Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Unspecified bipolar disorder
Treatment: Gencept Assay (Genomind)
The health plan should not cover the proposed treatment.

This request is not recommended for approval as it is noted that CYP 450 genetic testing is considered medically indicated for patients who have been prescribed clopidogrel (Plavix), or for patients who have been prescribed doses of tetrabenazine (Xenazine) greater than 50 milligrams (mg) per day, or for patients with Gaucher disease type-one who are being considered for treatment with eliglustat (Cerdelga). It is also considered medically indicated for Human Leukocyte Antigen B (HLA-B*5701) before beginning treatment with abacavir (Ziagen) for persons infected with HIV-1 and for treating hepatitis C virus (HCV) genotype 1a for the presence of the NS3 Q80K polymorphism before beginning treatment with OlysioTM (simeprevir) plus peginterferon and ribavirin. CYP 450 polymorphisms (diagnostic tests to identify specific genetic variations that may be linked to reduced/enhanced effect or severe side effects of drugs metabolized by the cytochrome P450 system including opioid analgesics, warfarin, tamoxifen, proton pump inhibitors, antipsychotic medications, and selective serotonin reuptake inhibitors) are noted to be experimental and investigational because the clinical value of this type of genetic testing has not been established.  Additionally, although mutations of the MTHFR gene have been associated with increased risk of developing a number of psychiatric conditions, its role in these conditions has not been established. There is insufficient evidence in the published peer-reviewed scientific literature to determine the clinical utility of genetic testing and its impact on net health outcomes. At this time the role of genetic testing for MTHFR has not been established.  Vitamin K reductase testing is indicated when the patient may have a potential blood clotting indication and it is noted that the medications being considered do not have that as a possible side effect.  Some antipsychotic drugs, such as haloperidol and ziprasidone, have a prolonged QT interval as a rare side effect, however, there is not sufficient evidence to conclude that the information obtained from genetic testing on risk assessment leads to important changes in clinical management. Most patients with long QT Syndrome can be treated with beta-blocker therapy and lifestyle modifications, and it has not been possible to identify a group with low enough risk to forego this conservative treatment. Conversely, for high-risk patients, there is no evidence suggesting that genetic testing influences the decision to insert an ICD/ implantable cardioverter-defibrillator and/or otherwise intensify treatment. Therefore, this request is not recommended for approval.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Substance abuse
Treatment: Continued inpatient detoxification
The continued inpatient detoxification was not medically necessary for this patient.
The continued inpatient stay and detoxification treatment and other medical services noted in the clinical summary could have been safely and effectively provided at a lower level of care. The acute inpatient treatment of this patient's
substance use disorder did not require the continued structure of an inpatient setting or 24-hour monitoring. The patient displayed no serious disturbance of mental status despite having a history of schizophrenia and ongoing substance use
disorder with alcohol and cannabis. Moreover, the patient did not show evidence for suicidal or aggressive behavior or risk, or severe cognitive impairment or psychosis, or perceptual disturbance that would have warranted inpatient level treatment for the time interval under review. There were no severe symptoms of withdrawal or biomedical issues in this case, and the patient had no complications that required withdrawal management or general medical services, as noted in the clinical summary. The patient had fair insight and control of impulses, and was cooperative and generally motivated to continue with substance use disorder treatment. Thus,
the continued inpatient detoxification was not medically
necessary in this case scenario.
This answer is consistent with New York State LOCADTR 3.0 Criteria and with established practice guidelines, the scientific literature, and ASAM Criteria, as referenced below.
In this case scenario, the patient was amenable to treatment with lower level care in a less restrictive setting. The requested inpatient level services were not medically necessary in this case scenario, as the health plan asserts. The patient could have been safely and effectively treated with lower level services in a less restrictive environment consistent with prevailing standards of medical practice and the scientific literature and published guidelines, referenced below, as well as the NY STATE OASAS LOCADTR 3.0 Guidelines and ASAM Patient Placement Criteria, also referenced below.
Appeal type: Medical necessity
Decision: Overturned in Part

This is apatient who has a long history of lower back pain. He developed this lower back pain after a motor vehicle accident in 2006. He describes his pain as constant, sharp, and localized in the lower back. His past medical history includes sleep apnea. There is no documented prior history of any low back surgeries. Physical examination was unremarkable except tenderness to palpation in the paraspinal region with positive facet loading test. 

The health plan's determination is overturned in part. This patient has a long history of low back pain since 2006, and failed extensive treatments including PT, and pain medications. It is medically necessary for two level RFA. The 3rd level RFA is not medically necessary based on available medical records.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Dyspnea
Treatment: Inpatient admission
Inpatient admission was not medically necessary; inpatient level of care was neither indicated nor provided.

