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

Diagnosis: Chronic kidney disease, Stage IV, Severe, essential Primary Hypertension, Type 2 Diabetes Mellitus without complications.  
 
Treatment: Jynarque 45 & 15mg OR TBPK

The insurer denied the Jynarque 45 & 15mg OR TBPK . The denial was upheld. 

This case involves a female patient who was seen in clinic in mid-2019 for suspected polycystic kidney disease.  The patient had a medical history significant for diabetes mellitus type 2, hypertension, stroke, retinopathy, thalassemia and was being seen at the clinic for evaluation of proteinuria.  The patient reported not taking any non-steroidal anti-inflammatory drugs (NSAIDs) or herbal medications. The patient denied any urinary urgency, dysuria, change in nature of urine, nocturia, bubbles in the urine or incontinence.  The physician reported that the patient's physical examination was within normal limits. The treatment plan included the possibility of Jynarque to help retard the progression of renal cysts.  The patient would follow-up in clinic in six months.

Per Chapman. A. B. (2018), "Tolvaptan may be used in patients ages 18 to 55 years who have eGFR =25 mL/min per 1.73 m2 who are at high risk for progression to ESRD.  We recommend not using tolvaptan in adults over the age of 55 years until there are adequate data on safety and efficacy... Patients below the age of 55 years with CKD stage 3 (eligibility criterion for REPRISE study) could be considered at higher risk of progression regardless of TKV and should be considered for treatment with tolvaptan.  However, most clinicians use imaging in addition to eGFR to stratify risk." 

In the clinical records submitted for review, there is documentation of a Glomerular Filtration Rate (eGFR) less than 25mL/min.  The patient's eGFR is 19.  However, there is also documentation that the patient age is conflicting with safety and efficacy of Tolvaptan in patients > 55-years of age.  In addition, it is not supported in patients with an eGFR<25mL/min1.73 m2; both of which are present in this patient.  Therefore, Jynarque 45 & 15mg OR TBPK is not considered medically necessary for this patient.  


The carrier's denial of coverage for the Jynarque 45 & 15mg OR TBPK is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Functional impairment
 
Treatment: Increase in Personal Care Assistance (PCA) Services

The insurer denied coverage for increase of Personal Care services. The denial was reversed.

The patient has a history of hypertrophic obstructive cardiomyopathy, spondylosis, bilateral osteoarthritis of knees, cervical radiculopathy, iron deficiency anemia, pituitary adenoma, Vitamin D deficiency, polycystic ovarian syndrome.  The patient also has diastolic congestive heart failure (CHF) due to refractory hypertension.  Her symptoms include syncope, shortness of breath (SOB) on exertion, decreased exercise tolerance, now confined to motorized wheelchair when out of the house. She also has chronic pain.     
                                                                                                                                                                                                                                     
A caregiver (child) helps with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) but the only task specifically identified is errands (Saturday). The UAS indicates the patient needs maximal or extensive assistance for all mobility related IADLs. The patient has multiple medical conditions causing symptoms that result in significant difficulty performing daily activities.  Assistance with these ADLs is necessary throughout the day. 

Per NYS regulations for personal care services, assistance from informal caregivers is voluntary.  In the absence of informal caregivers who can provide the assistance the patient needs, then it is medically necessary to provide assistance with PCA services. 

PCA services 11 hours per week (approved by the insurer) does not appear to be sufficient to meet the patient's daily care needs.  The patient has requested 50 hours PCA services per week.  The patient needs assistance for ADLs throughout the day, every day of the week. PCA services 50 hours per week will provide assistance during a more substantial time period each day.  

The carrier's denial of coverage for an increase in personal care assistance services from 11 to 50 hours per week is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chiari 1 Malformation
 
Treatment: 69990 - Assistant Surgeon - Microsurgical techniques requiring use of operating microscope.

The insurer denied 69990 - Assistant Surgeon - Microsurgical techniques requiring use of operating microscope.

The denial was reversed. 

This is a female with a diagnosis of Chiari 1 malformation. She underwent a suboccipital craniectomy and C1 laminectomy and duraplasty with microdissection by a surgeon with the assistance, of a Physician Assistant-Certificed. Per the operative report, there were no complications. Findings showed evidence of significant compression of the cerebellar tonsils. Per the clinical history, the patient had presented with severe, worsening suboccipital headaches. There was evidence of a progressively worse Chiari 1 malformation with peaking of the cerebellar tonsils. 
The operative note from date of surgery was reviewed.  Procedure performed was a suboccipital craniectomy and C1 laminectomy and duraplasty with microdissection.
In this case, the Physician Assistant assisted the Surgeon using a microscope while performing a craniectomy and laminotomy for a Chiari 1 malformation. Insurance notes the CPT code in question was 69990. The American College of Surgeons state the CPT code 69990 for assistant surgeons is sometimes necessary. The Physician Assistant must use a microscope to assist the surgeon when performing this type of cranial surgery and decompression. Therefore CPT 69990 is medically necessary.
Based on the above, the medical necessity for an Assistant Surgeon for cranial surgery is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Overturned

