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

Diagnosis:  Epileptic encephalopathy
Treatment: Physical Therapy (97535, 97530)
The insurer denied: Physical Therapy (97535, 97530)
The denial is upheld.

This patient is a school age female with a history of developmental delays and visual impairments due to epileptic encephalopathy. She has been receiving school-based therapies and has been attending intensive therapy sessions one to two times per year for a two-week duration at the Neurological and Physical Abilitation (NAPA) Center. Physical therapy sessions have been determined as not medically necessary. Following review by the health plan, coverage is not available for services provided by the school district. Clinical records point out the fact that similar services that have been provided in outpatient services have been provided by the school-based therapy.

The requested health service was not medically necessary.

In this case, the patient is a child with a rare form of epilepsy. She has been receiving skilled physical therapy services for the diagnosis of epileptic encephalopathy. Based on the review of medical records, this child does not meet criteria for skilled physical therapy interventions. The child's functional goals are designed to maintain function by using routine repetitive interventions and exercises for a chronic condition (lasting longer than three months). The patient has been receiving skilled physical therapy services at school as well as intensive therapy sessions one to two times per year for a two-week duration. However, the dates of service under review were not medically necessary as the medical records do not contain a physical therapy plan of care with evidence of specific statements of measurable, long- and short-term goals as well as 
estimates on when the goals will be achieved. The records presented do not show that this patient is making sufficient clinical gains or is meeting goals to warrant the services. Therefore, the proposed physical therapy was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder
Treatment: Vyvanse
The insurer denied: Vyvanse
The denial is overturned.

The patient is an adolescent male with known attention-deficit/hyperactivity disorder (ADHD). The patient has attempted generic and brand Adderall XR (extended release) with negative side effects of increased heart rate and difficulty sleeping with no improvement in school performance. The patient has been on Vyvanse (lisdexamfetamine) for 3 years.

The treatment with Vyvanse is medically necessary.

A review notes (1), "Since there are no reliable biomarkers that can predict individualized response to long-acting stimulants, clinicians need to consider their distinctive pharmacokinetic properties, including the pharmacokinetic profile, rate and extent of absorption, variability, dose proportionality, bioequivalence, and potential for accumulation. Clinicians also need to understand that certain factors can contribute to increased variability in pharmacokinetics and potentially affect outcomes."
The patient has had a positive clinical outcome on Vyvanse with a documented lack of a positive behavioral effect and a negative cardiac effect on the other medications. As it is known, medications with similar mechanisms of action used as treatment for this pathology do not always have the same clinical outcome. As such, as the patient has a positive clinical outcome on the prescribed medication, the patient should continue the medication. The proposed treatment is medically necessary.
Appeal type: Step Therapy
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Sotyktu
The insurer denied Sotyktu.
The determination is upheld.

This is a male patient with moderate to severe psoriasis (20 percent (%) body surface area involvement) that includes the scalp. The patient has tried and failed topical ketoconazole shampoo, mometasone solution, clobetasol, betamethasone, Protopic, Elidel, and Vitamin D analogs, as well as oral Otezla and Vitamin D analogs. Otezla was not tolerated due to significant nausea and diarrhea. The patient is reportedly clearing on Sotyktu. Sotyktu is under review for medical necessity.

Sotyktu is not at this time proven to be safe, effective, and have long-term favorable outcomes in patients of this patient's age as do other medications that are on the health plan formulary, such as Cosentyx. Sotyktu is therefore at this time not medically appropriate for this patient to utilize for his psoriasis at this time, even if clinical improvement to date has been noted.

Sotyktu is only Food and Drug Administration (FDA)-approved for adults (ages of 18 years or older) with moderate to severe psoriasis. The patient has no documented treatment failure with, or true medical contraindication to, other systemic therapies proven to be effective and safe for moderate to severe psoriasis in pediatric patients, such as Cosentyx. Alternative medications FDA-approved for pediatric patients with moderate to severe psoriasis include Enbrel and Stelara. Safety, efficacy, and long-term outcomes of Sotyktu for patients less than eighteen years of age is not known at this time. Accordingly, consistent with the current medical literature, the requested Sotyktu is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Right calcanea open reduction internal fixation.
Treatment: Subacute nursing facility admission.
The health plan denied Subacute nursing facility admission. 
The denial is upheld.