This was an elective, uncomplicated catheterization and PCI that was scheduled after a positive nuclear test. The patient was always hemodynamically stable with normal vital signs, normal electrocardiogram (EKG), normal left ventricular (LV) function, and no ectopy. The only care given after the uncomplicated catheterization was monitoring, intravenous fluids (IVF), and routine medications. This meets the definition of outpatient care without any indication for a higher level. Many institutions protocols include a same day discharge.  Centers for Medicare and Medicaid Services (CMS), Recovery Audit Contractors (RAC) surveys, proposed two midnight rule and all guidelines specify this as an outpatient procedure for an uncomplicated PCI.  

Successful vascular closure devices were developed with one of the advantages being the safety in early ambulation and discharge. An overnight stay for observation and telemetry does not change that determination. The patient was routinely monitored for femoral access issues. While possible, bleeding post intervention is not commonly seen, none occurred in this case and no indications for a higher level of care occurred. 

The letter of appeal was carefully considered but it offered no evidence to support a higher level of care. The only care provided was telemetry, frequently performed in observation and outpatient status. The patient was admitted for monitoring and routine post catheterization care; neither required an inpatient level of care. There was no additional "complex" care that was required in this patient's care post catheterization. While there is always a potential for an adverse event, one did not happen and no actual treatment was needed. 

In appeal letter it referenced Milliman Care Guidelines. The patient did not have evidence of hemodynamic instability. He did not have unstable angina nor treated for same. His diabetes was stable, controlled with oral medications, and did not require additional care. Elective intervention after more than a month of symptoms of dyspnea should not be considered urgent. There is no evidence to support the statement that this "could not be managed in an outpatient setting".  Milliman criteria requirements for acute coronary syndrome (ACS) do not apply as the patient does not meet criteria to support that diagnosis. All testing and therapy would be appropriate, safe and guidelines consistent to be in an outpatient setting. Thus, inpatient level of care was not medically necessary.

The denial was consistent with guidelines and usual community care. Post cardiac care as described is routinely performed at a lower level of care.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: C6 tetraplegia

Treatment: RT300 FES therapy system (E1399)

The insurer denied coverage for RT300 FES therapy system (E1399). The denial reversed.

This patient is a child who sustained a traumatic spinal cord injury due to a diving accident with resultant C6 tetraplegia.  A more recent neurological examination demonstrated 5/5 shoulder abduction, elbow flexion and wrist extension.  He has a 2/5 triceps on the right and 1/5 on the left.  Currently under review is the medical necessity of the requested RT300 FES system.

The requested RT-300 Functional Electrical Stimulator Cycle Ergometer is an FDA cleared class 2 medical device.  This device is intended for patients with spinal cord injury with minimal to no voluntary arm or leg movement.  The requested DME is not merely "a type of exercise device."  Proposed beneficial effects are improving cardiopulmonary function, increase muscle mass, decrease spasticity and increase bone density.  The accumulated peer reviewed medical literature supports a result of improvement in health outcome.  The long term beneficial effects of this device evaluated in the peer reviewed (randomized controlled) published medical literature are also promising.  

This physician disagrees with the insurer's denial of the requested RT300 FES therapy system (E1399).  Based on the patient's diagnosis, positive response to this device by patients with similar diagnoses and lack of alternative beneficial treatments, the proposed treatment is clinically reasonable, and medically necessary.  

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

The carrier's denial of coverage for the RT300 FES therapy system (E1399) for neuromuscular electrical stimulation is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cushing's syndrome
Treatment: Consumer directed personal care assistance hours 

Summary:
The patient is a female with a history of blindness and Cushing's syndrome. Due to these conditions, she requires assistance with many of her activities of daily living (ADLs). An appeal review requested for potential approval of an increase in consumer directed personal care assistance hours from 20 to 40 hours per week for increased assistance with completion of the patient's ADLs.

NY State regulations do not require personal care assistance services for safety supervision alone. Personal care assistance hours for companion care or for safety supervision, without the need for activity of daily living tasks is not medically necessary. Furthermore, the currently approved plan of 20 hours of consumer directed personal care assistance hours has been deemed sufficient to meet the patient's current ADL needs. For these reasons, the proposed treatment of an increase in consumer directed personal care assistance hours from 20 to 40 hours per week is not deemed medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Malpositioned Teeth
Dental/Orthodontic Procedure

The patient in question is a female presenting with a skeletal Class I malocclusion and mild spacing. She has a significant anterior open bite. She is treatment planned for 18-24 months of orthodontics to address the spacing and open bite, but the treatment was denied due to lack of medical necessity. This is the subject of this review.

