Persius/hicric huggingface dataset:
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Opioid Dependence
Treatment: Suboxone Film (Buprenorphine-Naloxone)
The insurer denied Suboxone Film (Buprenorphine-Naloxone).
The health plan's determination is upheld.

The patient is a female who is diagnosed with opioid use disorder. The patient was prescribed Suboxone (Buprenorphine/Naloxone) film strips as maintenance medication assisted treatment of the opioid use disorder. There are no current general medical or co-occurring psychiatric diagnoses noted in this case.

The patient's prescribing physician has requested that the patient have coverage for the brand formulation of Buprenorphine/Naloxone film strips indicating on the prior authorization questionnaire that formulary alternatives are not acceptable.
The requested treatment with Suboxone (Buprenorphine-Naloxone) film strips is denied coverage based on plan criteria and formulary indicating that the formulary alternative, Zubsolv (Buprenorphine-Naloxone) sublingual tab must be tried and fail due to lack of effect or adverse effects before a coverage exception is allowed under the plan (step therapy).

The health plan documents including formulary/preferred drugs, Zubsolv, and prior authorization guidelines/criteria pertinent to medications containing Buprenorphine/Naloxone were reviewed, as well as correspondence from the health plan, and the appeal documentation. 

In this case scenario, the formulary drug, Buprenorphine-Naloxone sublingual, Zubsolv, would be as likely to be as effective as the non-formulary drug, Suboxone Film (Buprenorphine-Naloxone), and would pose a similar risk for adverse effects.
The coverage denial is reasonable in this case scenario, as the patient has not tried and failed the sublingual Buprenorphine/Naloxone tablet (Zubsolv) that is a reasonable alternative to the request for Suboxone Film in the treatment of the patient's opioid use disorder with medication assisted treatment. The patient's prescribing physician has not reported tried and failed treatment with this formulary alternative as required under the plan.

Thus, the patient has not reported tried and failed treatment with this formulary alternative as required under the plan, and medical necessity for the requested non-formulary medication is not met in keeping with NY (New York) State instruction for this review and is not consistent with the scientific literature or published guidelines that supports the use of the formulary alternative in this case.

The health plan's determination is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Chronic neuropathic pain
Treatment: Oxycontin
The insurer denied Oxycontin
The determination is overturned.

This is a female patient who is requesting treatment with Oxycontin for chronic neuropathy pain. The drug was denied because the patient has not tried and failed 3 formulary alternatives of fentanyl patch, hydrocodone ext-rel, hydromorphone ext-rel, methadone, morphine ext-rel, oxycodone ext-rel, Nucynta ER, Xtampa ER. 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.

In the appeal letter, the provider states that the patient has tried and failed the following drugs for treatment of neuropathic pain: fentanyl patch, oxycodone ext-rel, and morphine ext-rel. These three medications are on the plan's formulary as formulary alternatives. The plan states that the patient must fail three alternatives and can then have access to the requested drug. As such, the patient meets criteria because drugs on the formulary have been ineffective.
Appeal type: Medical necessity
Decision: Upheld

Orthopedic
Home health care

Diagnosis: difficulty ambulating
Treatment; Home health care
The insurer denied Level 2 Personal Care Aide Services: 12 Hours x 2 x 7 Days (Split Shift) - Total of 168 Hours per Week. The health plan's determination is upheld.

The patient is a female with past medical history of coronary artery disease, diabetes mellitus type 2, hypertension, anxiety, osteoarthritis, spinal stenosis, asthma, and congestive heart failure (CHF) who had been assigned PCA (personal care aide) services 4 hours/day, 7 days/week, to total 28 hours/week. The patient was admitted to the hospital with COVID pneumonia and was hospitalized for approximately 2 weeks before transferring to rehabilitation.

Level 2 Personal Care Aide Services: 12 Hours x 2 x 7 Days (Split Shift) - Total of 168 Hours per Week are not medically necessary for this patient.
Although there is documentation that the patient requires assistance with walking, locomotion, transfer toilet, and toilet use and therefore has unpredictable and unscheduled care needs, there is no documentation of overnight assistance needs that would require 24/7 split shift services. There are no overnight care logs specifically documenting overnight assistance needs that would not allow a PCA 5 hours of uninterrupted sleep. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, PCA services 12 hours x 2 x 7 days to total 168 hours/week are not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Graves' Disease, hemiplegia and Bence Jones proteinuria.