The patient is an adult male with a history of right calcanea open reduction internal fixation (ORIF). He was admitted with removal of the hardware from the open reduction internal fixation, and he was admitted to a subacute nursing facility (SNF). He discharged himself out of the subacute nursing facility due to improvement after a week.

The patient wants to return to the subacute nursing facility after he had increased pain after going to the grocery stores. He is currently weight-bearing as tolerated. Prior to admission, he lived alone in a private house with fewer than 10 steps to enter the house and about 10 steps in the house to his bedroom/bath. He was independent with ambulation without using any assistive device indoors and outdoors.

No, the requested health service is not medically necessary.
The proposed stay in a subacute nursing facility (SNF) is not medically necessary because the patient's current limitations are minimal, and he has no ongoing medical issues that will require a stay in a subacute nursing facility.

The patient was under independent/close supervision with bed mobility, transfers, and was able to ambulate 15 feet times two using a rolling walker with a contact guard. Therefore, staying in a subacute nursing facility is not medically necessary and his 
rehabilitation needs can be met on an outpatient basis with home therapy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Acute diverticulitis
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is upheld.

The patient has a history of diverticulitis and presented with lower abdominal pain. The patient was afebrile and the vital signs were stable. There was abdominal tenderness but no peritoneal signs. There was no leukocytosis. A computed tomography (CT) scan was performed and showed diverticulitis with small pockets of extraluminal gas consistent with microperforation. Antibiotics were given and the patient improved. 

Medical necessity was determined using Milliman Care Guidelines (MCG) for Acute Diverticulitis M-150. Clinical indications for admission include hemodynamic instability, peritoneal signs, persistent gross bleeding, and a significant abnormality on an imaging study. This abnormality can be a fistula, obstruction, or a free perforation such as free air under the diaphragm. The patient did not have these conditions. There was no frank or free perforation with air under the diaphragm although there was a microperforation. The patient also did not need a drainage procedure, have bacteremia, severe vomiting, or an inability to maintain oral hydration after observation care.

This patient had diverticulitis with a microperforation. There was no abscess that would require drainage and she did not have a free perforation with air under the diaphragm. The patient required antibiotics but could have been started on intravenous (IV) antibiotics with observation care and then discharged on oral antibiotics. The patient did not meet MCG criteria for admission for Acute Diverticulitis. An inpatient hospital admission was not medically necessary. 

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably, with sound medical judgment, and in the best interest of the patient. 

The medical necessity for the inpatient hospital admission is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Memory Loss, Osteoarthritis.

Treatment: Consumer Directed Personal Assistance Program (CDPAP) 6 hours per day- 7 days per week- for a total of 42 hours per week.

The insurer denied coverage for Consumer Directed Personal Assistance Program (CDPAP) 6 hours per day- 7 days per week- for a total of 42 hours per week.

The denial is upheld. 

The patient is a patient with a history of coronary artery disease (CAD), diabetes, hypertension (HTN), and hypothyroidism. The Uniform Assessment System (UAS) New York evaluation reported maximal assistance with meal preparation, total dependence on housework, moderate assistance with medication management, and maximal assistance with shopping. There was limited assistance with walking, transferring to the toilet, and toilet use; independence with bed mobility and eating. There are no reports of incontinence and falls within the last ninety days. The treating provider has requested Consumer Directed Personal Assistance Program (CDPAP) 6 hours per day- 7 days per week- for a total of 42 hours per week, which is under review.

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

The Consumer Directed Personal Assistance Program (CDPAP) 6 hours per day- 7 days per week- for a total of 42 hours per week is not considered medically necessary for this patient.

This reviewer would agree that the patient may benefit from monitoring for safety.  However, companion care or safety supervision without the direct provision of activities of daily living (ADL) task assistance is not a covered service.  The patient's needs can be met within the approved 28hrs /week. Therefore, the request for a Consumer Directed Personal Assistance Program (CDPAP) 6 hours per day- 7 days per week- for a total of 42 hours per week is medically necessary and is not approved.

