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

Diagnosis: Status Asthmaticus. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is overturned. 

The patient has a history of eczema and obesity. The patient had been sick for days with a cough and nasal congestion. During this illness, her mother noted that she became less active and to have a decrease in her oral intake. When she developed fever and an increased respiratory effort, she brought her to the emergency room (ER) for medical treatment.

In the ER, she was noted to be in respiratory distress with retractions and tachypnea noted on physical examination. Her pulse rate was elevated at 180 and her respiratory rate was 35. On physical examination, she was noted to be in respiratory distress with substernal retractions, wheezing, and audible rales in her right upper and middle lobes. She was treated with 3 treatments with duoneb, dexamethasone, ceftriaxone and azithromycin. She also was treated with a bolus of normal saline. A chest x-ray was unremarkable. A respiratory viral panel was positive for rhinovirus. Her urine specific gravity was 1.028 and her serum bicarbinate (HCO3) was 18 which demonstrated a metabolic acidosis and risk of dehydration. After treatment in the ER, she continued to have respiratory distress with wheezing and increased work of breathing. Based on her failure to improve with treatment and evidence of a metabolic acidosis, the decision was made to admit her with a diagnosis of status asthmaticus for ongoing treatment with intravenous (IV) fluids and albuterol. 

The patient was treated appropriately in the ER for a cough, wheezing and respiratory distress. She had been febrile and having a decrease in her oral intake. Following treatment in the ER, she continued to have respiratory distress with persistent wheezing and increased work of breathing, she had a metabolic acidosis with a HCO3 of 18 and a concentrated urine with a specific gravity of 1.028 which demonstrated the need for continued intravenous (IV) fluid supplementation. It was appropriate and consistent with the standard of care to admit her to the hospital for ongoing treatment with albuterol and IV fluids with a diagnosis of status asthmaticus. The admission to the hospital was medically necessary. The health plan did not act reasonably with sound medical judgment. 

The medical necessity for the inpatient hospital admission is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cellulitis. 
Treatment: Inpatient hospital admission. 

The insurer denied coverage for inpatient hospital admission. 

The denial is upheld. 

The patient had a past medical history significant for paranoid schizophrenia, depression, and substance use who presented to the hospital with complaints of a finger injury. The patient was started empirically on intravenous antibiotics (vancomycin and Unasyn) for cellulitis of her finger. X-ray of right hand showed no evidence of fracture or osteomyelitis.  The patient remained afebrile, hemodynamically and clinically stable. She was discharged to continue oral antibiotics (doxycycline and Augmentin) as an outpatient. 

According to documentation, patient presented with right finger laceration/injury. Otherwise, patient was afebrile and hemodynamically stable. Laboratory results were unremarkable including a normal white blood count (WBC), c-reactive protein (CRP), and sedimentation rate (ESR). Imaging studies were negative. The patient had no evidence of a disseminated infection, and no surgical intervention was required. Based on above findings, patient met criteria for observation level of management.

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

The insurer's denial of coverage for the inpatient hospital admission is upheld.  Medical necessity for inpatient level of care is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Plantar Fasciitis. 
Treatment: Custom Shoe Inserts. 

The insurer denied the Custom shoe inserts. 
The denial is upheld. 

The patient is a male. The patient was initially seen when he was diagnosed with plantar fasciitis. According to the progress note of that day, he received a pair of custom and non-custom orthotics to wear. He returned to the provider stating that his custom devices had worn out, and he was seeking a new pair. 

A pair of custom devices (L3000) was prescribed to the patient. 

No, the requested Custom shoe inserts are not medically necessary. 

Contrary to the provider's statement that the patient has tried OTC (over-the-counter) orthotics (Powerstep etc.), the medical records do not document that the patient had failed treatment with non-custom devices. The literature quoted and current guidelines support that non-custom devices be tried before custom ones are dispensed. 

Although the health plan does not specifically make note of over-the-counter orthotics as conservative treatment for plantar fasciitis, it is established as a mainstay of treatment that is utilized in addition to stretching, etc. 

When used as per the literature cited, OTC (over-the-counter) orthotics are the first-line treatment. 

Therefore, given the above, the custom shoe inserts are not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: esophageal cancer status post chemotherapy and radiation, status post esophagectomy and jejunostomy placement

Treatment: Continued skilled nursing care

The insurer denied coverage for continued skilled nursing care.