Treatment is an increase in personal care services (PCS) to 24 hours a day split shift (two 12-hours per day), 7 days a week, for a total of 168 hours a week.

The insurer denied coverage for an increase in personal care services to 24 hours a day split shift (two 12-hours per day), 7 days a week, for a total of 168 hours a week.

The denial is overturned.

This is an older patient with multiple medical problems including Graves' Disease, hemiplegia and Bence Jones proteinuria. She lives alone in a 1-bedroom apartment.  The insurer approved PCS (live-in), 7 days/week and the request is for PCS 7 days x 12 hours x 2 shifts, for a total of 168 hours per week.

According to the Uniform Assessment System (UAS) report, the patient's cognition is described as "minimally impaired."  However, the clinical records are consistent with more severe cognitive impairment. She is totally dependent for much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework, and shopping. She requires maximal assistance for bathing, lower body dressing, locomotion, ambulation, and toilet transfer/use. She is frequently incontinent of bowel and bladder. Extensive assistance is needed for personal hygiene, upper body dressing, and bed mobility. Limited assistance is needed for eating.   

The patient's clinical condition, cognitive ability and functional deficits are at a level and unpredictable as to require the requested personal care services (PCS) 7 days per week, 24 hours per day split shift. Of particular concern is her essentially bed bound status; frequent urinary incontinence (underlying proteinuria) bowel incontinence and need for repositioning while in bed as noted by the enclosed nighttime log. Based on the clinical records, a live-in personal care assistant is unlikely capable of obtaining approximately 5 hours of uninterrupted sleep over the course of a 24-hour shift. This physician would agree that attention to the patient's functional needs are more appropriately provided and maintained by the requested PCS 24 hours a day split shift (two 12-hours per day), 7 days a week, total of 168 hours a week.

From a physical medicine and rehabilitation perspective, the requested increase in personal care services (PCS) to 24 hours a day split shift (two 12-hours per day), 7 days a week, for a total of 168 hours a week are medically 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 an increase in personal care services to 24 hours a day split shift (two 12-hours per day), 7 days a week, for a total of 168 hours a week services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Fracture
Treatment: Inpatient Hospital Admission
The insurer denied: Inpatient Hospital Admission
The denial is upheld

The patient is an adolescent male. The patient was admitted to the hospital and was discharged on Day #3. The patient sustained an injury of the left fourth digit the week prior to admission. The patient was instructed by the surgeon to come to the emergency department for surgery. The patient presented with a finger splint to the left fourth digit and an Ace wrap. The patient had deformity and pain. The patient had been seen in the 
office by the hand surgeon and was recommended to come to the emergency department for surgery the day after admission. The x-ray showed a transverse impacted fracture of the left distal fourth middle phalanx. The patient underwent surgery for open reduction internal fixation of the left fourth digit. The patient was evaluated the following day and discharged to home. This is a review for the hospital stay.

The inpatient admission was not medically necessary.

The patient sustained a fracture that had been treated on an outpatient basis and was recommended for surgical intervention. This was an elective outpatient procedure and did not require hospital admission. This could have been completed on an outpatient basis at the surgery center or on a same-day basis in the hospital. There is no need for hospital admission for the day prior to admission and surgery and there is no need for postoperative treatment with a day in the hospital. The patient did not have any complications or additional diagnoses that would require additional treatments beyond the routine treatment for this condition.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Shortness of Breath.
Treatment:  Inpatient Hospital Admission.
The insurer denied Inpatient Hospital Admission.  The denial is upheld.

The patient is an adult female with history of intracranial hemorrhage, chronic obstructive pulmonary disease (COPD), asthma, deep vein thrombosis (DVT), and psychiatric disorder who presented to emergency room with shortness of breath and wheezing. The patient was found to have a chronic obstructive pulmonary disease exacerbation and was treated in emergency room but continued to have shortness of breath and wheezing. The patient was admitted to acute in-hospital level of care for the management of chronic obstructive pulmonary disease exacerbation. This admission was denied due to lack of medical necessity. This denial is being appealed.

The proposed inpatient hospital admission was not medically necessary.

The patient was admitted to acute in hospital level of care for chronic obstructive pulmonary disease exacerbation. The patient received emergency room treatment with some improvement. 