"We propose an initial vision and bold first steps in this article to support the transformation of home health agencies and home-based care and its recognition in the overall health care system. In this article, the terms "home-based care" and "home health care" have distinct meanings. "Home-based care" refers to the spectrum of services provided in the home to support patients, including caregiving and personal care services, skilled services (such as nursing and therapy) provided in the home, home-based primary care, hospital-at-home, and even hospice when it is provided at home. "Home health care" in this article refers to Medicare skilled home health care, which is paid for under the Medicare home health benefit and delivered by Medicare-certified home health agencies. Home health care is one type of home-based care" (Landers, S. et al. 2016).

Based on the above, the insurer's denial must be upheld. The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient. 

The medical necessity for the Consumer Directed Personal Assistance Program (CDPAP) 6 hours per day- 7 days per week- for a total of 42 hours per week is not substantiated.
Appeal type: Medical necessity
Decision: Upheld


Diagnosis: neck/back pain
Treatment: Percutaneous Implantation of Neurostimulator 
The insurer denied Percutaneous Implantation of Neurostimulator 
The health plan's determination is upheld. 

The patient is a female who has a significant medical history of motor vehicle accident (MVA), S/P (status/post) cervical spine surgeries, anxiety, headaches and migraines. Her headache is located in bilateral temporal regions. Headache severity ranges from 6/10 to 10/10. Her neck pain is in the posterior cervical region with pain into anterior chest. She had tried cervical epidural steroid injections, facet injections and transforaminal injections with improvement of her tingling and numbness. This patient was recommended to have a cervical spine magnetic resonance imaging (MRI) for further evaluation. Physical exam (PE) was unremarkable except decreased cervical spine range of motion (ROM) and pain with extension.

Percutaneous Implantation of Neurostimulator is not medically necessary for this patient.
This patient has severe headaches and neck pain with pain into the anterior chest. There are some PNS clinical trials showing long-term pain relief for some chronic pain conditions. However, there are no published clinical trials to support its efficacy in this case, which is neck pain with pain into upper chest, and headache.
There is no clinical evidence to support the effectiveness of PNS (peripheral nerve stimulation) treatment in this case. Given her severe headaches and neck pain with pain into the anterior chest, it is unlikely she will benefit from PNS.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee replacement
Treatment: Inpatient hospital admission
The insurer denied coverage for the inpatient hospital admission.
The denial is overturned.

This is a patient admitted to the hospital. The patient underwent an elective right total knee replacement. The patient's past medical history was significant for obesity [body mass index (BMI) 36.83].

The patient's post-surgical course was complicated by hypotension, bradycardia, and tachypnea. The patient required additional medical management consisting of fluid boluses, Hespan, and continuous positive airway pressure (CPAP) for apnea. The patient was discharged to home. 

The medical records show a complicated post-surgical course. 

The criteria for ambulatory exception include: hypoxemia and hypotension. 

The records show prolonged periods of hypotension and the need for fluid augmentation and Hespan. Vasoconstrictors were also prescribed. The records showed hypoxemia with low pulse oxygen measurements. The diagnosis of chronic obstructive pulmonary disease (COPD) with need for respiratory support was noted. These factors and taking into consideration underlying obesity, support inpatient admission as necessary. Inpatient management was required to handle the post-surgical problems and need for monitoring.

Based on the above, the insurer's denial must be reversed. The health care plan did not act reasonably, with sound medical judgment, or in the best interest of the patient. 

The medical necessity for the full hospital admission is substantiated.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Overactive bladder/urinary retention
Treatment: Gemtasa
The insurer denied Gemtasa. 
The health plan's determination is overturned.

This is a male patient with a history of overactive bladder and urinary retention. Trospium, Myrbetriq, Oxybutynin, Solifenacin have been tried. The patient developed urinary retention with anticholinergic. Under review is the use of Gemtesa 75 mg (milligrams) Tablet.

A formulary exception is indicated in this case. The formulary drugs will not or have not been ineffective, would not be as effective as Gemtesa, or would have adverse effects. The Formulary drugs include Formulary alternatives include Oxybutynin, Oxybutynin ER (Extended Release), Tolterodine, Tolterodine ER, Trospium, Trospium ER, Darifenacin, Solifenacin, and Myrbetriq. These are both anticholinergic and B3 agonist drugs. Gemtesa and Myrbetriq have similar mechanisms of action. Myrbetriq, Solifenacin, Trospium and Oxybutynin have been tried without benefit. Only the anticholinergics remain. All anticholinergic medication carries risk of urinary retention which this patient has suffered from. Therefore, they all should be avoided. Gemtesa is indicated in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Mobility issues
Treatment: Environmental Modification (E-Mod): Installation of 1 indoor stair lift
The insurer denied E-Mod: Installation of 1 indoor stair lift.
The determination is overturned.

