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

This is a patient who presented with difficulty breathing for one day. As per her mother, the patient had two days of rhinorrhea. On the day of presentation, she began having coughing and post-tussive emesis, about 4-5 episodes. Her mother reported a tactile fever. The patient was placed on 2 liters (L) of oxygen via nasal cannula. The admission physical exam was done after the patient recently received an albuterol treatment. At that time, she was not tachypneic or having retractions but she was on oxygen. The examiner did report decreased air entry bilaterally with bilateral expiratory wheezing. The assessment was moderate persistent asthma presenting with difficulty breathing and cough most likely asthma exacerbation secondary to bacterial pneumonia. She was continued on albuterol every two hours and oxygen to be weaned as tolerated. She was noted to have poor air entry bilaterally, more on the right than the left, with chest tightness and pain on inspiration. There was no change in her condition after three nebulizer treatments with albuterol and Atrovent. The health plan's determination is overturned. This patient presented with significant respiratory distress as well as poor aeration requiring ventilatory pressure support in the form of BiPAP. Although the patient showed some improvement, she had to be maintained on BiPAP and supplemental oxygen. She was unable to tolerate albuterol treatments every 2 hours. She had to be placed on continuous albuterol and after that still continued to deteriorate requiring aminophylline. Aminophylline has a very narrow therapeutic window and requires close monitoring and serum levels in order to prevent toxicity. This patient required highly skilled and technical care to manage her disease process. She was found to have x-ray evidence of pneumonia in the face of status asthmaticus.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a history of hypertension and obesity who had undergone a ventral hernia repair with mesh and had complaints of an indurated mass under the surgical incision.  Vital signs were stable.  Lab results were normal without signs of an infection.  A computed tomography (CT) scan revealed a fluid collection suspicious for a seroma versus abscess.  The health plan's determination is upheld.  The patient was found to have a postoperative seroma which was not infected.  The collection was drained.  The patient had stable vital signs, was tolerating oral (PO) intake and PO pain medication and did not have systemic signs of infection or sepsis with a fever, elevated white blood cell count (WBC) or hypotension.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: Cervical Spine Decompression C2-T2 Posterior Spinal Instrumented Fusion and C3-C6 Laminectomy

Treatment: Air Ambulance Transport

The insurer denied the Air Ambulance Transport.  The denial was upheld.       

This case involves an elderly female patient was admitted to the hospital after falling down multiple stairs. Her MRI revealed a hemorrhagic contusion of the lower cervical spinal cord. The patient reported an inability to move her bilateral lower extremities with dense sensory deficits from the xiphoid distally. The upper extremity movement/sensation was intact. The patient had cervical and lumbar spine tenderness as well as no rectal tone on examination. Subsequently, the patient underwent surgical intervention inclusive of a cervical spine decompression C2-T2 posterior spinal instrumented fusion and a C3-C6 laminectomy. The patient's hospital course included hypercapnic respiratory failure which required intubation and a tracheostomy, and a Percutaneous Endoscopic Gastrostomy (PEG) placement for feeding. Due to the patient's new spinal injury, she was in need of comprehensive spinal cord rehabilitation. It was stated that the patient needed total assistance for all transfers and positioning.  Travel by ground was medically contraindicated as it would place her out of range of medical care in the event of complications during transit.  

Map Quest indicates that the ground mileage from the origin to the destination would be approximately over 600 miles and that it would have taken more than half a day. The air travel took approximately less than two hours.
It is stated that the patient was transferred to the closest facility to meet her needs and at the facility she was transferred to specialized spinal cord rehabilitation. However, the records supported the patient was stable and did not have a need for rapid transport.  Although it was noted the patient needed specialized spinal cord rehabilitation, the records failed to support that the patient was transferred to the closest facility that could have provided appropriate services.  There are top-rated rehabilitation hospitals in the state of origin. Documentation did not reveal a rationale as to why care needed to be in another state. 

Therefore, the healthcare plan acted reasonably, and with sound medical judgment, and in the best interest of the patient.  Air ambulance transport provided is not considered medically necessary for this patient.

Based on the above, the medical necessity for air ambulance transport provided is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
Treatment: Inpatient admission
The inpatient admission was medically necessary.
At the time of admission, the patient was hypoxic, with respiratory distress including dyspnea. The patient was febrile, tachypneic and tachycardic. The patient was started on intravenous (IV) antibiotics as well as given supplemental oxygen. The patient's hypoxia, dyspnea, and sepsis improved with IV antibiotics treatment. The patient was at high risk for 30 day mortality from hypoxic respiratory failure from hospital acquired pneumonia. Thus, acute in-hospital level of care for IV antibiotics, along with supplemental oxygen and nebulization treatment was standard of care and was medically necessary.
Appeal type: Medical necessity
Decision: Overturned

This is a patient who presented to their dental provider's office for evaluation and treatment of periodontium and teeth. In question is the medical necessity of the planned treatment of scaling and root planing (4341) for three quadrants (upper left [UL], lower left [LL], lower right [LR]). The health plan's determination is overturned.

