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

This is a patient with a medical history of multiple episodes of diverticulitis, gastritis, hiatal hernia, hyperlipidemia, irritable bowel syndrome, depression, anxiety, and recurrent urinary tract infection. She presented to the emergency department  with several days of left lower quadrant abdominal pain and nausea. Vital signs were notable for tachycardia with a pulse rate of 108/minute, which normalized within hours. The health plan's determination is upheld.
The patient was noted to have improvement from the prior day, and improved pain on Dilaudid. Lab results showed improvement in her white blood cell count to 13.4 K/uL. A Gastroenterology consultation noted 5 days of bilateral lower abdominal pain, nausea, and a fever; no diverticulitis on magnetic resonance imaging a week prior; the consultation concluded that there was uncomplicated diverticulitis clinically improving on antibiotics, and recommended continued antibiotics, proton pump inhibitor, pain control, and advancement of diet. 
She rapidly improved on intravenous antibiotics and was discharged on oral antibiotics. In this case of diverticulitis without peritonitis, abscess, fistula, sepsis, or other complication, the inpatient level of care was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Fractured Facial Bones, Clavicle and Left Ilium
 
Treatment: Increase Consumer Directed Personal Assistance Program (CDPAP)
	
The insurer denied the Increase Consumer Directed Personal Assistance Program (CDPAP). The denial was reversed.   

This is an elderly female patient with a history of coronary heart disease, hypertension, hyperlipidemia, stroke, transient ischemic attack, end stage renal disease, renal dialysis, A-V fistula on hemodialysis, renal osteodystrophy, depression, anxiety, age related cognitive decline, dysphagia, osteoarthritis, falling, gastroesophageal reflux disease and urinary incontinence. She is status post fall where she sustained fracture of her facial bones, left clavicle, and right ilium. Post hospitalization she was transferred to a rehab facility. It was reported that she is wheelchair bound; she cannot walk or take care of herself. It was reported that the patient currently had 30 hours per week of CDPAP but was requesting an increase to 70 hours per week due to the multiple chronic medical conditions and substantial functional impairments she suffers from.

The need for additional CDPAP hours is not for safety supervision alone. Based on the patient's functional deficits and level of assistance needed for all ADLs, it is medically necessary for the patient to have a caregiver present throughout the day and night for all routine scheduled activities; and for those that occur at various and unpredictable times, including toileting, incontinence care, repositioning in bed (due to discomfort/pain, and for pressure relief).

The patient lives with several family members. In the UAS only one informal helper was identified. The circumstances of the other family members and their daily schedules are not known. The family is requesting CDPAP 10 hours per day x 7 days per week. However, the family is still providing assistance and supervision during the other hours of the day/night. Considering the request is for an increase of 4 hours per day x 5 days, plus 10 hours per day for the other 2 days of the week, it is reasonable to conclude that there are no informal caregivers who can consistently provide care for those periods of time. Assistance from informal caregivers is voluntary, as per NYS regulations for personal care services (in this case CDPAP). The family wants to keep the patient safe, and provide necessary care but are unable to do so for these additional hours each day. When informal caregivers are not able to provide necessary care for daily activities, then it is medically necessary for care to be provided by personal care services, in this case CDPAP.

The carrier's denial of coverage for an increase in Consumer Directed Personal Assistance Program (CDPAP) services at 10 hours per day, 7 days a week, for a total of 70 hours per week is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:   Muscle weakness, fatigue, pain, and dizziness
 
Treatment: Personal Care aide (PCA) Level 2 

The insurer denied the Personal Care Aide (PCA) Level 2. The denial was reversed. 

This is a an elderly female patient with a medical history of atherosclerotic heart disease, cerebral infarction, hypertension, type 2 diabetes mellitus, hypercholesterolemia, gastroesophageal reflux disease, osteoarthritis, gout, overactive bladder, urinary incontinence, glaucoma. The patient was status post hospital admission for a syncopal episode with an associated acute myocardial infarction. She was transferred to a rehabilitation facility. It was reported that the patient is housebound and has extreme difficulty walking due to muscle weakness, fatigue, pain, and dizziness. She requires constant supervision and help with her activities of daily living. 

The patient's functional status as reported in the UAS report from late 2019 indicates the patient is dependent on a high level of caregiver support (extensive or maximal assistance, or total dependence) for all IADLs and ADLs (except phone use: limited assistance and eating: supervision).  The patient is totally dependent on others for all household related tasks.  She needs extensive assistance for medication management.  For ADLs, the patient needs substantial weight-bearing assistance for all ADLs except eating. 

It is medically necessary and in the best interest of the patient to have PCA services beyond 9 hours per day. The patient's health is at risk due to confinement in bed for extended hours without assistance for toileting, incontinence needs and repositioning.  There does not appear to be an informal caregiver who can provide the necessary assistance through the night. Assistance from informal caregivers is voluntary as per NYS regulations for personal care services. Therefore, without informal caregivers to provide assistance, PCA services are medically necessary.

