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

Diagnosis: Chronic obstructive pulmonary disease (COPD) 
Treatment: Inpatient admission 
The insurer denied coverage for the inpatient admission.
The denial is upheld.

The patient has a history of (H/O) chronic obstructive pulmonary disease (COPD) and hypertension (HTN). She presented to the emergency department (ED) on with complaints of (C/O) shortness of breath (SOB) for 2 days which was getting worse progressively. The patient also reported some near syncope. At presentation to the ED, the patient was hypertensive with blood pressure (BP) 190/100 mm Hg (millimeters of mercury) and was given sub-lingual Nitro. She was placed on bilevel positive airway pressure (BiPAP) and given a Combivent nebulizer.

The patient was ill appearing and noted to have decreased breath sounds and faint wheezing and was using some accessory muscles. She was admitted to rule out (R/O) acute coronary syndrome (ACS), congestive heart failure (CHF), and a chronic obstructive pulmonary disease (COPD) exacerbation.

The patient was treated with intravenous (IV) steroids, bronchodilators (BD) and Magnesium. Labs revealed a white blood cell count (WBC) 7K (thousand), Hb (hemoglobin) 11.3, VBG (venous blood gas) 7.26/65/22/29.

Chest x-rays (CXR) revealed no acute infiltrates or effusion or pneumothorax (PTX). Some hyperinflation was noted.

As per the admission history and physical (H&P), Vital signs (V/S) were Blood Pressure 123/64, Heart Rate 76, Respiratory Rate 21, oxygen (O2) saturations 99% on room air. The patient was alert and oriented (AAO x3) and in no acute distress (NAD). Bilateral rhonchi were noted. The patient was continued on Steroids, BD (bronchodilators), Symbicort and Singulair.

Other Labs: D Dimer Negative, Troponin and CPK (Creatine phosphokinase) WNL (within normal limits) and an ECG (electrocardiogram) - No acute ST-T (interval on an ECG) Changes

The patent was on BiPAP (bilevel positive airway pressure) 14/7 50 % FIO2 (fraction of inspired oxygen) and improved with treatment.  Repeat atrial blood gas (ABG) was 7.36/43/241/24.

She was cleared for discharge (DC) on oral (PO) steroids and broncho-dilators (BD).

This patient could have been placed in Observation status while diagnostic testing and treatment were initiated. Observation could be for up to 48 hours with discharge home on oral medications and close follow up (FU) in an outpatient setting. There was no evidence of myocardial infarction (MI), congestive heart failure (CHF) or pneumonia (PNA). The patient improved rapidly after treatment in the ED.  She was taken off BiPAP and was stable on nasal cannula and room air. 

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 inpatient admission services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary artery disease, diabetes, gait instability and Alzheimer's dementia
Treatment: Increase Home Care/Personal Care HHC-level 2 - 15 minutes Increase To 24 Hours A Day (live in)
The insurer denied Increase Home Care/Personal Care HHC-level 2 - 15 minutes Increase To 24 Hours A Day (live in).
The denial is overturned.

The patient is an elderly female who reportedly has multiple comorbidities including coronary artery disease, diabetes, gait instability and is suffering from Alzheimer's dementia. Over the past two years, the patient has been having worsening physical and functional status. The patient has progressive dementia. The patient is not able to take care of herself. Her biggest issue is functional and physical capability. She needs assistance with all her ADLs (activities of daily living). The patient cannot eat by herself. She needs help with eating, bathing, transfers. She requires constant care by her aides. The request is for increased home care/personal care to 24-hour a day live-in. Previously, the health plan approved personal care services 49 hours/week.

The requested Increase Home Care/Personal Care HHC (home health care)-level 2 - 15 minutes Increase To 24 Hours A Day (live in) is medically necessary.
The patient has multiple comorbidities, including coronary artery disease, diabetes, unsteady gait and Alzheimer's dementia. The patient lives alone. The patient demonstrates unsteady gait. The patient needs maximum to total assistance with all aspects of ADLs (activities of daily living) and IADLs (instrumental activities of daily living). The patient uses pull-ups and needs to be changed three to four times daily. The patient has been found at home multiple times covered in her feces. The patient has significant physical and functional decline. The patient has progressive neurologic condition, dementia which is likely going to worsen. The patient needs help both during daytime and nighttime. The requested increase in personal care services to 24 hours a day, live-in, is medically necessary and appropriate to ensure the patient's safety. The plan-approved 49 hours/week is not sufficient, because the patient has dementia and needs frequent help and reminders both during daytime and nighttime. The increase in personal care services is medically necessary and appropriate.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Diabetes, hypertension, coronary artery disease (CAD), dementia, and arthritis
Treatment: Increase in personal care services (PCS), 24 hours a day (live-in), 7 days a week, a total of 91 hours a week
The insurer denied the increase in personal care services (PCS), 24 hours a day (live-in), 7 days a week, a total of 91 hours a week.
The denial is overturned.

