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

Diagnosis: Migraines.

Treatment: Ajovy.

The insurer denied coverage for Ajovy.

The denial is overturned. 

This female patient has a history of migraines.

The physical examination does not reveal any significant abnormalities.  She is alert and oriented, and coordination and reflexes are normal.  The physician indicated the headache frequency and intensity has improved with the addition of Ajovy.  The medication is well-tolerated and should be continued.

These therapies have been shown to be safe without additional safety concerns in the young patients.

This patient has failed previous treatments including topiramate and nortriptyline.

These drugs previously tried do not have primary indication in migraines.

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

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

Diagnosis: Spinocerebellar Atrophy. 
Treatment: Genetic testing for inherited conditions. 

The insurer denied coverage for genetic testing for inherited conditions. 	

The denial is overturned. 

This case involves a patient seen for a follow-up regarding balance difficulties.  She stated she had slurred speech at times.  She has more difficult times when she is in a dark room and also has complaints of numbness and tingling to her hands and fingers.  She was initially seen and underwent a brain MRI (magnetic resonance imaging).  The physical examination revealed she was alert and oriented.  The motor examination revealed 5/5 strength with intact sensation.  Reflexes were normal.  The physician indicated she has progressively worsening balance difficulties with paresthesia and therefore it is recommended she undergo a MRI of the brain and cervical spine.  The documentation indicated that the patient was recommended to undergo genetic testing based on clinical signs for spinocerebellar atrophy.  She had an MRI showing cerebellar atrophy and a small cervical cord volume to support the diagnosis.  The physician indicated genetic testing was needed in order to counsel family regarding risks for other family members. 

The patient's MRI and clinical picture are consistent with a diagnosis of spinocerebellar atrophy, which is a broad category that includes numerous genetic syndromes, each with distinct pathophysiology, prognosis and treatment options. In earliest stages, many of these appear similar by imaging and MRI, and therefore genetic testing is needed for a precise and potentially actionable diagnosis. 

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 genetic testing for inherited conditions performed is overturned. Medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left Middle Cerebral Artery (MCA) Infarct. 

Treatment: Continued Care. 

The insurer denied coverage for continued care. 

The denial is upheld. 

This is a patient who developed a left middle cerebral artery (MCA) infarct with resulting hemiplegia, aphasia and dysphagia.  She was originally hospitalized for stroke, and subsequently admitted to subacute rehab.   The patient was transferred to the hospital with septic shock and readmitted. She was approved for skilled services including physical therapy (PT), occupational therapy (OT) and speech therapy (ST).  She was discharged from skilled services. 

The patient was initially an appropriate candidate for subacute rehabilitation at the Skilled Nursing Facility (SNF) (1, 2, 3).   She had functional (mobility, activities of daily living and communication) deficits that were potentially amenable to comprehensive rehabilitation.  Unfortunately, progress was limited.  The patient remained totally dependent to maximal assistance for bed mobility and transfer tasks.  She remained non-ambulatory.  A similar level of dependence was documented by the OT; with maximal assistance for dressing, bathing and toileting activities.  Swallow and oral (PO) intake improved; however, she remained aphasic (expressive and receptive).  There were no acute medical or complicated nursing issues to support continued skilled nursing facility (SNF) level of care.  Wound care was routine.  The patient could have been safely transferred to a lower level of care (e.g., long term care or home care with visiting nursing services). 

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

From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, continued care was not medically necessary. 

The insurer's denial of coverage for continued care is upheld. Medical Necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Tinea Unguium
Treatment: Formulary exception for Tavaborole
The insurer denied the Formulary exception for Tavaborole
The denial is upheld 

The patient is a female. The patient has been using Tavaborole topical antifungal for several years.

Pathology report was positive for onychomycosis.

No, the health plan should not cover the Formulary exception for Tavaborole.

The formulary drugs would are likely to be more effective than the topical. There is no documented indication that the patient had or would have adverse effects to the oral itraconazole or terbinafine alternatives. The oral medicines are effective for the indication of onychomycosis, and the patient's provider has not documented why the patient would be unable to use the oral formulations.

Therefore, given the above, the health plan should not cover the formulary exception.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic dermatitis. 
Treatment: Dupixent Syn 300. 