During hospitalization, the patient received oral prednisone, nebulization, and azithromycin. The patient's condition had improved significantly within 24 hours of hospitalization. The patient was not on any invasive drips or intravenous medications. The patient was ambulating and was tolerating oral diet. The patient's oxygen levels were above 92% on room air. The patient could have been safely and effectively treated at a lower level of care. Given the patient's signs and symptoms due to chronic obstructive pulmonary disease exacerbation improved significantly with emergency room care, the patient's treatment course would have been expected to be safe and effective at a lower level of care. The treatment provided in this patient was reasonably expected to be provided but did not require an acute inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: PFO (patent foramen ovale). 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

The patient is an adult female for which an inpatient hospitalization is under review. There was history of a CVA (cerebrovascular accident), hypertension, and PFO (patent foramen ovale). The patient underwent a successful and uncomplicated PFO (patent foramen ovale) closure. She remained stable. Vital signs were essentially normal. Electrolytes and the creatinine were normal. 

The Inpatient Hospital Admission was not medically necessary. 

The patient in this case was stable and underwent uncomplicated PFO (patent foramen ovale) closure. In such a scenario, inpatient level hospitalization, compared to for example outpatient, has not been established as standard of care for improved cardiac outcomes. It is therefore considered not medically necessary in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Deep Vein Thrombosis
Treatment: Inpatient Hospital Admission
The insurer denied the inpatient hospital admission.
The health plan's determination is upheld.

The patient is a male with a history of deep vein thrombosis (DVT) (on Eliquis) who presented to the hospital with right leg swelling. He was evaluated in the outpatient setting with noted right leg edema, and it was confirmed that there was a second DVT in the gastrocnemius vein by an outpatient doppler ultrasound. He was referred to the emergency department to obtain a computed tomography (CT) scan of the abdomen and to be evaluated by hematology. The patient denies any trauma, prolonged immobility, or palpitations. The CT of the abdomen and pelvis completed in the ED showed no intra-abdominal pathology, but no vasculature was mentioned.

His vital signs were stable. The examination was unremarkable except for the right leg, which was wrapped by a dressing and it had a larger diameter than the left, with plus 1 pitting edema. His hemoglobin was 9.6 and his international normalized ratio (INR) was 1.84. The medical team started the patient on a Heparin drip and ordered a hypercoagulable workup. They also consulted hematology to evaluate the patient.

Over the next 24 hours, the patient was stable. The decision was made to transition to a different direct oral anticoagulant and to complete a hypercoagulable workup as an outpatient. The patient's leg swelling improved. However, the decision was changed to the bridge and treat with Warfarin for six months. Vascular surgery recommended repeating the CT scan with contrast.

The patient's vital signs continued to be stable. The patient remained in the hospital and was reassessed. His INR was subtherapeutic. He was encouraged to ambulate as tolerated. The plan was unchanged, and his INR was 1.64. The INR increased to 1.78 by the next day. The patient was discharged on Coumadin therapy.

Yes, in its determination of medical necessity, the health plan acted reasonably, with sound medical judgment, and in the patient's best interest.

The inpatient hospital admission was not medically necessary. The patient developed a recurrent DVT while anticoagulated with a direct oral anticoagulant. He was switched over to Heparin and bridged to Warfarin. The medical team does not mention contraindications to using Enoxaparin or Fondaparinux as a bridging therapy to warfarin, which can be accomplished in the outpatient setting. There was no evidence of a pulmonary embolism, with a normal heart rate and lack of hypoxemia.
There were no clinical contraindications, to using Enoxaparin or Fondaparinux in this clinical setting, such as recent spinal surgery, mechanical aortic valve, or intracranial bleed. There was no reported history of GI bleeding that would require ongoing monitoring. A hypercoagulable workup can be completed in an outpatient setting. The patient was hemodynamically stable. He did not have a threatened limb or require a mechanical thrombectomy. Therefore, indications for an inpatient admission are not satisfied.

The health plans determination of medical necessity is upheld in whole.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Major depressive disorder and generalized anxiety disorder.
Treatment: Social Day Care 2 Days A Week.
The insurer denied: Social Day Care 2 Days A Week.
The denial is overturned.

This patient is an elderly female who is appealing denial of social day care two days per week. The plan approved service for one day per week. She currently receives personal care services at five hours per day six days per week and three hours per day one day per week. The patient reportedly lives alone and had been attending Day Care twice per week prior to COVID. A letter from the patient's psychiatrist notes that the patient has diagnoses of major depressive disorder and generalized anxiety disorder. She remains sad, anxious, and socially isolated despite psychotropic medications. Two days of daycare is recommended to avoid social isolation. A letter from the patient's provider notes that the patient has a physical and mental disability, and that she requires day care at least two days per week.