This is a female patient with a medical history notable for age related physical debility, hearing loss, visual loss, and incontinence. The patient and her care team requested environmental modification for installation of one indoor stair lift.

The patient's son provided a letter of support for this appeal. The letter states that the patient has lived in the same home for a long time. The only bathroom is located on the second floor and requires 14 stairs. She has bowel and bladder incontinence which require frequent toileting, cleaning, and hygiene. She has been crawling to get up the stairs when an aide is not available. She has a history of six falls over the past year when not receiving sufficient care assistance. Because the patient requires assistance and is still at risk for falls, they are requesting the stair lift to assist her with using the bathroom.

The patient's physician provided a letter of support for this appeal. The letter states that the patient has a history of hypertension, diabetes, peripheral artery disease, and chronic kidney disease. She is home bound and incontinent of urine/stool. She requires maximal assistance with activities of daily living (ADLs) including toileting, transfers, ambulating, bathing, and dressing. The physician certifies that the chair lift is necessary for the patient, and that without it she is in danger of injury.

Under review is the medical necessity for the requested health service/treatment of environmental modification (E-Mod): installation of 1 indoor stair lift.

The requested health service of E-Mod: installation of 1 indoor stair lift is medically necessary for this patient. The patient requires maximal assistance for stairs. She lives alone but has a personal care aide 12 hours/day; going up the stairs is challenging even when the aide is present. Her bathroom is on a different floor from the main living area. She will continue to require assistance with reaching the bathroom and does not have a care aide for all hours of the night.

A Uniform Assessment System was completed. The patient's cognition was minimally impaired. She requires total dependence or maximal assistance for most instrumental activities of daily living (IADLs). She requires maximal assistance for stairs. For her ADLs, she requires maximal assistance for bathing and dressing lower body. She requires extensive assistance for most others. She is frequently incontinent of urine and occasionally incontinent of stool. The requested E-Mod is therefore medically necessary to help the patient meet all of her personal care needs. Failure to provide the requested E-Mod could result in falls and injury.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia
Treatment: Inpatient admission
The insurer denied: Inpatient admission
The denial is upheld.

The patient is a preschool male child born prematurely at 36-weeks of gestation. He has a medical history significant for autism, speech delay, eczema, neutropenia, and developmental delay. He presented to the emergency department with a 15-
day history of intermittent fevers, seven-day history of persistent fevers and decreased intake, and one-day history of decreased urine output. The patient's vital signs included temperature 38.5, heart rate 157, and respiratory rate 26. His examination was significant for tired appearance, non-toxic appearance, no tears with crying, bilateral purulent bulging tympanic membranes, tacky mucous membranes, scattered crackles right more than left, no retractions, benign abdomen, no rashes, and non-focal neurologic deficit. Chest X-ray revealed right-sided infiltrate. Lab results included white blood cell (WBC) count 14.9K (thousand), platelets 334K (thousand), potassium 5.2, and creatinine 0.58. He was treated with a normal saline bolus, Tylenol, Motrin, and a dose of ceftriaxone prior to admission for ongoing management of moderate dehydration, bilateral otitis media, and lower respiratory tract infection. The patient's admission orders included transition from ceftriaxone to high-dose amoxicillin, 
maintenance intravenous fluids, regular diet for age, and routine vital signs. By day #3, the patient was drinking juices and starting to eat small amounts. He was playful and in no respiratory distress. He was deemed stable for discharge home on no antibiotics.

The proposed treatment is not medically necessary. He did not require acute inpatient admission.

This young male child presented with persistent fevers, poor intake, and decreased urine output. He was diagnosed with moderate dehydration, bilateral otitis media, and lower respiratory tract infection (right-sided pneumonia on chest radiograph). While it was reasonable to monitor him in 
the hospital while providing fluid rehydration, he was overall hemodynamically stable with no need for supplemental oxygen, no vomiting or diarrhea, and no significant metabolic derangements. He did not require acute inpatient admission and could have been safely managed at lower level of care.