This elderly female has extensive medical history associated with functional impairment. The patient lives alone and needs assistance for all instrumental activities of daily living (IADLs) and activities of daily living (ADLs). One family member provides some informal help, but the patient relies primarily on personal care services (PCS) for assistance with daily activities. The insurer approved PCS 84 hours per week (12 hours per day). The patient's daughter (as patient designee) requested an increase of PCS to 24 hours per day, live-in services, which was denied. An external appeal was requested.

The most recent Uniform Assessment System (UAS) provided was reviewed. Functional status for IADLs indicated the patient is totally dependent for ordinary housework, meal preparation, shopping; she needs maximal assistance for managing medications and finances, phone use, stairs, transportation. For ADLs, the patient needs maximal assistance for bathing, dressing lower body; extensive assistance for personal hygiene, dressing upper body, transfer toilet, toilet use, walking, locomotion; limited assistance for eating, bed mobility.
The prior UAS was reviewed. The only difference in ADL function between the two assessments was bed mobility; reported as setup help; and limited assistance.

As per NYS (New York State) regulations for personal care services, in order to qualify for 24-hour live-in services, the patient's care needs must be sufficiently infrequent so that the aide can have 5 uninterrupted hours of sleep in an 8-hour sleep period per day. There are no nighttime activity logs available to help determine the frequency of the patient's nighttime ADL needs. However, the available information supports the patient's need for assistance with daily activities that extend from morning to evening; plus at least some nighttime ADL care (e.g., toileting/ incontinence care, bed mobility). The UAS does not indicate difficulty sleeping or frequent nighttime activity by the patient; and so, it appears her care needs can be met with live-in services. At night, assistance with ADLs (e.g.,toileting/incontinence care) can be provided before and after the aide's 5-hour sleep period. 

Recommendation is given to approve an increase in Personal Care Services, 24 hours per day (live-in), 7 days per week, for a total of 91 hours per week.

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

The medical necessity for personal care services (PCS), 24 hours a day (live-in), 7 days a week, for a total of 91 hours a week services is substantiated.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Uterine Fibroids
Treatment: Radiofrequency Ablation of Symptomatic Uterine Fibroids (0404T)
The insurer denied Radiofrequency Ablation of Symptomatic Uterine Fibroids (0404T).
The denial is upheld.

The patient is an adult female who was recommended treatment of her uterine myomas using radiofrequency ablation. Coverage was denied as this treatment was deemed not experimental/investigational (unproven).

The health plan should not cover the proposed treatment.
There are no data from well conducted, large, prospective trials to show that use of this treatment is safe, and/or effective. It is not standard of care, it is not supported by peer reviewed data, and it is not supported by professional organizations.
The requested health service or treatment is not more beneficial than any standard treatment for the patient's condition or disease.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Chronic eustachian tube dysfunction
Treatment: Procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral)
The insurer denied coverage for procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral)
The denial is upheld

This is a case of an adult who underwent ear tube placement and balloon eustachian tube dilation. The patient has been treated for chronic eustachian tube dysfunction with nasal steroids. A nasopharyngoscopy was normal, and audiogram was normal with normal tympanograms. The patient also may have temporomandibular joint (TMJ) and gastroesophageal reflux disease (GERD).   

Eustachian tube balloon dilation appears to be associated with improvement in subjective and objective treatment outcome metrics. The improvement appears stable at 3 to 12 months after dilation. Patients with eustachian tube dysfunction are likely to benefit from balloon dilation, particularly those with medication-refractory disease.

It is approved by the Food and Drug Administration (FDA) and endorsed by the American Academy of Otolaryngology.

The patient is not a good candidate for the requested procedure. The patient had a normal audiogram and normal tympanogram prior to procedure.

The requested procedure is not the best available treatment for this patient at this time. The patient needs to have TMJ, and GERD ruled out as a cause of symptoms.

The adverse risks are not increased over standard treatment/services.

This patient has chronic eustachian tube dysfunction, especially in the setting of baro challenge. The patient also has possible TMJ and GERD. The audiology work up does not show abnormal tympanograms or conductive hearing loss. Due to normal audiology work up, it is not clear if balloon eustachian tube dilation is indicated in this patient. 

In summary, the denial of  procedure code 69706 (nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral) and coverage for the requested service/treatment should be upheld. This treatment is not likely to be more beneficial than any standard treatments for this patient's condition and the adverse risks are not substantially increased over standard treatments.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic idiopathic urticaria.
Treatment: Xolair dosed 300mg (milligrams) every 14 days
The insurer denied Xolair dosed 300mg every 14 days.
The denial is overturned.