This is a patient with history of constipation who was directly admitted for abdominal washout for constipation. The patient about a month prior began having intermittent vomiting. The patient was taken to the emergency department early the month prior and the abdominal x-ray showed large stool burden. The patient continued with intermittent vomiting. The patient was admitted, a nasogastric (NG) tube was placed, and GoLytely was slowly infused. The health plan's determination is overturned, in whole. Per current recommendations, if disimpaction is not achieved as an outpatient, admission for lavage via NG Tube is recommended. This patient also failed outpatient management. This patient was planned for large volumes of electrolyte solution via NGT, close monitoring of vital signs, as well as strict intake (Is) and output (Os) are of paramount importance. The inpatient level of care was medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cervical radiculopathy
Treatment: Inpatient admission
Inpatient stay was not medically necessary.
This patient underwent an uneventful anterior cervical single level fusion which is typically done as an outpatient procedure.  The patient was hemodynamically stable and there were no complications that required prolonged hospital stay.  
There was no reason for a prolonged hospital stay.  This procedure has been shown in the literature to be safely done as an outpatient and prolonged hospital stay has not been shown to improve outcomes.
Appeal type: Medical necessity
Decision: Overturned

The patient has a history only of asthma who presented to the emergency department on 5/20/2019 at 15:48 with the chief complaint of "penis pain". The admission resident note reports that the patient had had one similar episode, although more mild, approximately one month prior that resolved spontaneously. The emergency department physician note reports no difficulty in urination although the admission resident note reports "some pain and difficulty in urination". He reported a history of falling down while playing with his sister one day prior but did not complain of immediate pain then. The patient was admitted to the hospital. 

The health plan's determination is overturned. The inpatient stay was medically necessary. The patient had resolution of his initial priapism while in the emergency department. As this was the first was appropriate. The causes of ischemic priapism include hemoglobinopathy (which had not been presentation to medical care for this patient, admission for observation and further evaluation for etiology excluded at the time of admission and ultimately required specialty hematology consultation to exclude), leukemia, tumor, infection, neurogenic, toxins, HSP, medications (ref 4). Several of these causes are life threatening and inpatient hospital admission for further workup was appropriate.Priapism in children, especially ischemic priapism, is a medical emergency.
Appeal type: Medical necessity
Decision: Upheld

The patient presented to the emergency department (ED) via Emergency Medical Services (EMS) on 5/13/19 following an incident in which a pane of glass fell on both forearms with resultant lacerations to bilateral forearms. The patient was hemodynamically stable (heart rate 92/min) at the time of presentation. His ED evaluation with physical exam and lab data did not identify other injury. He did report paresthesia in the distribution of the left median nerve and the forearm of the right was tense to palpation. Orthopedic and trauma surgery consultations were obtained. The lacerations were bandaged in the ED. 

The health plan's determination is upheld. The medical record does not support that inpatient level of care was medically necessary for this patient. The care and treatment provided could have reasonably and safely been provided with aa lower level of care. An inpatient designation is not in accordance with generally accepted standards of medical practice for the patient's condition. There is no clinical documentation to support need for inpatient admission for this patient. The patient remained hemodynamically stable throughout the period of monitoring from 5/13/19-5/14/19 and there was no documented complication of his injury. The records include no documentation of comorbid medical condition that required an inpatient level of care. This patient's clinical needs could have been satisfied at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: shortness of breath, dyspnea on exertion, leg swelling, orthopnea and paroxysmal nocturnal dyspnea

Treatment: inpatient admission

The insurer denied coverage for inpatient admission. The denial was reversed.

The patient is a female with a history of congestive heart failure with an ejection fraction (EF) 30%, status post automatic implantable cardioverter-defibrillator (AICD), coronary artery disease status post myocardial infarction and coronary artery bypass graft, hypertension, chronic obstructive pulmonary disease (COPD), chronic hypoxic respiratory failure, chronic kidney disease, Hepatitis C and anemia.  The patient presented to the hospital with complaints of progressively worsening shortness of breath, dyspnea on exertion, leg swelling, orthopnea and paroxysmal nocturnal dyspnea. The patient also reported non-compliance with fluid restriction. She had been recently hospitalized for similar symptoms and was admitted for pneumonia/heart failure (HF) exacerbation.

