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

Diagnosis: Respiratory system/Breathing problem
Treatment: Diagnostic testing
The insurer denied the medical necessity of the Attended Sleep study.
The determination is upheld in whole.

This is the case of a patient who was referred to the sleep lab to have a sleep study. The patient has been complaining of symptoms of sleep apnea including sleepiness, snoring, hypertension, and obesity with a body mass index (BMI) of 31. The provider is requesting a sleep study to rule out sleep apnea. 

Attended Sleep Study is not medically necessary for this patient.

According to Rosen et al, A home sleep apnea test (HSAT) is an alternative to polysomnography for the diagnosis of obstructive sleep apnea (OSA) in uncomplicated adults presenting with signs and symptoms that indicate an increased risk of moderate to severe OSA.

Based on the Canadian Sleep Society, when used appropriately under the supervision of a physician with training in sleep medicine, and in conjunction with a comprehensive sleep evaluation, PM may expedite treatment when there is a high clinical suspicion of OSA.

Laratta et al considered Polysomnography as the gold standard for diagnosis of sleep apnea. However, home sleep apnea testing may be used to confirm the diagnosis in symptomatic patients with a high pretest probability of OSA and without clinically important cardiopulmonary comorbidity.

According to the American Academy of Sleep medicine (collop et al) portable or home PSG is a viable option for evaluating adults with high clinical suspicion for obstructive sleep apnea if it is performed and evaluated by a comprehensive sleep medicine program.

Review of the submitted medical information shows that the patient suffers from snoring, hypertension, obesity, and daytime somnolence. However, the patient does not have any medical (chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), neuromuscular disorder) or sleep (narcolepsy, central apnea) comorbidities that can degrade the accuracy of a home/portable study. There is no evidence the patient failed a home sleep testing or has any contraindication to a portable home sleep study. Therefore, the patient does not meet the MCG guidelines for PSG, Sleep Center. According to the peer reviewed literature and guidelines, the home sleep study is as adequate as an in-laboratory sleep study to evaluate this patient for possible sleep apnea. Therefore, the in-laboratory sleep study was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Myasthenia gravis, shingles, and viral upper respiratory tract infection
Treatment: Inpatient admission
The insurer denied the inpatient admission.
The denial is upheld. 

The patient is a female with past medical history significant for pregnancy associated hypertension, migraines, obesity, anxiety, and myasthenia gravis, on Pyridostigmine.  She presented to the hospital with complaints of sore throat for five days duration.  She was also noted to have left facial rash and pain.  Medical records noted that the patient was seen at Mount Sinai Hospital earlier in the week for myasthenia gravis flareup; she declined hospital admission for IVIG (intravenous immunoglobulin).  She was started on prednisone 10 mg daily, but discontinued after two days due to pain/burning rash.  

The patient's review of systems was positive for congestion, sore throat, cough, nausea, and rash.  She denied fever, chills, dyspnea, and eye pain.

The patient's assessment was myasthenia gravis, shingles, and viral upper respiratory tract infection. Management plan included admission to inpatient, for uncontrolled myasthenia gravis. Valtrex was prescribed for shingles.  Rapid strep was negative, and throat culture was requested.

A Neurologic consultation was completed.  Chest x-ray was unremarkable.  It was noted that the patient had mild myasthenia crisis last week.  She has no weakness except slight pharyngeal weakness which she has had for months.  Neurology recommended the discontinuation of prednisone and to reduce the dose of Mestinon. Further hospital investigation noted that throat culture was negative.

No, the Inpatient admission was not medically necessary.

The patient was hemodynamically stable on admission. There was no evidence of sepsis, change in mental status, acute respiratory failure, active hemorrhage that required blood transfusion, cardiac arrhythmia, severe heart failure, acute renal failure, and severe electrolyte abnormalities.   