The proposed treatment of Social Day Care two days per week is considered "medically necessary". 

Adult day care is indicated for older adults with cognitive impairments or for homebound seniors who are isolated and need social interaction and some physical activity. This patient lives alone, has cognitive decline, and diagnoses of depression and anxiety. The appeal letters support resuming adult day care at two days per week to decrease social isolation and improve mental health. The proposed increase of social day care to two days per week is in the best interest of the patient and is considered medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Shortness of Breath. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This now adult female patient was hospitalized for shortness of breath. Her past medical history is significant for known congestive heart failure with implantable cardioverter defibrillator (ICD), polysubstance abuse including cocaine and tobacco, chronic congestive heart failure (COPD) and prediabetes. She presented to the emergency department for evaluation shortness of breath for 3 days. The patient's vital signs were stable. Her oxygen saturation was 92% on room air. Brain natriuretic peptide (BNP) was elevated to 8116. Electrocardiogram showed sinus rhythm without any acute changes. Chest computed tomography (CTA) was negative for pulmonary embolism (PE) or pneumonia and there was moderate emphysema. Treatment included diuretics, bronchodilators, oral steroids and supportive care. The request for coverage for inpatient hospitalization has been denied by her policy and the patient is appealing the decision. 

The proposed treatment was not medically necessary. 

Based on the peer reviewed medical literature, the documentation submitted for review do not establish the requested acute inpatient hospital stay was medically necessary for this patient. According to the 2022 InterQual criteria, Acute Adult Heart Failure and Acute Adult COPD, criteria for the inpatient admission was not met, including documentation of dyspnea at rest and not returned to baseline after 2 hours of treatment, oxygen saturations less than (<) 89%, change in mental status, heart rate 100 to 120 beats per minutes, sustained, blood urea nitrogen (BUN) or creatinine greater than 1.5 times the upper limit of normal (ULN) and greater than (>) baseline, dyspnea and failed outpatient treatment (includes oral intake) 2 visits within last 7 days or positive troponin not explained by chronic kidney disease (CKD) and congestive heart failure (CHF). There was no hemodynamic instability, respiratory distress, pulmonary edema, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, pulmonary embolism (PE), aortic dissection, pneumonia, severe electrolyte abnormalities or any other medical condition or other medical instability or acute care needs that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient hospital stay. 

The care the patient received for mildly decompensated congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) is routinely provided safely and effectively at a lower level of care. Therefore, the proposed treatment was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Flatfoot 
Treatment: Custom shoe inserts (L3000 x 2)
The insurer denied coverage for Custom shoe inserts (L3000 x 2)
The denial is overturned

The patient is a child with a history of orthotic use, for the flatfoot deformity and posterior tibial tendinitis. The records date back to the patient's first visit with the podiatrist when it was determined that the child would need orthotics to treat the pain. The documentation shows clear improvement in the level of pain with the use of orthotics. Given the patient is a child with open growth plates it is imperative that the child have access to orthotics as the feet grow.  

The decision should be overturned. It is well documented in the literature, that in cases where all conservative measures have been attempted custom orthotics play a major role prior to and after surgical intervention. Children with flexible flatfoot who wore customized arch support insoles for 12 weeks exhibited significantly improved pain/comfort, physical health, stair ascent time, upper extremity and physical function, and transfer and basic mobility. Furthermore, a systematic review found that orthotics show potential as a treatment method for children with flexible pes planus. As such, it is in the best interest of this young patient to use custom orthotics prior to having to undergo any type of surgical intervention for the ongoing pain and discomfort.

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

Custom shoe inserts (L3000 x 2) is considered medically necessary for this patient.

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 custom shoe inserts (L3000 x 2) is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Class I malocclusion
Treatment: D8080 Comprehensive Orthodontic Treatment, D8670 Monthly Visits
The insurer denied: D8080 Comprehensive Orthodontic Treatment, D8670 Monthly Visits
The denial is overturned.

The patient is a school aged male. The request is for orthodontic benefits (including monthly visits). The patient has a skeletal Class I malocclusion, mild upper and lower spacing, deep bite and severely excessive overjet. The prior denial was due to handicapping index score of 15.

The proposed treatment is medically necessary.

Although the patient's handicapping index score was only 15, he has an impacted upper left permanent canine. When there is an impacted anterior permanent tooth where extraction is not indicated, this is an automatic qualifier for treatment. This case has medical necessity and needs orthodontic treatment to correct things. The monthly follow up visits are to monitor the treatment progress.