The denial is overturned.

This case involves a male with a history of diabetes as well as esophageal cancer status post chemotherapy and radiation, status post pacemaker placement and status post esophagectomy and jejunostomy. The documentation indicated there were complications following surgical intervention and he was admitted to long-term care. The patient was initially admitted and approved for services through a time period. The documentation indicated he was admitted for restorative care given a very poor tolerance for activity and the need for a two-person assist for all mobility related tasks. The documentation indicated he was receiving wound care and participating in therapy services. He was seen to undergo management wounds located on the left quadrant of the abdominal fold as well as right lateral chest and sacrum. Prior therapy notes indicated he had decreased dynamic balance and demonstrated excellent rehabilitation potential. The documentation indicated he continued with treatment. A note indicated he continued to have hyperglycemia and was utilizing insulin. The submitted documentation indicated he continued with multiple services to include additional therapy as well as wound care. The patient's wife was requesting discharge. The documentation indicated a discharge date would be determined by the needed equipment at home. Discharge was delayed due to the original social worker leaving her job. The patient was ultimately discharged.

Based on the medical documentation, the patient was admitted to a long-term care facility for continued skilled care. He required maximum assistance for mobility. According to the medical literature, the request for continued care is considered medically necessary due to the patients continued functional deficits and medical comorbidities. The patient had decreased dynamic balance, however still demonstrated rehabilitation potential. He continued to require wound management and medication management due to his functional deficits. Therefore, the request is considered medically necessary.

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

The insurer's denial of coverage for the continued skilled nursing care is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left parietal brain lesion, traumatic brain injury, seizure disorder, asthma, aphasia and dementia.

Treatment: Personal care aide (PCA) level 2 services of 7 hours per day, 5 days per week for a total of 35 hours per week.

The insurer denied coverage for the personal care aide (PCA) level 2 services of 7 hours per day, 5 days per week for a total of 35 hours per week.

The denial is upheld. 

The patient has a past medical history of a left parietal brain lesion, traumatic brain injury, seizure disorder, asthma, aphasia and dementia. He is totally dependent for meal preparation, ordinary housework, managing finances, managing stairs and shopping. The patient needs maximum assistance with managing medications, transportation and equipment management. He needs extensive assistance with phone use. The patient needs limited assistance with bathing, dressing his upper and lower body. He needs supervision, oversight or cueing with walking, bed mobility and locomotion. The patient uses an assistive device for locomotion. He is independent and needs setup help only with personal hygiene, eating, toilet transfer and toilet use. The patient is frequently bladder incontinent but has complete bowel control. He uses pull ups for incontinence. An increase to personal care aide (PCA) level 2 services of 7 hours per day, 5 days per week for a total of 35 hours per week is being requested.

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; note:

"(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse."

The assessments of the patient's personal care needs vary. The Uniform Assessment System (UAS) notes supervision/set-up for ambulation, toileting, transfers, bed mobility. The son notes more. Review of the UAS (the last tasking tool) reveals that from what the patient noted he needs supervision and cuing. There are no documented personal care services (PCS) needs that will be more effectively addressed by more hours fewer days/week (7 hours/day x 5 days versus. 4 hours/day x 6 days). 

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

The insurer's denial of coverage for the requested PCA Level 2 Services of 7 hours per day, 5 days per week for a total of 35 hours per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypoxic Respiratory Failure. 
Treatment: Long-term acute care hospital (LTACH). 

The insurer is denied coverage for long-term acute care hospital (LTACH). 

The denial is overturned. 

This is the case of a patient with a history of acute hypoxic respiratory failure, requiring intubation (secondary to COVID-19 [2019 Novel Coronavirus]), right-sided temporal parietal stroke (status post tissue plasminogen activator (TPA) and thrombectomy), status post right hemicraniectomy, with placement of bone flap. He was initially hospitalized and was transferred to a long-term acute care hospital (LTACH), for ventilator weaning, and further medical management. The patient was decannulated on, and services were approved. He was noted to have developed confusion and he was monitored for infection. The patient was discharged. 

Considering the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practiced guidelines developed by the federal government, national or professional medical societies, boards and associations, the health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. 