The proposed treatment is not medically necessary, because the care rendered could have been performed at a lower level of care without adversely affecting the patient's health.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Buccal mass
Treatment: MRI of eye orbit, face and neck with and without contrast
The insurer denied the MRI of eye orbit, face and neck with and without contrast.
The denial is upheld. 

The patient is a male with right buccal mass of three to four months.  The patient underwent magnetic resonance imaging (MRI) of the eye orbit, face and neck with/without contrast. 

No, the proposed MRI of the eye orbit, face and neck with and without contrast was not medically necessary. 

The medical records provided were very limited. The reason for the study is only referenced on the MRI report itself as a buccal mass. There is no documentation of history or physical examination to establish the medical necessity of this imaging study.  MRI for buccal masses may be indicated when clinical decision making will be altered by the anatomical extent of a lesion, where there are other clinical findings such as facial paralysis or as a preoperative study after needle biopsy shows a necessity for surgery; however, there is no clinical information to support the medical necessity of this imaging study for this patient.  Based on the limited records provided, the patient does not meet necessity for the MRI.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Headache, Dizziness, Chills, Diaphoresis
Treatment: Inpatient admission
The insurer denied inpatient admission. The denial is upheld.

The patient is an adult male with a history of polysubstance abuse. He presented complaining of generalized myalgias secondary to having been attacked in his home. He relapsed and used heroin, and he then self-administered Narcan after he felt different. He admitted to headache, dizziness, N/V (nausea/vomiting), chills and diaphoresis.  

The patient's VS (vital signs) were as follows: Temperature 99.1, heart rate 109, respiration rate 19, blood pressure 95/60, oxygen 96% on RA (room air). His exam was remarkable for diffuse abdominal tenderness, weakness with tenderness of extremities and torso, paranoia and anxiety.  

The patient's labs were as follows: WBC (white blood count) 16.2. H/H (hemoglobin/hematocrit) 14.2/39.9. Plt (platelets) 201. Na (sodium) 136. K (potassium) 3.3. BUN/Cr (blood urea nitrogen/creatinine) 21/1.2. Troponin .13, .15. BNP (brain natriuretic peptide) 23. His EKG (electrocardiogram) revealed NSR (normal sinus rhythm), no ST elevation.  

The patient was given Suboxone in the ED. The patient was admitted for opioid withdrawal and elevated troponin.

The following day, the patient's vital signs were stable. He evidenced NAD (no acute distress). He had no signs of opioid withdrawal. He had no physical signs of significant trauma. The plan was for Pan Scans, and to discharge if the scans were normal.  

The next day, the patient signed out AMA (against medical advice).

The patient was hemodynamically stable. He had normal oxygenation. He did not have persistent tachycardia or tachypnea. He did not have tremors or perspiration. He did not have active comorbid conditions. Inpatient admission was not medically necessary, because there were no physical signs of withdrawal. The patient did not have vomiting, diarrhea, dehydration or severe electrolyte abnormalities. He did not require around-the-clock care.  

The requested Inpatient admission is not medically necessary, because it is not in accordance with generally accepted national standard of medical practice for this patient. He was without the signs of opioid withdrawal that would have required an inpatient level of care.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left patella fracture.

Treatment: Physical therapy services.

The insurer denied coverage for physical therapy services. The denial is upheld.

This patient is a female who sustained a left patella fracture after a fall.  She underwent surgical repair of the fracture and received post-surgical physical therapy.  She began physical therapy in 2019.  Currently under review is the medical necessity of physical therapy provided.

The physical therapy treatment notes do not establish the medical necessity of the additional (4th unit) codes during the structured out-patient physical therapy treatment sessions for the time period under review.  After several months of treatment the patient should have been independent with a home exercise program.  The added physical therapy 4th unit codes for therapeutic exercises (e.g., squats, step prone knee flexion, biking, and double knee to chest stretch) were no longer medically necessary.  The exercises were routine, did not require the expertise of a skilled therapist to complete since they were performed on prior visits and could have been performed independently by the patient via a home exercise program.  