The requested health service/treatment of deep gum and root cleaning, upper and lower left quadrant, deep gum and root cleaning, lower right quadrant are all medically necessary for this patient. As the patient has the diagnosis of generalized mild chronic periodontitis, the therapy of scaling and root planing is medically necessary and is independent of the amount of bone loss. With the diagnosis of mild, moderate, or severe chronic periodontitis there is a need for scaling and root planing during the active phase of disease and the amount of bone loss is not a factor in the initial treatment.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute Myelogenous Leukemia; Chronic graft versus host disease 
Treatment: Jakafi
Summary:
The treatment with Jakafi is not medically necessary.
Jakafi has been shown to be effective in the treatment of chronic GVHD, but it is not FDA-approved for this indication.  Ibrutinib, however, has also been shown effective for treatment of chronic GVHD and is FDA-approved for this indication.  Given that there is more compelling evidence supporting use of ibrutinib and that this agent is FDA approved for this indication, and given that there are no apparent contraindications to use of this medication based on review of submitted medical records, use of Jakafi over that of the FDA-approved agent for this indication is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Asthma
Issue under review: Inpatient admission

Determination:
The Inpatient admission was not medicaly necessary.

At the time of admission, the patient was hemodynamically stable. The patient was not in any respiratory distress. The patient had wheezing on physical exam. The blood work revealed leukocytosis thought to be due to past medical history of CML (chronic myelogenous leukemia). By the following day, the patient's asthma exacerbation symptoms improved. The wheezing resolved. The patient was hemodynamically stable. The persistent leukocytosis was thought to be due to CML. The patient was discharged home.

Since the patient's symptoms started to improve with emergency room care and resolved within 24 hours of admission, the acute in hospital stay was not medically necessary. The observation level of care would have been more appropriate.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Vulvodynia
Issue under review: Formulary exception for Cymbalta

Determination:
No, the health plan should not cover the Formulary exception for Cymbalta.

The American College of Obstetrics and Gynecology, in its Committee Opinion, states: "As noted in earlier publications, most evidence for treating vulvodynia is based on clinical experience, descriptive and observational studies, or reports of expert committees. Few randomized trials of vulvodynia treatment exist. The reader is referred to the 2013 Vulvodynia Guideline Update for more details. Multiple treatments were previously reported, including vulvar care measures; topical, oral, and injectable medications; biofeedback training; physical therapy, especially pelvic floor physical therapy; dietary modifications; cognitive behavioral therapy; sexual counseling; and surgery. Newer treatments include the use of stimulators and botulinum toxin. Medications used to treat vulvar pain include topical, oral, and intralesional medicinal substances, as well as pudendal nerve blocks and botulinum toxin. Tricyclic antidepressants and anticonvulsants also can be used for vulvodynia pain control. When first prescribing these medications, clinicians should avoid polypharmacy. One drug should be prescribed at a time. Before prescribing antidepressants or anticonvulsants for a patient of reproductive age, the clinician should emphasize the need for contraception. Tricyclic antidepressants and anticonvulsants take up to three weeks to achieve adequate pain control. Patients usually develop tolerance to some of the adverse effects of these medications (particularly sedation, dry mouth, and dizziness). Amitriptyline often is used as a first-line agent. Gabapentin, used to manage neuropathic pain disorders, is the most studied and used anticonvulsant for vulvodynia. A review of the peer-reviewed medical literature has resulted in no controlled studies evaluating the use of duloxetine for the indication of vulvodynia.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Chest pain and hypertension
Treatment:  Inpatient Stay

The inpatient stay is not "medically necessary".

This patient presented for evaluation of chest pain and hypertension.  The diagnosis of an acute MI (myocardial infarction) was ruled out by cardiac enzymes, which were negative, and the patient was referred for a nuclear stress test.  Ischemia was ruled out by stress testing.  There was no evidence of acute myocardial infarction, ACS (acute coronary syndrome), decompensated CHF (congestive heart failure), malignant arrhythmia or hemodynamic instability.  CTA was negative for aortic dissection or aneurysm.  The blood pressure was controlled with oral medications.  Therefore, the clinical information provided in the record submitted for review does not support medical necessity for this admission, and the care required could have been provided at an observational level of care.
Appeal type: Medical necessity
Decision: Upheld

This patient has a history of breast augmentation with implants in 2002. The patient developed breast pain and asymmetry. The surgeon performed bilateral breast implant removals with capsulectomies on 3/28/18. The patient complained of breast asymmetry following the procedure and continued pain in the breasts. The surgeon recommends revision her breasts with fat grafting and muscle repair.