The carrier's denial of coverage for an increase in personal care aide (PCA) level 2 services at 12 hours per day, 7 days per week for a total of 84 hours per week is reversed.  The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Pneumonia
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission. The denial was reversed.  

This is a female patient with a medical history of asthma. She presented to the Emergency Department (ED) with complaints of chest pain, cough, and mucus. She reported using her respiratory inhalers more often than usual. She had a temperature in the ED of 102.2 with a white blood cell count (WBC) of 18,000, and a lactic acid of 4. A chest x-ray was performed that revealed a right upper lobe pneumonia. She had a pneumonia severity index (PSI) was 11; which allowed for outpatient management. She received intravenous (IV) fluids and antibiotics. The patient was discharged home when she was medically stable.

The patient was not admitted for asthma.  She was noted to have bronchial breath sounds and crackles in the right upper lobe which correlated with the diagnosis of right upper pneumonia.  She did not have any wheezing.  Her chest pain, cough and mucous were due to her pneumonia.  She initially was a sepsis alert in the ED due to the lactic acid and venous oxygen levels.  Her pneumonia severity index (PSI) scoring was 11 which meant she could be managed as an outpatient.  However, she had other co-morbidities that are considered "independent factors" that increased her need for admission including: presentation at a specific inner city hospital, asthma and nausea.(1) Following the algorithm for: Community-acquired pneumonia: Determining the appropriate site of treatment in adults(1) her vomiting (inability to maintain oral intake) placed in the group that required hospitalization. This patient required admission to the hospital. This admission is approved.

The insurer did not act reasonably, or with sound medical judgment, or in the patient's best interest.

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

Diagnosis: Idiopathic Short Stature
 
Treatment: Growth Hormone - Genotropin

The insurer denied the Growth Hormone - Genotropin. The denial was reversed.  

This is a young female patient with a medical history of idiopathic short stature. She has been on growth hormone therapy since mid-2019. In 2019 she has underwent extensive growth testing with a pre-treatment height less than or equal to -2.25 SD. The patient's height velocity for Tanner stage is poor. Her MRI was normal. Her bone age in late-2018 was 11 years at an older chronological age (CA).

Classic GH deficiency

Classic GH deficiency criteria are outlined in the consensus guidelines for the diagnosis and treatment of GH deficiency published by the GH research society(1), the Lawson Wilkins Pediatric Endocrinology Society(2, 3), and the medical guidelines for GH use provided by the American Association of Clinical Endocrinologists(4). The above referenced guidelines are the latest available guidelines from these respective societies. The diagnosis is based on auxological, biochemical and sometimes radiological findings. The auxological criteria based on consensus guidelines upon which a biochemical evaluation is to be initiated are 1) severe short stature, defined as a height more than 3 standard deviation (sd) below the mean; 2) height more than 1.5 sd below the mid-parental height; 3) height more than 2 sd below the mean and a height velocity over 1 year more than 1 sd below the mean for chronological age, or a decrease in height sd of more than 0.5 over 1 year in children over 2 year of age; 4) in the absence of short stature, a height velocity more than 2 sd below the mean over 1 yr or more than 1.5 sd sustained over 2 year. The biochemical criteria include low IGF1 or IGFBP3 or GH stimulation testing with a peak GH less than 10ng/ml .

The patient did not meet biochemical criteria. Growth hormone stimulation testing peaked at greater than 10. 

Idiopathic Short stature

Growth hormone in the treatment of idiopathic short stature (ISS) is supported by randomized controlled trials and consensus guidelines (4-9). FDA approval for this indication is for "non-growth hormone-deficient short stature, defined by height SDS less than or equal to -2.25, and associated with growth rates unlikely to permit attainment of adult height in the normal range, in pediatric patients whose epiphyses are not closed and for whom diagnostic evaluation excludes other causes associated with short stature that should be observed or treated by other means."

The patient has a pre-treatment height less than or equal to -2.25 SD. The patient's height velocity for Tanner stage is poor. The patient therefore met idiopathic short stature criteria. 