The health plan's determination is overturned. Comprehensive Orthodontic Treatment of the Adolescent Dentition: Braces is medically necessary for this patient.
Studies have shown that patients with severe malocclusions, including anterior open bite, have significantly lower masticatory and gastrointestinal digestive function than persons with normal occlusion. However, it has also been shown that after orthodontic treatment, there was no difference in masticatory function and gastric emptying between the treated group and the control group with normal occlusion.4 Given the patients malocclusion and the likelihood of significantly reduced masticatory function and digestive function, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Longstanding congestion and runny nose
Treatment: Inpatient admission 

Summary:
The patient is a male infant born at 38 weeks' gestation. He was referred to the ED after hours with one-day history of fever to 100.9 (rectal), longstanding congestion and runny nose, not feeding as well, with some grunting and heavy breathing at night. 

Based on the documentation provided, this young male infant did not require acute inpatient management. He was overall hemodynamically stable, with no respiratory distress, no impending cardiorespiratory failure, and no evidence of sepsis. He could have been safely managed at a lower level of care.

Of note, the Milliman Care Guidelines were provided for Pediatric Sepsis. At six weeks of age with a rectal temperature of 100.9, he would have required more compelling evidence of serious bacterial infection to justify acute inpatient management. In the absence of such complicating factors, lower level of care would have been appropriate.
Appeal type: Medical necessity
Decision: Upheld

Colon Cancer 
Home Health Care

The patient is with metastatic colon cancer. The patient's past medical history is significant for colon cancer, Alzheimer's dementia, depression, anxiety, diabetes, coronary artery disease, peripheral artery disease, hypertension, insomnia and degenerative joint disease. 

The patient's provider requests personal care service assistance, 7 days a week 12 hours per day (split shift) for a total of 168 hours per week. 
The health plan determination is upheld in whole.

No, the requested health service is not medically necessary for this patient.  Additional patient care service hours are not medically necessary. This patient with metastatic colon cancer. The past medical history is significant for colon cancer, Alzheimer's dementia, depression, anxiety, diabetes, coronary artery disease, peripheral artery disease, hypertension, insomnia and degenerative joint disease. The patient is approved for 24 hours per day live-in 2 days per week and 12 hours per day 5 days for a week for a total of 60 hours a week. Noting the following, most of the patient's ability to perform physical function were maximal assistance and did not change since the previous evaluation. Specifically, the Uniform Assessment System (UAS) stated that it did not support nighttime hours. 

On the reassessment, according to the nurse, it was noted that the patient had no recent falls, is able to use incontinence supplies with assistance, patient is able to change position in bed with assistance, and his family pre-pours medication that is administered at night. Safety monitoring and supervision as a stand-alone task is not medically necessary. 

The patient has significant needs including most Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). These needs can be met according to the documentation provided in the allotted time. Additional services, specifically services in the nocturnal hours, are not noted to be medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Rule out infantile spasms

Treatment: Inpatient admission

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

This patient is a female who was brought to the emergency department after having multiple episodes of eye rolling and abnormal body movements up to 10-20 episodes on the day of admission.  During one episode the patient dropped a piece of food from her right hand.  The patient had a previous similar episode 2 weeks prior and had also been having increased episodes of emesis.  Her vital signs were temperature of 36.5 degrees Celsius, blood pressure 99/61, heart rate 118, respiratory rate of 32.  Neurology was consulted and recommended admission for video Electroencephalography (EEG) to rule out infantile spasms.  She was admitted to the hospital. The EEG was negative for seizure activity, and was discharged.

Admission was denied as not being medically necessary. The health care plan did not act reasonably and with sound medical judgment and in the best interest of the patient. These guidelines do not address individuals who are being evaluated for possible seizures.  In this instance, the Neurologists were concerned about possible infantile spasms which require an inpatient admission and video EEG monitoring. The patient was exhibiting repetitive, stereotyped movements that were concerning for seizure. Therefore, the inpatient admission was medically necessary for this patient.

"A systematic review and meta-analysis was conducted to assess seizure recurrence after a first unprovoked seizure and found that in a child who is neurologically normal with no history of prior neurologic illness has a recurrence risk of 25 percent of having an additional seizure in the next 1 year and a 45 percent risk over the next 3 years" (Garcia Pierce, J. et al. 2017). "Long-term EEG in adults includes three modalities: sleep deprived-EEG lasting 1 to 3 hours, 24 hours ambulatory-EEG and continuous prolonged video-EEG lasting from several hours to several days. The main indications of long-term EEG are: syndromic classification of epilepsy; search for interictal discharges when epilepsy is suspected or for the purpose of therapeutic evaluation; positive diagnosis of paroxysmal clinical events; and pre-surgical evaluation of drug-resistant epilepsy. Sleep deprived-EEG and ambulatory-EEG are indicated to detect interictal discharges in order to validate a syndromic classification of epilepsy when standard EEG is negative" (Michel V. et al. 2015).

