression of the substance use disorders and increasing symptoms related to the co-morbid psychiatric condition including irritable dysphoria that triggers the substance use. 

Residential Substance Use Disorders Treatment on the days in question is medically necessary for this patient. The patient's severity of substance use disorder, risk of relapse, and lack of sober supports do support the medical necessity for an admission and continued treatment at the acute residential level of care. The patient could not have been effectively treated at a lower level of care during the time interval under review, and does meet medical necessity for the continued residential level services in keeping with prevailing standards of medical practice, ASAM Criteria, and the Scientific Literature, referenced below, as well as NY State instruction and application of NY State Office of Alcoholism and Substance Abuse Services (OASAS) Level of Care for Alcohol and Drug Treatment Referral (LOCADTR) 3.0 Criteria.
Moreover, the patient's lack of insight and coping skills as well as co-morbid psychiatric condition are factors that warranted the Continued Inpatient Residential Treatment Center Services. The need for a disposition with continued involvement with recovery groups and to facilitate sober supports are other factors that support the necessity for the Continued Inpatient Residential Treatment Center Services.
Appeal type: Medical necessity
Decision: Upheld

Dx: Cancer
Tx: Radiation Therapy
Denied: Proton Beam Therapy
Denial: UPHELD in whole

This is the case of a female who presented with rectal cancer. She is also status/post (s/p) total abdominal hysterectomy (TAH) followed by chemotherapy and radiation therapy. For the rectal cancer she was treated with chemotherapy. She has persistent rectovaginal fistula and rectovesical fistula. She has progression of disease. The subject under review is the medical necessity for proton beam therapy.

The health plan's denial is upheld in whole.

The requested health service/treatment of outpatient proton beam radiation therapy is not medically necessary for this patient.
This patient has advanced rectal cancer with fistula. She has progression of disease in abdomen-pelvis as well as inguinal adenopathy. The patient had prior radiation. Radiation side effects decay each year and 34 years have passed since radiation. The details of previous radiation therapy (RT) treatment are not available. Not disregarding previous RT, the plan is to consider short palliative RT which can be done using routine techniques in this patient who has widespread recurrent disease. This is a palliative situation and proton beam is not medically necessary. Medically necessary treatment is defined as treatment which is in accordance with generally accepted standards of medical practice in the United States. Proton beam for palliation is not in accordance with generally accepted standards of medical practice in the United States. This patient has advanced recurrent disease and likely needs palliative radiation therapy (RT) which can be done with conventional RT techniques. Proton beam is not medically appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia
Treatment: Increase in personal care assistance hours from 84 hours per week to split shift (24 hours/ (2) 12 hour shifts.  
The health plan denied an increase in personal care assistance hours from 84 hours per week to split shift (24 hours/ (2) 12 hour shifts.
The determination is overturned.

This is a patient with a past medical history of dementia, osteoarthritis, atrial fibrillation, hypertension, constipation, schizophrenia, anxiety, urinary incontinence and recurrent falls who had been assigned personal care assistant (PCA) services 12 hours/day, 7 days/week to total 84 hours/week based on assessment tool. The patient has two daughter who alternated days provided her care the 12 hours when the PCA was not there. Both of the daughters are unable to provide care any further due to their own medical issues. The patient had a fall when the aide and daughter were assisting patient to her bed when she slid and fell. No medical evaluation was needed. PCA services 24 hours/day in split-shifts were requested and patient had assessment tool performed again 0. The patient was noted to have moderately impaired cognitive skills. The patient was noted to have declined in the tasks of meal preparation, ordinary housework, shopping, personal hygiene, dressing upper extremities and bed mobility compared to prior  assessment. The patient was noted to improve in tasks of managing medications, stairs and toilet use. It was noted the patient required physical guidance with rising from seated position, getting in and out of bed and with ambulation throughout the home. The patient's Mini-Mental State Examination (MMSE) was 11/30; it had been 21/30. The insurer denied coverage for 24 hour/day in split shift, 7 days/week. The patient's primary care physician (or provider) (PCP) wrote a letter stating the patient had sundowning due to her dementia which caused her to confuse day and night hours, which led her to be awake most nights for periods of time. During the night time hours, the patient needs assistance with tasks of bed mobility, toileting, toilet transfer and incontinence cares. The PCP also noted that the patient had to be persuaded to keep her diaper on and due to underlying constipation required frequent trips to the bathroom as well as requiring help with tasks of locomotion, walking and meal preparation during the night hours. The patient's legal advocate provided a letter summarizing the letter from the PCP and again noted that the two daughters who had been caring for their mother the 12 hours when there were no PCA service coverage were no longer able to provide care due to their own medical issues. At issue is the medical necessity of personal care assistance hours from 84 hours per week to split shift (24 hours/ (2) 12 hour shifts
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Type II diabetes
Treatment: Invokana
The insurer denied the Invokana.  The denial is upheld.

The health plan should not cover the Formulary exception for Invokana.

The patient is a male with type II diabetes. He has been successful on Invokana with improvement in his A1C (glycated hemoglobin). Request for Invokana is under review. 

This patient is on Invokana, a sodium-glucose cotransporter-two inhibitor. The formulary alternatives are Farxiga and Jardiance. These alternatives are in the same class as Invokana. This patient does not have a documented trial of these alternatives or documented contraindication to these alternatives. Farxiga and Jardiance are expected to have the same efficacy and safety as Invokana. The American Diabetes Association clinical guidelines do not recommend the use of Invokana over Farxiga and Jardiance. Therefore, no, the health plan should not cover the Formulary exception for Invokana.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Psoriatic arthritis.
Treatment:  Xeljanz.
The insurer denied Xeljanz.  The denial is overturned.