Based on the above, the medical necessity for the growth hormone therapy Genotropin is substantiated.  The insurer's denial is reversed.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic Obstructive Pulmonary Disease, Asthma Exacerbation, Acute Bronchitis
 
Treatment: Inpatient Admission

The insurer denied the Inpatient Admission.  The denial was upheld.  
This is a patient who presented to the hospital with complaints of shortness of breath with an audible expiratory wheeze secondary to chronic obstructive pulmonary disease and asthma exacerbation.  She received duo nebulizer treatments and dexamethasone while in the emergency room.  The patient was still wheezing after a couple of treatments.  The peak flow 200 L/min.  The patient's blood pressure was 135/74.  The patient's respiratory rate was 24 and the pulse oximetry was 96%.  The pattern was irregular and the respiratory depth was shallow.  The breath sounds revealed an expiratory wheeze.  The electrocardiogram revealed sinus tachycardia, possible left atrial enlargement and a septal infarct.  The patient was treated with antibiotics, Breo elliptical, and Combivent Respimat.  Peak flow rate was monitored.  A chest x-ray was performed that revealed no significant findings.  The patient was stabilized and discharged with antibiotics and oral steroids. 
The inpatient hospital services at the acute inpatient level of care were not medically necessary for this patient because the patient did not satisfy the MCG admission guidelines for bronchial asthma and asthma exacerbation.  The patient did not have unstable vital signs, there was no evidence of acute respiratory failure, she did not require ventilatory support required, and there was no prior history of asthma requiring intubation.  There was no hospitalization for asthma within past year.  There is no documentation that she has had current or recent use of oral corticosteroids for asthma.  She used more than 1 canister of inhaled beta2-agonist in past month, she had exacerbation due to allergic reaction to food, she had inadequate access to medical care or medications or that adherence to post-discharge asthma regimen cannot be assured (eg, psychosocial problems, poor adherence, no available follow-up care).  

The carrier's denial of coverage for the inpatient hospital services at the acute inpatient level of care is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain
 
Treatment: Inpatient Admission

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

This is male patient with a medical history of hypertension, immunodeficiency, depression, anxiety, and substance abuse. He presented to the hospital with complaints of chest pain for two days. He described the pain to be intermittent, sharp and present at rest. His presenting vital signs were stable. Serial troponin levels were drawn with negative results. An electrocardiogram (EKG) was performed that showed sinus bradycardia. An echocardiogram was done with negative results. The patient was treated for oral candidiasis. He was evaluated by psychiatry for vague symptoms of suicidal ideations. He was medical stable and discharged home. 

The patient presented with chest pain.  The initial evaluation in the ER was unremarkable, including non-diagnostic EKG and cardiac biomarkers. Inpatient admission was not medically necessary for this patient. The patient's care could have been provided in the observational setting, allowing for additional diagnostic testing. Further evaluation was warranted, however inpatient admission was not. There was no hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care. 

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

Based on the above, the medical necessity for the inpatient hospital admission from is not substantiated.  The insurer's denial is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Impacted teeth
Treatment:  Braces
The braces are medically necessary.

The patient has an impacted upper right lateral incisor and canine.  When there is an, "impacted permanent anterior tooth where extraction is not indicated," as is the case for both of these teeth, this is an "automatic qualifier," as per the handicapping index.  The patient needs, and is justified to receive, orthodontic benefits in this case.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Psoriasis
Treatment: Cosentyx
The proposed treatment with Cosentyx is not medically necessary.

The patient is a woman with psoriasis and psoriatic arthritis for whom Cosentyx is requested. She has tried and failed topical steroids and vitamin D derivatives.

The current treatment guidelines that are in accordance with nationally accepted standards of medical practice for moderate to severe plaque psoriasis recommend typical first line treatments such as topical corticosteroids and calcipotriene followed by typical second line treatments such as ultraviolet phototherapy, oral systemic treatments (methotrexate, acitretin, cyclosporine) or biologics. The patient has tried and failed topical treatments. 

The next appropriate treatment would be phototherapy or biologics. Since the patient is of childbearing age, use of methotrexate and acitretin are not medically appropriate. Additionally, they carry a much higher risk of adverse events, while not offering an advantage in efficacy. Cyclosporine is not an appropriate long term solution due to the side effect profile and especially in light of the patient's family history of hypertension.

The health plan offers coverage for phototherapy. There are no documented contraindications to use of phototherapy and there is no national guideline preference for biologics over phototherapy in plaque psoriasis such as in this patient. Therefore, Cosentyx is not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroenteritis

Treatment: Inpatient Admission

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

This is a female patient who presented to the Emergency Department with complaints of vomiting and diarrhea. The patient reported that she had recently returned from traveling to Pakistan. A physical exam was performed that showed no abnormal findings. Laboratory work up was performed that revealed mild elevated liver function test (LFT). An ultrasound of the abdomen was done that showed gallbladder sludge; negative for cholecystitis. Gastroenterology consulted the patient and determined the patient had a diagnosis of gastroenteritis. The patient received intravenous (IV) and IV anti-emetics. The patient's symptoms improved and she was discharged home with outpatient instructions. 

According to the MCG guidelines for inpatient admission for gastroenteritis (M-170), the clinical indications for admission include a suspected severe infection such as bloody diarrhea, severe abdominal pain, peritoneal signs, hemodynamic instability, severe and/or persistent vomiting and severe dehydration. Based on the review of this patient's clinical presentation, including vitals and physical exam, the patient did not have these clinical conditions that required the need for inpatient level of care.