The insurer is denied coverage for Dupixent Syn 300. 

The denial is upheld. 

This male patient has a history of atopic dermatitis. 

The requested medication Dupixent is not medically necessary based on the standard of care, and there are no unique clinical circumstances to this particular individual in the documentation provided that would make it medically necessary.  It is noted that the patient has a diagnosis of atopic dermatitis, and the patient has failed therapy with topical steroids and tacrolimus ointment.  However, the patient has no true contraindications to the conventional medications commonly used for atopic dermatitis. 

According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the conventional medications such as topical steroids, protopic, elidel, and methotrexate are effective treatments for the management of atopic dermatitis. 

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 Dupixent Syn 300 is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Artery Disease (CAD), Diabetes and congestive heart failure (CHF)

Treatment: Personal care assistant (PCA) services of 7 days times 24 hours (split shift)

The insurer denied coverage for personal care assistant (PCA) services of 7 days times 24 hours (split shift)

The denial is overturned.

This case involves an elderly female with a history of coronary artery disease status post 3 stents, angina, congestive heart failure, hypertension, peripheral vascular disease, diabetes, arthritis, prior hip fracture in addition to a fall resulting in an additional fracture to the right ulna.  It is noted she is wheelchair-bound.  The documentation indicated she has been amended for increased home care hours to 12 hours a day due to her being totally dependent on others.  The documentation does include discharge summary where it was noted her indication for admission was due to a fall causing a nondisplaced right hip fracture.  The documentation does indicate she is insulin-dependent.  The patient was consulted by orthopedics where she was placed in a right upper extremity posterior splint and was recommended to be weightbearing as tolerated to the right lower extremity.  She did not undergo surgical intervention.  She was offered rehabilitation; however, the family refused and requested the patient be discharged.  She was discharged with a wheelchair in addition to pull-ups and a commode and was given oxycodone in addition to Tylenol.

The patient has multiple medical issues including coronary artery disease (CAD), diabetes and congestive heart failure (CHF). She has sustained three falls which resulted in a fracture every single time. She is said to be wheelchair bound and dependent on others for all her activities of daily living (ADL).
 
Based on the provided information this lady has been declining and is at extremely high risk for adverse events due to her high fall risk from increased frailty and debility. She is also at higher risk for hospitalization due to her underlying comorbidities. She is appropriate to receive the requested PCA services of 7 days x 24 hours (split shift) due to all the reasons mentioned.

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

Based on the above, the medical necessity for the requested Personal Care Assistant (PCA) Services of 7 days times 24 hours (split shift) is substantiated. The insurer's denial is overturned.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chest Pain.
Treatment: Inpatient admission.
The insurer denied the inpatient admission.
The denial is upheld.

The patient is a male. He presented to the ED (emergency department) for evaluation of chest pain, and he was hospitalized.

The patient underwent cardiac catheterization and had a drug-eluting stent placed to the proximal RCA (right coronary artery). TTE (Transthoracic Echocardiogram) showed low normal LV (left ventricle) systolic function. There were no acute changes overnight, and he was discharged to home the following day.

This is an appeal of the denied claim that the requested service was medically necessary for this patient.

No, the Inpatient admission was not medically necessary.
Based on the peer-reviewed medical literature and this reviewer's expert medical opinion, there was not a medical need for the acute inpatient hospital stay. The severity of this patient's illness did not meet the intensity of service for inpatient hospital stay. In the medical records available for review, there was no evidence of acute myocardial infarction (AMI), ACS (acute coronary syndrome), PE (pulmonary embolism), aortic dissection, pneumonia, or hypertension requiring inpatient hospitalization or any other medical condition, symptom or finding for which a lower level of care had failed or was not considered appropriate. The care that the patient received, including urgent cardiac catheterization with successful PCI (percutaneous coronary intervention), as in this case, is routinely provided safely and effectively at a lower level of care. Therefore, based on the submitted information and the current published medical literature, the proposed treatment is not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Right knee pain
Treatment: Joint Surgery (removal of one knee cartilage using an endoscope, repair of anterior cruciate ligament or knee)
The insurer denied the Joint Surgery (removal of one knee cartilage using an endoscope, repair of anterior cruciate ligament or knee).
The denial is overturned.