The health plan's determination is upheld. The requested surgery is not medically necessary. The patient has breast asymmetry, but the breasts are not currently causing any functional or medical problems, and the patient will not suffer any adverse health consequences if plastic surgery on the breasts is not performed. The patient is reported to have pain, but the records do not document a need for analgesics or problems with activities of living.
Appeal type: Medical necessity
Decision: Overturned

The patient has with atopic dermatitis treated with topicals including steroids and topical calcineurin inhibitors, cyclosporine, methotrexate, and phototherapy.  The treating provider is requesting Dupixent.
The subject under review is the medical necessity of the Dupixent.  The health plan's determination is overturned.

While Dupixent is not yet approved in this age group, it has been studied in pediatric patients and is now approved down to age 12.  Cases such as these should be handled on case-by-case basis.  The current standard of care for atopic dermatitis is to initiate topical therapy with steroids as well as topical calcineurin inhibitors, and aggressive skin hydration and avoidance of irritants and allergens.  If topical measures fail, phototherapy is considered second line.  If phototherapy fails, systemic agents such as cyclosporine and methotrexate can be tried, although these are not Food and Drug Administration (FDA) approved for this condition.  Therefore, given that the patient has tried all of these measures, there are no alternative therapies.  Pediatric trials have shown no difference in safety of Dupixent in pediatric patients compared to adults (and similar efficacy).  Siegfried et al. summarized 5 different trials currently underway involving patients younger than 12 with Dupilumab and concluded that Dupilumab should be available to children younger than 12 who have failed other therapies.
Appeal type: Medical necessity
Decision: Overturned in Part

This patient presented to the hospital with the complaint of severe abdominal pain and vomiting of 1-day duration. She had been having abdominal pain for several weeks.
The patient reported increasing abdominal pain and she presented to the emergency department (ED). Initial vital signs were normal. The abdomen was tender in the right upper quadrant. Lab data showed an elevated alkaline phosphatase of 168. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were elevated at 1330 and 751, respectively. Total bilirubin was 1.6. Electrolytes and renal function were normal. Abdominal ultrasound showed gallstones, biliary sludge.
The patient was admitted for provision of intravenous (IV) fluid, antibiotics, and antiemetics. Gastroenterology consultation was obtained. Magnetic resonance cholangiopancreatography (MRCP) showed small stones and sludge in the gallbladder and dilated common bile duct. Endoscopic retrograde cholangiopancreatography (ERCP) was performed showing a common bile duct (CBD) stones. The duct was swept with a balloon and a sphincterotomy was performed.  The patient was provided a liquid diet; she was afebrile and was without abdominal pain. The patient underwent cholecystectomy. The post-surgical recovery was uncomplicated, and she was discharged home.

The health plan's determination is overturned, in part. 

Inpatient stay was medically necessary in part. The care and treatment provided required the coordinated care of the GI and surgical services, Imaging with MRCP, and treatment with ERCP in addition to provision of IV fluid, antibiotics, pain medications and parenteral antiemetic medications. The care and treatment provided for cholecystitis and CBD stones reasonably spanned a period of greater than 2-nights and was appropriately provided in the inpatient setting. However, cholecystectomy was delayed. Had surgery been performed following successful ERCP the day prior, then this patient would have been stable for discharge from the inpatient setting earlier. There was a delay in performance of cholecystectomy that resulted in a 2-day increase in the hospitalization.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Retinal detachment
Treatment: Face Down Recovery System
The proposed treatment, face down recovery system, is not established as medically necessary per standard of care.
Vitrectomy with gas tamponade has generally been regarded as essential to success in macular hole surgery, and strict face-down positioning for at least seven days has become the widely accepted standard post-operative routine. Older studies suggested better surgical outcomes with longer durations of face-down posturing. For example, Thompson et al found a hole closure rate of 94.4% when patients postured facedown for 14 days 90% of time followed by 14 days 50% of time, compared with a hole closure rate of 65.6% when patients postured face-down for seven days 90% of the time. However controversy still remains as to whether face-down posturing following macular hole surgery is necessary and, if so, for how long. 
In this case, the patient is not identified as having surgery to address a macular hole but rather retinal detachment repair. A review of the peer reviewed medical literature does not establish the use of vitrectomy support systems as medically necessary per for this patient's diagnosis per standard of care. Vitrectomy support systems are only supported in macular hole cases, not in cases of retinal detachment repair.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with Helsmoortel-van der Aa syndrome due to a mutation in the Activity Dependent Neuroprotector Homeobox (ADNP) gene.  He has short stature and poor growth velocity, hypotonia, gastroesophageal reflux disease (GERD), small bowel hypomotility, developmental delay, laryngeal cleft status/post (s/p) repair, chronic lung disease, moderate persistent asthma, cortical visual impairment, and secondary adrenal insufficiency from exogenous steroids.  The patient responded to growth hormone (GH) therapy with a boost in growth velocity and improvement in muscle tone, and continuation of therapy is being requested. The health plan's detemination is overturned.
The patient meets most of the criteria for GH treatment of short stature. His rare genetic syndrome is known to be associated with poor growth and hormone deficiencies. He responded to a trial of GH therapy with improved growth velocity and improvement in his muscle tone. Continuation of GH therapy is medically necessary in order for him to achieve his height potential.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Non-ischemic cardiomyopathy
 