While a Long-Term Acute Care Facility, the patient required acute ICU (intensive care unit) medical management of sepsis with associated hypotension due to hypovolemia.  He was treated with IV (intravenous) antibiotic therapy, IV pressor agents, and IV fluids and volume expanders.  The patient would not be medically stable to be transferred to a lower level of care and could not receive equivalent critical care interventions in a skilled nursing facility. 

Continued care in a long-term acute care hospital (LTACH) is considered medically necessary for this patient. 

"The evolution of the techniques used in the intensive care setting over the past decades has led on one side to better survival rates in patients with acute conditions and severely impaired vital functions. On the other side, it has resulted in a growing number of patients who survive an acute event, but who then become dependent on one or more life support techniques. Such patients are called chronically critically ill patients." (Marchioni, A. et al. 2015) 

The patient required ICU level care for management of sepsis with hypovolemia.   He required 24-hour medical and nursing management and monitoring of response to treatment to sepsis within an ICU setting. This level of care would not be available in a skilled nursing facility. It is standard of care and duty of care that necessitated that the patient remains at the long-term acute care hospital while medically unstable due to sepsis and that care be provided in that setting to achieve medical stability. 

The insurer's denial of coverage for continued care in a long-term acute care hospital (LTACH) is overturned. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, aphasia

Treatment: Increase in personal care services to 24 hours per day, 7 days per week (split shift), total 168 hours per week

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

The denial is overturned.

The patient has a history of Alzheimer's dementia, aphasia, back pain, osteoarthritis, and incontinence. She has been receiving personal care services for assistance with activities of daily living 12 hours per day, 7 days per week. Toilet use has gone from limited assistance on Uniform Assessment Score (UAS) to maximal on the UAS. She needs limited assistance with transfers, bed mobility and locomotion. The nurse observed the aide using hands to guide patient in bed and providing assistance with ambulation and toileting.  The patient wanders when she needs the bathroom as she cannot remember where it is. She is incontinent. 

New York Codes Rules and Regulations, Title: Section 505.14 Personal care services; notes:

(a) Definitions and scope of services.

(1) Personal care services means assistance with nutritional and environmental support functions and personal care functions, as specified in clauses (5)(i)(a) and (5)(ii)(a) of this subdivision. Such services must be essential to the maintenance of the patient's health and safety in his or her own home, as determined by the social services district in accordance with this section; ordered by the attending physician; based on an assessment of the patient's needs and of the appropriateness and cost-effectiveness of services specified in subparagraph (b)(3)(iv) of this section; provided by a qualified person in accordance with a plan of care; and supervised by a registered professional nurse.

The patient has recent worsening of dementia. She also has had significant deterioration in toileting this year. She is able to get out of bed and wander, but normally needs assistance with bed mobility, transfers and ambulation and especially with toileting. There is a safety element to her need for assistance, but the need is still there. She is incontinent and is not on a toileting schedule. She is unable to use the bathroom or handle soiled pullups herself. 

The provision of diapers and other durable medical equipment (DME) is not by itself adequate for prevention of pressure sores. Changing diapers regularly and positioning are also necessary. The fact that the patient has not yet had bed sores does not mean that with deteriorating function she is not at higher risk.

In view of the need for assistance as noted above the health plan did not act reasonably with sound medical judgment in the best interest of the patient.  

The insurer's denial of coverage for personal care services 24 hours per day, 7 days per week (split shift), total 168 hours per week is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal Pain. 
Treatment: Inpatient admission. 

The insurer denied the inpatient admission.  The denial is upheld. 

The patient is a female with reflux, hypertension, diabetes, and gastroparesis who was admitted with emesis and epigastric pain.  The initial blood pressure was in the 200s/140's and intravenous labetalol was provided along with oral clonidine and Norvasc.  The blood pressure dropped to the 90's/60's in the emergency department.  Cardiac enzymes were negative.  The electrocardiogram showed sinus rhythm without acute ischemic changes.  Labs were notable for a creatinine 0.9, potassium 11.1, glucose 202, and potassium 4.4.  Intravenous fluids, antiemetics and oral antihypertensive agents were provided.  Serial glucose levels were followed with the home subcutaneous insulin regimen administered.  Twenty-four-hour urine for plasma meta-deference was normal.  Psychiatry was consulted for anxiety and lorazepam was provided. 