Vital Signs at presentation were: Temperature (T) 98.6, heart rate (HR) 121, blood pressure (BP) 153/65 mm Hg and respiratory rate (RR) 24.  Oxygen (O2) saturation was 96 % on Bilevel Positive Airway Pressure (BIPAP).  The patient was in severe respiratory distress and was using accessory muscles of respiration.  Jugular Venous Distention (JVD) was elevated.  Lung exam revealed bilateral wheeze and rales with decreased air entry. The patient had bilateral pitting edema. The patient was admitted for decompensated heart failure (HF), possible healthcare-associated pneumonia (HCAP) and respiratory failure.

An inpatient admission was appropriate for this patient with multiple medical problems who presented with decompensated heart failure (HF), possible healthcare-associated pneumonia, possible Non ST Elevation Myocardial infarction (NSTEMI) and underlying severe coronary artery disease (CAD), chronic kidney disease (CKD), Anemia, chronic obstructive pulmonary disease (COPD), and respiratory failure.  Furthermore, the patient's hemoglobin (HB) dropped the following day to 6.6 gms and she required transfusion with packed red blood cells (PRBC).  This patient was critically ill with multiple co morbidities which needed very close monitoring.

The patient needed acute inpatient hospitalization to accomplish this.  It does not appear that the healthcare plan acted reasonably, with sound medical judgment or in the best interest of the patient.  

The carrier's denial of coverage for the inpatient admission is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Asthma exacerbation
Treatment:  Inpatient admission
The inpatient admission was medically necessary.
Asthma is an inflammatory process characterized by airway obstruction due to airway hyper-responsiveness, bronchospasm, airway inflammation, and mucus production.  Gas exchange abnormalities are due to ventilation/perfusion mismatch, as a result of atelectasis and airway over-distention.  Status asthmaticus is defined as "severe asthma that fails to respond to inhaled beta-agonists, oral or intravenous steroids, and requires admission to the hospital for treatment." (1)  Asthma can still be a fatal illness if treatment is not initiated quickly or aggressively enough.  "Despite advances in asthma management, acute exacerbations continue to be a major problem in patients ... our review findings support the importance of controlling persistent asthma ... early episodic intervention appeared to be crucial in preventing severe attacks and future exacerbations." (2)
In the ED, primary management strategies include correction of hypoxia, rapid improvement of airflow obstruction, and prevention of progression.  This is achieved with supplemental oxygen, bronchodilators, and steroids.  Fluid hydration may also be necessary.  For patients with moderate to severe exacerbations that do not respond to such intensive therapy in the ED, admission is necessary.

This child with mild persistent asthma presented to the ED with significant distress and, following multiple treatments, required admission to the PICU for continuous albuterol.  It took days for her bronchospasm to resolve sufficiently to deem her stable for discharge home.  Asthma is still a deadly disease, and even patients with previously mild symptoms may suffer a severe attack.  This child required aggressive care to help her recover from status asthmaticus.  The full duration of the hospital stay was medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Upheld

This is a patient with a past medical history of diabetes, hypertension (HTN) and hyperlipidemia who presented to the hospital on 2/9/19 with bilateral flank pain (left greater than right [L>R]) associated with nausea but no vomiting, fevers or dysuria.  His physical exam showed that he was in no acute distress with left costovertebral angle (CVA) tenderness.  The health plan's determination is upheld.
The patient presented with renal colic secondary to a 5.8 mm proximal left ureteral stone with moderate left hydronephrosis. He did not have any documented hemodynamic instability, severe vomiting or pain requiring inpatient management, acute kidney injury, bilateral renal obstruction, obstruction of a solitary or transplant kidney, documented complicated urinary tract infection or bacteremia, or need for an inpatient urologic procedure. His planned cystoscopy and stent placement could be performed on an outpatient basis and is not medically necessary to be done on an inpatient level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: DMD
Treatment: Exondys
The proposed treatment with Exondys is medically necessary.  

The patient has Duchenne's muscular dystrophy with mutation amenable for Exondys mechanism of action.  The patient has preserved pulmonary and cardiac function and has residual upper extremity strength.  Medical literature indicates that the medicine requested has a significant potential to preserve pulmonary function and the cardiac function as well as upper extremity strength.   
According to Khan, significant, clinically meaningful attenuation of FVC%p decline was observed in eteplirsen-treated patients versus controls. Mendell indicates that over three years of follow-up, eteplirsen-treated patients showed a slower rate of decline in ambulation compared to untreated matched controls.  
Even though this patient is nonambulatory already, this study is still pertains to the rate of deterioration of the muscle power which has applicability to the patient's upper extremities.  The patient is already on prednisone for many years which did not prevent the decline.  Natural history of Duchenne muscular dystrophy is of relentless progression of pulmonary and cardiac dysfunction.  Considering that in the patient's case cardiac and pulmonary functions are preserved and the medical literature indicates that these functions can be preserved with Exondys, the medicine requested has potential benefit, and without this medicine the patient is likely to deteriorate; therefore the treatment requested is medically necessary. 
The treatment requested is expected to stabilize pulmonary and cardiac function and upper extremity strength which improves the patient's net health outcomes and quality of life.  Therefore, the denial by the health plan is not reasonable.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hepatitis C
Treatment: Mavyret + Solvaldi + Ribavirin