This patient is a male who reported a five day history of right knee pain. He stepped awkwardly and twisted his knee. He was found to have tenderness, effusion and positive Lachman. An magnetic resonance image (MRI) showed an anterior cruciate ligament (ACL) tear and possible meniscal tear. He underwent an anterior cruciate ligament (ACL) reconstruction with partial medial meniscectomy.

Yes, the proposed surgery was medically necessary.
There was evidence of a traumatic injury with resultant anterior cruciate ligament (ACL) deficiency and torn meniscus. The patient had instability and effusion. A pain generator had been defined. His ligament and meniscus was torn. This type of injury will not heal with conservative management.

Per the Evicore guidelines:
Meniscal surgery:
Conservative treatment is not required if at least two of following four criteria are met:
1) Positive McMurray's or positive Thessaly test
2) twisting or acute injury of the knee , MET
3) locked knee/inability to fully extend the knee  NOT MET
4) knee effusion, MET

The meniscus tear is traumatic; it is different than degenerative. The patient has a new injury from trauma. There would be no restriction to performing the surgery.  As criteria met, the surgical procedure would be indicated.

The records were consistent for a traumatic event and resultant instability. The magnetic resonance image showed a torn ligament and torn meniscus. The next step would be surgery to repair the damage.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Acute Myelogenous Leukemia (AML)
Treatment: Venclexta 10mg TAB, Pre-service
The insurer denied the Venclexta 10mg TAB, Pre-service.
The denial is overturned.

The patient is a male with a history of refractory AML who has failed standard induction chemotherapy with dexrazoxane, cytarabine and Gemtuzumab, which failed then mitoxantrone and cytarabine. The provider is recommending he be treated with venetoclax and decitabine.

Although 50-70% of children who are newly diagnosed with acute myeloid leukemia can be cured with frontline therapy, those with relapsed disease have a dismal outcome with further chemotherapy and allogeneic bone marrow transplant is the only known curative therapy. Ventoclax and decitabine have been shown to be a safe and effective combination to treat patients with refractory AML (acute myeloid leukemia). Although most of the data is in adults, there is sufficient information to support the use of this combination in children. The reported response rate is 65% and in one pediatric report of eight patients who received this regimen, six have had responses including three with CR (complete remission), all of whom became MRD (minimal residual disease) negative. There are no other known more effective therapies. Therefore the use of venetoclax and decitabine would be considered medically necessary for this patient.

The patient has failed standard chemotherapy for the treatment of acute myelogenous leukemia. It is the standard of care to offer venetoclax and decitabine to patients with refractory to AML (acute myeloid leukemia) and this combination has been shown to be effective in pediatric patients.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atrial fibrillation, coronary artery disease, cerebral embolism with cerebral infarction

Treatment: PCA (Personal Care Aide) level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week

The insurer is denied coverage for PCA level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week.

The denial is upheld. 

The patient is a female with a past medical history of atrial fibrillation, coronary artery disease, cerebral embolism with cerebral infarction, depression, dysarthria, hyperlipidemia, hyperparathyroidism, hypertension, hypertrophic cardiomyopathy, osteoarthritis, spastic hemiplegia affecting nondominant side, and type 2 diabetes mellitus. The patient's past surgical history includes appendectomy and pacemaker placement. According to a Uniform Assessment System (UAS) assessment done, the patient reported that she needs help for all her daily activities and others. The patient lives alone in a 1-bedroom apartment on the second floor of walkup apartment building, 20 steps approximate. 

The patient requires assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) due to pain and stiffness related to osteoarthritis, shortness of breath, fatigue/weakness, unsteady gait, and other health problems. She needs extensive assistance with most functions and limited assistance for bed mobility. She has occasional urinary incontinence and has cognitive problems. Findings in Uniform Assessment System (UAS) done are similar. Task Sheet indicates 35 hours/week. 

An increase to Personal Care Aide (PCA) Level 2 services of 12 hours per day, 7 days per week for a total of 84 hours per week is being requested.

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

(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.