No, the proposed inpatient admission was not medically necessary. 

The patient had labile glucose levels but did not have evidence of hypertensive emergency, as there was no end-organ damage related to the elevated blood pressures.  Despite transient hypotension, there was no evidence of septic, cardiogenic, anaphylactic, or hypokalemic shock.  The patient did not require intravenous antihypertensive agents after admission.  The patient had a history of known gastroparesis and did not have evidence of acute intra-abdominal process such as obstruction, ileus, acute pancreatitis or acute colitis.  The patient remained afebrile with a normal white blood cell count.  No endoscopic or surgical intervention was provided.  Glycemic control was acceptable, and there was no evidence of diabetic ketoacidosis.  Intravenous insulin was not required.  In summary, inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Prostate Cancer
Treatment: PET/CT scan
The insurer denied the PET/CT scan. 
The health plan's determination is overturned.

This is a male with prostate cancer. A prostate-specific antigen (PSA)  was 0.53 which has represented a slow increase from 0.06. A bone scan on was negative. A computed tomography (CT) of the abdomen and pelvis demonstrated only stable sclerotic foci without evidence of new disease. A Positron Emission Tomography and Computed Tomography (PET-CT) was ordered and is under review.

The requested Positron Emission Tomography and Computed Tomography (PET-CT) is medically necessary for this patient.

This patient has a history of known metastatic prostate cancer with a rising PSA and unremarkable conventional imaging. The potential clinical impact of a PET/CT was addressed in a systematic review of 15 studies totaling 1163 patients (the vast majority with biochemical failure following initial local therapy) by Perera, et al. Scan results altered management in 54 percent of cases. Among men with biochemical failure, the proportion treated with radiation therapy (RT) (from 56 to 61 percent), surgery (from 1 to 7 percent), focal therapy (from 1 to 2 percent), and multimodal treatment (from 2 to 6 percent) all increased, while that of systemic treatment (from 26 to 12 percent) or no treatment (from 14 to 11 percent) decreased with use of PET/CT.

Both the National Comprehensive Cancer Network (NCCN) and the authors of UpToDate recommend the use of PET/CT in this clinical scenario. This is similarly supported by the peer-reviewed literature and is considered a standard of care. For these reasons, the requested testing is considered medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: exercise induced asthma.

Treatment: Ventolin HFA (hydrofluoroalkane) 90 mcg (microgram).

The insurer is denied coverage for Ventolin HFA 90 mcg.

The denial is upheld. 

This female patient has a history of exercise induced asthma.

Insurance company had denied the medication as it is Non-Formulary. The Alternate drug is Albuterol Sulfate 90mcg HFA which is a generic equivalent.

As per documentation provided by prescriber Generic Albuterol 90mcg HFA has caused throat ulcers and mucosal erosions and hence Ventolin HFA prescribed.

Albuterol HFA and Ventolin HFA have exactly the same chemical composition.

There is no documentation that this patient suffered from serious complications from the use of Albuterol HFA. There is no evidence that Ventolin would be a better drug for this patient.

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

The carrier's denial of coverage for the Ventolin HFA 90 mcg is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Migraines
.
Treatment: Medication Aimovig

The insurer denied coverage for medication Aimovig.

The denial is overturned.

The patient has the diagnosis of chronic migraines. The treating provider prescribed Aimovig (erenumab). The treating provider is requesting plan approval for treatment with Aimovig (erenumab). 

The medication Aimovig for the treatment of migraines is considered medically necessary for this patient. The patient has the diagnosis of chronic migraines. The treating provider prescribed Aimovig (erenumab). The patient failed multiple preventative medications. The patient suffers from severe headaches. 

While Aimovig is approved for patients who are over a certain age, this is a post pubertal female and should be treated like an adult. Aimovig is an option for the patient who failed multiple other preventative medications, including 2 other calcitonin gene-related peptide (CGRP) blockers. Therefore, the request for Aimovig (erenumab) is medically necessary for this patient. 

"Conclusions: One-year efficacy, supported by functional improvements and favorable safety and tolerability profiles, supports further investigation of erenumab as a preventive treatment in patients with EM [episodic migraines]." (Ashina, et al, 2017)
                                   
The health plan did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The insurer's denial of coverage for the medication Aimovig for the treatment of migraines is overturned. Medical necessity is substantiated.