The proposed Xeljanz XR is medically necessary.

The patient is a male with severe psoriasis and psoriatic arthritis.  He failed treatment with the disease-modifying anti-rheumatic drugs (DMARDs) Otezla, leflunomide, methotrexate, sulfasalazine, as well as the biologics Remicade, Cosentyx, Humira, Enbrel and Stelara.  The attending physician now wishes to treat with Xeljanz XR as monotherapy, which has a different mechanism of action from prior therapies.  Appeal is for Xeljanz XR for the treatment of psoriatic arthritis.

Xeljanz XR is FDA-approved for the treatment of psoriatic arthritis, as seen in this patient, when used in combination with non-biologic DMARD therapy.  This patient has already failed treatment with numerous non-biologic DMARDs and biologic therapies, as enumerated above.  Therefore, it is not clinically appropriate at this juncture to mandate that Xeljanz XR be prescribed in combination with a non-biologic DMARD in a patient who has already failed treatment with multiple non-biologic DMARDs.  Furthermore, Xeljanz XR may be safely and effectively be used as monotherapy for the treatment of rheumatoid arthritis.  Therefore, the proposed Xeljanz XR monotherapy for the treatment of psoriatic arthritis in this specific patient is clinically appropriate and in accordance with standard of care in the rheumatology community, and, thus, is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acquired hallux interphalangeus of the left foot

Treatment: Custom Shoe Inserts (L3000)

The insurer denied coverage for Custom Shoe Inserts (L3000). The denial is upheld. 

This patient is a male with a history of a left foot phalanx fracture.  The patient had been treated with a cam walker boot and power step inserts.  The patient had used the over-the-counter inserts without much improvement.  The patient had tenderness in the area of the distal phalanx lateral base.  Hallux interphalangeus was noted at left hallux.  The patient's diagnoses included acquired hallux interphalangeus of the left foot, and pain in the left foot.  The patient's x-rays revealed no acute fracture or dislocation, and there was no significant arthritic change or osseous abnormality.

Although custom orthotics is utilized for various foot related pathologies and biomechanical instability, there is limited data/research to show benefit for patient's dealing with an issue at the hallux interphalangeal joint (IPJ). Based on the review of the medical records provided, it seems as though the patient was dealing with issues related to a healed fracture of the hallux proximal phalanx, which was deemed to be healed based on this patient's most recent x-ray report. Based on this patient's history, it is possible that the patient is having arthrofibrosis of the hallux IPJ.  However, custom orthotics is not indicated to treat this type of issue. Thus, the custom orthotics is not considered medically necessary to treat this patient's medical condition.

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

The carrier's denial of coverage for the Custom Shoe Inserts (L3000) is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Genitourinary/Kidney Disorder
Pharmacy/Prescription Drugs

The patient is a male with a diagnosis of hypogonadism. Associated symptoms include low libido, fatigue and low energy level. Under review is a non-formulary Testosterone 50mg/5gm(1%) TD (transdermal) Gel. The health plan's determination is upheld. The requested mediation is not indicated. Current medical literature does not support that the formulary drug (testosterone gel (generic Androgel 1.62%), testosterone solution, Androderm) will be or has been ineffective, would not be as effective as the non-formulary drug (Testosterone 50MG/5GM (1%) TD gel), or would have adverse effects. The standard of care for patients with hypogonadism includes testosterone replacement. This can be performed using transdermal gels, intramuscular injections or subcutaneous implants. Current medical literature does not support superiority of one approach over the other. Transdermal therapy can be delivered using one of the many available compounds on the health plan's formulary. The requested medication is not superior nor does it have less side effects than formulary alternatives.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Possible stroke
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medically necessary.

The patient is an elder female with a history of atrial fibrillation on oral anticoagulation who presented with the complaint of dizziness, neck pain and abdominal pain. At presentation, she had left facial droop. CT brain and CT angiogram were negative. She was admitted for possible stroke. MRI was negative for stroke. 

The patient was already on maximum stroke preventive therapy when she presented with mild neurological findings. The evaluation, diagnostic studies, monitoring and treatment could have been safely and effectively completed at a lower level of care.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, chronic kidney disease (CKD) stage 4 and nephrotic range proteinuria. His CKD was felt to be secondary to diabetic or hypertensive nephropathy. The patient was treated with oral medrol 24 milligrams (mg) daily without an improvement in his nephrotic proteinuria. The provider is requesting to start Acthar gel to manage his nephrotic range proteinuria. At issue is the medical necessity of Corticotropin.
The health plan's determination is upheld.
Acthar gel is Food and Drug Administration (FDA) approved to induce a diuresis or a remission of proteinuria in the nephrotic syndrome without uremia of the idiopathic type or that due to lupus erythematosus. This patient has a documented history of nephritic range proteinuria though secondary to diabetes or hypertension. There was no documented kidney biopsy to confirm the diagnosis. There was no documentation that the patient had lupus nephritis or an idiopathic type of nephrotic syndrome. Acthar gel is not FDA approved to treat diabetic or hypertensive nephropathy and associated proteinuria. Acthar Gel is not medically necessary to treat the condition documented in this case.