Task Sheet indicates 5 hours/day. At issue is a denial of 12 hours/day instead of 7. She does need more cueing and supervision. The documentation does not establish what tasks need to be performed during the extra 5 hours/day beyond supervision/cueing.

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

The insurer's denial of coverage for the requested Personal Care Aide (PCA) Level 2 Services of 12 hours per day, 7 days per week for a total of 84 hours per week is upheld. Medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Hypercholesterolemia

Treatment: Praluent (alirocumab) 75 milligrams per milliliter (mg/mL)

The insurer denied coverage for Praluent (alirocumab) 75 milligrams per milliliter (mg/mL).

The denial is overturned.

The patient has a history of hypercholesterolemia despite maximally tolerated statin therapy plus ezetimibe.  Past medical history includes diabetes, recurrent syncope, deep vein thrombosis and asthma. Medical records document myalgia on multiple statin medications including pitavastatin, pravastatin and simvastatin. She also has an "allergy" listed to atorvastatin. While on rosuvastatin 10mg [milligrams] and Zetia 10mg,  low-density lipoproteins (LDL) cholesterol was 194mg/dl.  She did not tolerate rosuvastatin at the 20mg dose due to myalgia.  Praluent (alirocumab) was prescribed).

The health plan did not act reasonably, with sound medical judgment and in the best interest of the patient. This patient's cholesterol panel prior revealed a total cholesterol of 291, a high density lipoprotein (HDL) of 44 and an low density lipoprotein (LDL) of 194.  This patient could not tolerate statin therapy in doses sufficient to reduce LDL cholesterol below guideline recommended level (less than 70). Current American Heart Association and American College of Cardiology guidelines clearly note that in patients with no documented atherosclerotic cardiovascular disease and LDL cholesterol greater than or equal to 190mg/dl and statin associated muscle symptoms or recurrent muscle symptoms (despite appropriate rechallenge), randomized trial proven non statin therapy should be considered. (Reference 1) Alirocumab was demonstrated to reduce major adverse cardiovascular events by 15% (percent) in the Fourier randomized clinical trial (2).  American Heart Association/American College of Cardiology (AHA/ACC) guidelines recommend the use of PCSK9 (gene for making protein) inhibitors in patients without atherosclerotic coronary disease and LDL levels greater than 189 mg/dl in patients on maximally tolerated statin therapy. (Reference 1).  Medical records clearly indicate that this patient suffered from statin induced myalgias on multiple agents.  Given these findings, Alirocumab(Repatha) therapy is medically necessary and is the current standard of care according to recent guideline statements. (Reference 1,3).  

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 Praluent (alirocumab) 75 milligrams per milliliter (mg/mL) for the treatment of high cholesterol is reversed. Medical Necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Pneumonia/Asthma Exacerbation

Treatment: Acute inpatient hospitalization

The insurer is denied coverage for acute inpatient hospitalization

The denial is upheld. 

This male patient has a history of asthma, diabetes, gastroesophageal reflux disease (GERD), obesity, latent tuberculosis, hypertension, pulmonary embolism, laminectomy and seasonal allergies.

This patient did not need acute inpatient hospitalization. He could have been placed in observation status while diagnostic testing and treatment initiated.
The patient could have placed on observation for up to 48 hours.
The patient had a transient episode of desaturation to 84 % (percent) on room air (RA). The patient was managed with supplemental oxygen (O2).

The patient's saturation improved over next day or so. Requited 1 liter oxygen  and subsequently was discharged. the patient was described to be in no acute distress.
vital signs were: Temperature 96.1, Heart Rate 83, Respiration Rate 19, Blood Pressure 131/87. Oxygen saturation was 98% on 2 liters of oxygen. The lung exam revealed mild wheeze and some decrease in air entry. The rest of exam was unremarkable.

This patient was stable to have been placed on Observation and then subsequently discharged home on oral steroids, bronchodilator (BD) and other maintenance medications.

the patient's asthma had responded after treatment in the emergency department and the patient did not have pneumonia or pneumothorax. Even if pneumonia was present it was mild. The patient did not receive antibiotics after admission.

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 acute inpatient hospitalization is upheld.  The medical necessity is not substantiated.