The patient is an adult female with chronic urticaria associated with mast cell activation syndrome. Treatment has included Xolair 300mg (milligrams) every 4 weeks, which has improved her symptoms. However, her symptoms are not adequately controlled, and a higher dose of Xolair is being requested. Other treatments have included cimetidine, levocetirizine, famotidine, montelukast, fexofenadine, cetirizine, Benadryl, and corticosteroids.

The health plan denied coverage of the request because the requesting dosing was considered experimental/investigational. The reason for the appeal is that Xolair has been used in higher doses for urticaria and other conditions and that in this case, Xolair has been effective, but a higher dose is needed.

The health plan should not cover the requested health service.

In this case, the patient has chronic urticaria and has had some benefits with Xolair at the approved dose of 300mg (milligrams) every 4 weeks. Some studies suggest the effectiveness of higher doses of Xolair; however, these studies are all observational studies as reviewed by Metz and colleagues in 2020. There are currently no published randomized placebo-controlled clinical trials that support the safety and efficacy of higher doses of Xolair for use in patients with chronic urticaria. Additional studies are needed to determine the safety and efficacy of this dose for this indication.

In this case, it is not clear that a higher dose of Xolair would be more beneficial than any standard treatment for chronic urticaria.

The patient is currently receiving standard treatment, and other treatment options may be considered per guidelines published by Bernstein and colleagues in 2014. There are the most current United States-based guidelines for the management of chronic urticaria. It is not clear that increasing the dose of Xolair would be effective as there are only observational studies to support this strategy.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Chronic idiopathic urticaria.
Treatment: Xolair dosed 300mg (milligrams) every 14 days
The insurer denied Xolair dosed 300mg every 14 days.
The denial is overturned.

The patient is an adult female with a diagnosis of chronic idiopathic urticaria (CIU). The health plan denied coverage of the requested Xolair, as a higher dose than the FDA (United States Food and Drug Administration)-approved dosing has been requested for Xolair.

The health plan should cover the requested Xolair (dosed 300 milligrams every 14 days).

The patient has idiopathic mast cell activation syndrome and associated chronic idiopathic urticaria (CIU). She has had CIU (chronic idiopathic urticaria) for many years. She has improved on Xolair but continues to have symptoms despite also taking fexofenadine three tablets twice per day, montelukast, cromolyn 200 milligrams four times per day, and cimetidine 400 milligrams twice per day. She takes systemic steroids often due to her hives.

There is evidence from several observational, retrospective, and real-world studies that assessed up dosing of omalizumab up to 600 mg (milligrams) in patients who either failed or had a partial response to 300 mg (milligrams) of omalizumab. Overall, it was observed that up-dosing in suboptimal responders was safe and effective (Metz et al. 2020). Additionally, doses of Xolair up to 600 mg (milligrams) every 2 weeks have been approved for certain adult patients with nasal polyps, so there are reassuring safety data for high dosing of Xolair in adults. Lastly, the alternative additional medication, cyclosporine, is less specific to the treatment of CIU (chronic idiopathic urticaria) and has more adverse effects than Xolair.

It is recommended that Xolair be approved for three months to assess clinical response to this off-label higher dose of Xolair.

The requested health service is more beneficial. The alternative additional medication, cyclosporine, is less specific to the treatment of CIU (chronic idiopathic urticaria) and has more adverse effects than Xolair.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Endocrine/Metabolic/Nutritional/Other/Prader-Willi Syndrome
Treatment: Pharmacy/Prescription Drugs/Norditropin Flexpro 10mg/1.5ml, 0.3 mg subcutaneously injected daily for one year
The health plan denied the requested  Norditropin Flexpro 10mg/1.5ml, 0.3 mg subcutaneously injected daily for one year as not medically necessary. 
The health plan's determination is upheld.

This is a female diagnosed with Prader-Willi Syndrome (PWS). This request is for Norditropin. As reported; she was diagnosed with PWS since being an infant. She was started on growth hormone (GH) therapy and she was maintained on GH therapy. As per visit note , she has hypogonadism, and she is on GH therapy and estrogen therapy. She is on Nutropin 0.4 mg (0.18 milligrams/kilograms/week (mgxkgxwk).
Her Insulin-like Growth Factor 1 (IGF1) IGF1 was 109.
At a later date her IGF1 was 103.
At a later date her IGF1 was 103 (107-367).
At issue is the medical necessity for Norditropin Flexpro 10 milligrams (mg)/1.5 milliliters (ml), 0.3 mg.

The health plan's determination of medical necessity is upheld, in whole.