This patient had gastroenteritis. The treatment that this patient received as inpatient was intravenous (IV) hydration and anti-emetics and Gastroenterology consult, which could all have been safely provided at the observation level of care.  The patient did not meet the MCG criteria for admission for gastroenteritis.  The patient did not have evidence of acute cholecystitis or liver failure.  

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

The carrier's denial of coverage for the inpatient hospital stay is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Cardiac/Circulatory Problems
Durable Medical Equipment

This is a patient with a history of tachycardia. She is otherwise healthy. For evaluation of symptomatic tachycardia, the patient underwent a Holter monitor which was normal. An echocardiogram was also normal with normal cardiac function and no significant valve disease. The patient was previously evaluated in the office by her cardiologist. Due to persistent sinus tachycardia with significantly elevated heart rates, 150 beats per minute (bpm) in the office, the patient's treating cardiologist ordered a Zio Patch Mobile Cardiac Outpatient Telemetry (MCOT) for 1 week for further evaluation of supraventricular tachycardia (SVT). The patient's health plan has denied the MCOT service as not medically necessary. At issue is the medical necessity of the MCOT.

No, MCOT monitoring is not medically necessary. Upon my review of the patient's clinical documentation which demonstrates frequent tachycardia episodes in the context of a previously normal Holter monitor result, MCOT was not medically necessary for this patient. Based on the published medical literature, an event monitor or external loop recorder would be considered the standard of care in cases such as these. As discussed in the American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Rhythm Society (HRS) guideline for the evaluation and management of patients with syncope published in Journal of the American College of Cardiology (JACC) in 2017, the diagnostic yield of an event monitor or loop recorder is better compared to holter monitor given the ability to monitor for a longer duration of time (1). In studies directly comparing 48-hour monitoring to a longer evaluation by loop recorder, the diagnosis of arrhythmia was significantly increased by loop recorder upwards of 83% compared to approximately 39% with Holter monitoring for patients with palpitations (2). Therefore, the MCOT monitoring was not medically necessary in this case.
Appeal type: Experimental/Investigational
Decision: Upheld

This is a female patient with a medical history of mitral valve repair and several episodes of thromboembolism to her finger. An echocardiogram revealed patent foramen ovale. Recommendations were made for close of the patent foramen ovale. The submitted documentation states the patient has had a total of three presumed thromboembolic events to her finger while on aspirin. After the most recent she was started on a novel oral anticoagulant (NOAC) and has remained stable. 

Patent foramen ovale (PFO) closure has been considered as an alternate treatment to medical therapy (antithrombotic, and antiplatelet) for individuals with a cryptogenic stroke and associated PFO.  Mas, et al. recently completed a large multinational randomized trial (total of 660 patients with a cryptogenic CVA and PFO followed for at least 24 months post CVA, median follow up 3.2 years) of PFO closure and antiplatelet therapy versus antiplatelet therapy alone.  There was a recurrent CVA/TIA in 1.4% of the PFO group versus 5.4% in the control (medication only) group.  The decreased recurrence of a neurologic event was statistically significant for the PFO group (p 0.002).  This study demonstrated that in this setting of a cryptogenic CVA and PFO closure with antiplatelet therapy, compared to antiplatelet therapy alone, is associated with decreased future occurrence of a CVA.  Literature regarding a PFO closure for a peripheral thromboembolism, as in this case, is limited.  No definitive association has been established.  Based on available data, PFO closure in the setting of this case, compared to medical therapy (i.e. anticoagulation) has not been demonstrated to improve vascular outcomes.

Per Sidia, B., Saleh, C., El Issa, M., & Mono, M. L. (2018), "The reviewed studies showed great methodological diversity rendering an exhaustive and balanced comparison between studies difficult.  Low recurrence rates under prevention regimens, crossovers, procedure and device related complications, as well as inappropriate patient selection might explain the inconsistency of trials.  However, despite the methodological heterogeneity certain patterns could be detected.  It appears that device closure as secondary prevention measure is an effective and safe procedure reducing the recurrence of neurological events in cryptogenic stroke patients <60 years with large PFOs.  Standardization of procedures and larger trials are needed to arrive to definitive conclusions."      

This patient is not a good candidate for the requested heart procedure (closure of a patent foramen ovale).  Literature regarding a PFO closure for a peripheral thromboembolism, as in this case, is limited.  No definitive association has been established.  Based on available data, PFO closure in the setting of this case, compared to medical therapy (i.e. anticoagulation) has not been demonstrated to improve vascular outcomes.  
The carrier's denial of coverage for the requested heart procedure (closure of a patent foramen ovale) should be upheld.