Treatment: Wearable cardiac defibrillator (Zoll LifeVest)

The insurer denied coverage for wearable cardiac defibrillator (Zoll LifeVest). The denial is upheld. 

This patient is a man with a history of hyperlipidemia and non-ischemic cardiomyopathy. He presented to his cardiologist with a cough and phlegm. He had dizziness upon standing up. Echocardiography from mid-2019 showed ejection fraction 25-30%. He was referred for repeat echocardiography in 1 month to discuss internal cardiac defibrillator (ICD) implantation. At follow-up in late-2019 there was no change in symptoms. He had been wearing a Life Vest from mid-late 2019.

The Life Vest is FDA approved for prevention of sudden cardiac death; however, the use of Life Vest for the dates under review is not medically necessary. The patient was diagnosed with dilated cardiomyopathy, with ejection fraction less than 25-30%. The use of Life Vest technology has not been shown to be beneficial compared with standard-of-care medical therapy for prevention of sudden cardiac death in patients with newly diagnosed cardiomyopathy, when compared with conventional medical therapy alone.  For the dates under review, Life Vest technology is not medically necessary. There is no clinical research evidence documenting incremental benefit of this technology over conventional medical therapy in prevention of sudden cardiac death. This technology would not represent the standard of care for such patients. The patient's clinical presentation and the absence of extenuating circumstances do not support medical necessity for use of Life Vest for the dates under review. The health plan acted reasonably in the best interest of the patient.

Based on the above, the medical necessity for wearable cardiac defibrillator (Zoll LifeVest) is not substantiated. The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Toxoplasmosis, major depressive disorder, asthma
 
Treatment:  Personal Assistance Services

The insurer denied the coverage for Consumer Directed Personal Assistance Services. The denial was reversed.

The patient has been receiving assistance from a friend for several years, but she is unable to continue to assist as a volunteer.  The patient gets confused and forgetful, leaves things on the stove, can't find things, doesn't take medications correctly, and forgets his appointments.  The patient has multiple medical conditions including toxoplasmosis, major depressive disorder, and asthma.  He requires assistance for light housekeeping, meal preparation, food shopping, and laundry due to chronic asthma and shortness of breath.  The voluntary caregiver is currently providing these services, plus going with the patient to medical appointments and providing reminders for medications.
                                                
The UAS indicates the patient needs assistance with most IADLs (including meal preparation, housework, shopping, transportation, managing medications, managing finances) and one ADL (lower body dressing). 

Per NYS regulations for personal care services, assistance from informal caregivers is voluntary.  In the absence of a voluntary caregiver who is capable and available to provide assistance, it is medically necessary to provide assistance through personal care services, in this case, consumer directed personal assistance services.
Appeal type: Medical necessity
Decision: Overturned in Part

This is a patient  with a history of coronary artery disease (CAD), osteoarthritis, blindness, Alzheimer's disease, hypertension, cerebrovascular accident (CVA), and hearing loss. A change in her personal care aide service from 12 hours per day, seven days a week, for a total of 84 hours, to 24 hours a day, seven days a week, for a total of 168 hours is being requested. The patient's provider states that the patient's condition has deteriorated over the last six months. 
The health plan's determination is overturned in part. The requested number of hours is not medically necessary for the patient based on the general stability of her physical function. However, because her physical function has declined moderately compared to the prior evaluation, it would be reasonable and medically necessary to increase her support from 12 hours per day to 16 hours per day. This would reduce the fall risk for the patient and address the decline in some activities of daily living, such as toilet use.