No. The request is not medically necessary.
GH for adults with PWS is not Food and Drug Administration (FDA) approved. [1,-2] There are a few small studies that show a small beneficial effect on fat mass and lean body mass. [5-11]
The consensus statement recognizes that patients with Prader-Willi syndrome may be growth hormone deficient. [3,4] The recommendations of the consensus statement are to test all adult patients with Prader-Willi syndrome for growth hormone deficiency.
The patient has Prader-Willi syndrome and a low IGF-I but does not have documentation of growth hormone stimulation testing. Although it is likely that the patient has growth hormone deficiency, testing of the growth hormone axis will be necessary to confirm that.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Lower extremity thrombosis
Treatment: Eliquis
The insurer has denied: Eliquis
The denial is: Upheld

The patient is a male with a history of progressive left lower extremity thrombosis while on Xarelto. The treating provider has requested Eliquis, which was denied by the plan as there are alternative formulary options, warfarin. The use of the formulary option versus the non-formulary drug is the subject under review.  

The health plan's determination is upheld.

This patient has progressed on a novel oral anticoagulant (NOAC) (Xarelto). There is a paucity of data indicating that sequential use of alternative NOACs following failure lead to different outcomes. Warfarin has a different mechanism of action and would generally be considered a treatment of choice in this clinical scenario. Documentation that this patient is not a candidate for warfarin has not been supplied. Neither the authors of UpToDate nor the peer-reviewed literature recommend a NOAC in this clinical scenario; the formulary option is reasonable and would not have adverse effects that the non-formulary alternative would.
Appeal type: Medical necessity
Decision: Upheld

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

This patient has a history of hypertension, tobacco use, chronic alcohol use and was brought by Emergency Medical Services (EMS) to the emergency department (ED) for evaluation of the acute onset of chest pain at rest. Records show that the patient described his chest pain as sharp, substernal, 9/10, associated with diaphoresis, nausea and vomiting. In the ED he was found to be hypertensive, 162/93. An electrocardiogram (ECG) showed normal sinus rhythm with nonspecific inferior T wave abnormalities. Cardiac troponins were negative. The cardiac examination was normal. The patient was admitted to telemetry under an inpatient level of care for rule out of acute coronary syndrome (ACS) versus gastritis. He was treated for a urinary tract infection (UTI), started on a proton pump inhibitor (PPI) for gastritis, and cardiology was consulted. An exercise nuclear stress test was negative for ischemia. ACS was ruled out, the patient's chest pain improved, and he was discharged home. At issue is the medical necessity of an inpatient stay.
The inpatient admission was not medically necessary. The patient presented with chest pain without objective evidence of ischemia. His cardiac troponins were negative. His HEART (History, electrocardiogram (ECG), Age, Risk factors) Score was calculated to be 3, low risk for major adverse cardiac events (MACE) events. Based on the well validated HEART pathway, evaluation and management of this patient's chest pain would have been medically appropriate and safe at a lower level of care (1, 2). Additionally, based on the 2014 American College of Cardiology (ACC) / American Heart Association (AHA) guideline for the management of patients with non-ST-elevation acute coronary syndromes, a lower level of care was appropriate in this case to rule out ACS and evaluate for ischemia with noninvasive stress testing prior to discharge (3). Inpatient level of care was not medically necessary given the patient's low risk HEART Score, lack of objective evidence of ischemia and negative stress test results. A lower level of care would have been medically appropriate, safe and supported by peer reviewed medical literature and expert consensus guidelines on non-ST- elevation acute coronary syndromes (1-3).
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Coronary artery disease
Treatment: Personal Care Aide (PCA) Services 12 Hours per Day, 7 Days per Week / 12 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours per Week
The insurer denied Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week / 12 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours per Week. The health plan's determination is upheld. 

The patient is a male with past medical history of urinary incontinence, hypertension, hyperlipidemia, osteoarthritis, coronary artery disease, diabetes mellitus type 2, venous insufficiency, AAA (abdominal aortic aneurysm), peripheral artery disease, low back pain, elevated prostate-specific antigen (PSA), chronic obstructive pulmonary disease (COPD), prostate cancer, and carotid artery stenosis who had been assigned PCA (personal care aide) services.

Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week / 12 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours per Week are not medically necessary for this patient.

There is no documentation of overnight care needs that would not allow a PCA to obtain at least 5 hours of uninterrupted sleep. There is no documentation of night logs showing overnight care needs that require assistance. There is no recommendation by the patient's medical provider of turning and repositioning every 2 hours. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, Personal Care Aide (PCA) Services: 12 Hours per Day, 7 Days per Week / 12 Hours per Day, 7 Days per Week (Split-Shift) - Total of 168 Hours per Week are not medically necessary for this patient.