"For new-onset seizure, appropriate work-up includes imaging and EEG to help determine the cause and type of epilepsy. Current definition of epilepsy includes patients with one unprovoked seizure with a probability of further seizures or two seizures separated by a 24-hour period." (Stafstrom, C. E. et al. 2015)                                                         

Based on the above, the medical necessity for the inpatient admission is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Malpositioned teeth
Treatment:  Dental Orthodontic Procedure 

The patient  with severe maxillary and mandibular crowding.  Tooth #22 has erupted labial within the arch due to lack of space. 
The health plans determination is upheld in whole. 
Orthodontic treatment is not medically necessary.  Tooth#22 is crowded, but it has erupted successfully.  There are no indications of gingival recession or pathology from the tooth position of #22.  It is not as if the tooth was so crowded it was prevented from erupting, which left untreated it could damage the roots of other permanent teeth leading to more invasive and procedures than orthodontic treatment.
While the patient has crowded teeth, there is no indication supplied of a functional impairment due to the position of her teeth. There is no evidence of wear or periodontal recession, and no narrative of potential tooth pain has been supplied.  If the  teeth were corrected it would provide an esthetic improvement, but it would not create a medically significant improvement to the patient's health.  In the Handicapping Labio-Lingual Deviation (HLD) scoring from the provider there was documentation of anterior open bite.  This patient has lost all her primary teeth, but there is not complete eruption of teeth yet, as indicated by incomplete eruption of the maxillary canines and lack of eruption of the second molars.  Maxillary canines typically do not even erupt until 11-12 years old (2).  In patients such as this simply allowing time for these teeth to erupt more may likely close the anterior open bite.
Therefore, orthodontic treatment of braces is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Migraine headache
Treatment:  Aimovig

The treatment with Aimovig is not medically necessary.

The patient is a female with migraine headache disorder.  She has tried and failed duloxetine, metoprolol and gabapentin for migraine prevention. 

There is no documented reason as to why the patient cannot be treated with the preferred formulary agents.  The preferred formulary agents are considered first line standard of care oral migraine preventive agents.  There are no high quality clinical trials or standard of care guidelines supporting that Aimovig is superior or should be used preferentially to the preferred agents.  The preferred formulary agents are Topiramate, Divalproex delayed-release or extended-release tablet, and Amitriptyline.
Appeal type: Medical necessity
Decision: Upheld

Osteoarthritis
Nursing Services (including Private Duty Nursing)

The patient is a female with past medical history significant for pelvic fracture, vertebral compression fracture, osteoarthritis, gait abnormality, insomnia, squamous of carcinoma of the skin of the face, chronic pain, stress incontinence, hypertension, weakness, dizziness and repeated falls.
This review is for medical necessity of increased personal care worker service, level 1, 7 days a week 24 hours per day for total of 168 hours per week. This is the subject under review. 

The health plan's determination is upheld. The Increase in Personal Care Worker (PCW) Service, Level 1: Continuous Care by More Than One Person, 7 Days per Week/24 Hours per Day (168 Hours per Week) is not medically necessary for this patient. The time allotted by the health plan is adequate to meet the patient's needs. Additional service hours are not noted to be medically necessary. The patient is able to walk transfer and toilet with help and the use of an assistive device, walker. Bladder continence is noted to be occasionally incontinent according to documentation, but is noted to be less than daily.
The patient requires assistance with most activities of daily living and IADLs (Instrumental Activities of Daily Living). However, these tasks can be completed during the allotted time. There was a notation that the patient did have a recent fall resulting in a compression fracture. However, the patient is still able to ambulate with an assistive device, walker.
There was a notation in the overnight history that the patient gets up a few times a night to use the bathroom. This is not unusual. There is no evidence in the record noting that the patient needs frequent turning or nocturnal treatments other than help with the bathroom. There is no noted sacral wounds or other associated non-healing ulcers, requiring repositioning and the necessity for nocturnal aid. Treatment for nocturnal incontinence if necessary can be provided by alternate means.
Safety monitoring without medical necessity for an activities of daily living (ADL) or Instrumental activities of daily living (IADL) is typically not a covered service. Splitting the shift into 2 separate shifts may be a better use of her time for these needs. But additional hours are not medically necessary based upon the documentation provided.