The proposed combination regimen with Sovaldi (NS5B inhibitor) plus Mavyret (combination of Glecaprevir, NS3 inhibitor, and Pibrentasvir, NS5A inhibitor) plus ribavirin for 12 weeks is not appropriate or medically necessary. 

The patient could be treated with Mavyret for 16 weeks as it has been shown to be effective with excellent sustained virologic response (SVR) (94%) in patients who were previously treated with an NS5A inhibitor or an NS3/4A protease inhibitor and failed (MAGELLAN-1 trial). 

In the Magellan-3 trial, the patients who were treated with Sovaldi plus Mavyret and ribavirin for 12 weeks were the patients who failed Mavyret before (Wyles D. J Hepatol. 2019 Mar 8.MAGELLAN-3 Study: GLE/PIB + SOF + RBV in patients who failed GLE/PIB).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Chronic left knee pain
Treatment:  Inpatient admission
The inpatient admission was medically necessary.

The patient underwent a complex and extensive surgical procedure.  There has been a recent trend over the past few years to include knee arthroplasty as a same day procedure.  The procedure can be performed in an outpatient setting, but only in select individuals with limited comorbidities and no complications. 

The medical record demonstrates the patient received regional anesthesia with a peripheral nerve block.  She was found to be unable to move her legs the following day.  She had poor motor function secondary to the block.  She could not participate in PT secondary to this problem.  It took several days of recuperation before she could bend her knee, or be mobilized.  The ability to take three steps on POD (post-operative day) #3 is unusual.  She was also found to have ongoing pain requiring changes in medications.  She was also reported to have nausea, which required parenteral medication. 

Based upon the patient's clinical course, the admission and length of stay were warranted and standard of care.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Obesity, Mental Retardation, Autism, Metabolic Syndrome, and Pre-Diabetes
 
Treatment: 56 hours per week of Personal Care Assistance (PCA) Services 

The insurer denied the 56 hours per week of Personal Care Assistance Services. 
The denial was modified. 

This is a male patient whose diagnoses include pre-diabetes, hyperlipidemia, autistic range and mental retardation, obesity, metabolic syndrome. Information from an individualized education program (IEP) included a classification of autism. The patient received special education, and graduated from high school.  He had moderate cognitive deficits and profound deficits in receptive and expressive language skills, limited attention span, required positive reinforcement, and repetitions to complete every task. The patient exhibited echolalia; he flapped his hands throughout testing, and rocked back and forth. Responses were often delayed. Based on testing, cognitive functioning was noted as moderate intellectual disability.  The patient is pre-diabetic. He is followed by a primary care physician; however, he does not take any medications. There are some behavioral issues and he has difficulty communicating his needs; he is occasionally aggressive (pushing). The patient can perform activities of daily living (ADLs) but needs assistance. He can perform some simple household tasks with supervision. He travels in the community supervised at all times.  He needs verbal prompts to pay attention to his surroundings. He knows his address; has some reading/writing skills, but poor comprehension. 

The Uniform Assessment System -Aide Task Service Plan (UAS-ATSP) Summary of Hours Recommended allocates relatively short periods of time for assistance with ADLs (10 minutes for bathing, 5 minutes for each personal hygiene task).  On review of the reports from the psychologist and Licensed Clinical Social Worker (LCSW), it is noted that the patient needs frequent prompting to complete tasks and is slow or resistive to respond at times to perform various activities.  It was noted that the patient has a limited attention span and needs repetitions to complete tasks.  With these behavior patterns, it is reasonable to consider that the patient needs more than 5 or 10 minutes per task for bathing and personal hygiene to allow for cognitive and behavioral delays in completing the tasks.  For these ADLs, increasing the time allocated by 10-15 minutes per task is a reasonable accommodation for a patient with this type of behavioral history. 
With the addition of 5-15 minutes per task for bathing and personal hygiene, plus 10-15 minutes for upper and lower body dressing, plus 20-25 minutes per meal (x 2 meals/day), plus the time previously allocated to instrumental activities of daily living (IADLs) on the UAS-ATSP, 30 PCA hours per week can provide a reasonable timeframe to accommodate the patient's IADL and ADL needs.

The carrier's denial of coverage for 56 hours per week of personal care assistance services, from is modified.