The health plan acted reasonably, with sound medical judgment and in the best interest of the patient.  Including but not limited to, the clinical standards of the plan, the information provided concerning the patient, the attending physician's recommendation and applicable generally accepted practice guidelines developed by the federal government, nation or professional medical society's boards and associations were taken into consideration.  

From a physical medicine and rehabilitation/pain management perspective, as well as within a reasonable degree of medical certainty, physical therapy services provided were not medically necessary.  

The carrier's denial of coverage for the physical therapy services provided is upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Persistent hypertension

Treatment: Inpatient hospital admission

The insurer denied coverage for inpatient hospital admission. The denial is upheld.

This patient is a female with a past medical history notable for hypertension who presented to the Emergency Room (ER) with complaints of chest pain, shortness of breath, and cough.  The patient's blood pressure was elevated at 169/114, and otherwise, the patient's vital signs were stable.  The patient's chest radiography was unremarkable.  The patient had persistent hypertension in the ER.  The patient's electrocardiogram (EKG) revealed a normal sinus rhythm with no acute ischemic changes. The patient's computed tomography angiography (CTA) was negative for a pulmonary embolism.  In the ER, the patient was given hydralazine and tessalon.  The patient was admitted to the Medicine unit with dyspnea on exertion and hypertension. The patient's rapid viral panel was positive for coronavirus.  The patient's echocardiogram revealed an ejection fraction of 60-65% with normal left ventricular internal dimensions and wall thicknesses.  The care plan was implemented and the patient's blood pressure improved after treatment.  The patient was discharged after a period of medical stability.

Based on the review of the medical record, the patient's initial evaluation in the Emergency Room was unremarkable, including a non-diagnostic electrocardiogram (EKG) and negative cardiac biomarkers. There were no other high-risk symptoms suggestive of acute coronary syndrome, rather that of stable symptomatology. The patient's computed tomography (CT) scan of the chest ruled out pulmonary embolism.  Though it was appropriate and indicated for the patient's symptoms to be evaluated and her blood pressure treated, inpatient admission was not medically necessary.  The patient's care could have been provided under the observational setting, allowing for additional diagnostic testing, which was done here.  There were no high-risk or concerning findings on diagnostic testing to necessitate further inpatient evaluation.  During the patient's initial evaluation and subsequent hospitalization, there was no objective evidence of hemodynamic instability, cerebrovascular insufficiency, hypoxemia requiring supplemental oxygen or support, myocardial ischemia, or other medical conditions warranting acute inpatient level of care.  For all of these reasons, inpatient admission was not medically necessary.

The health 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 admission should be upheld.  The medical necessity is not substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

The patient is a male paraplegic with hematemesis. He was brought to emergency room for evaluation. 

The patient's emergency room evaluation showed likely bronchitis. The patient was admitted to acute in-hospital level of care. The patient received IV antibiotics, as well as monitoring for hematemesis as well as hemoptysis.  After 24 hours of care, the patient was hemodynamically stable. The patient was thought to have pneumonia, and antibiotics were continued. The patient was deemed stable to be transferred back to sub-acute rehab/skilled nursing facility.  

No, the Inpatient admission was not medically necessary.

After 24 hours of care, the patient was hemodynamically stable. The patient was thought to have pneumonia, and antibiotics were continued. The patient was deemed stable to be transferred back to sub-acute rehab/skilled nursing facility.  The entire admission was not medically necessary. The observation level of care is medically appropriate due to evidence of hemoptysis as well as hematemesis
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Leukemia.
Treatment: Formulary exception for Sandimmune 100mg/ml solution. 
The insurer denied the Formulary exception for Sandimmune 100mg/ml solution.
The denial is upheld. 

No, the health plan should not cover the Formulary exception for Sandimmune 100mg/ml solution.

The patient is a male. He presented with bruising and was found to have pancytopenia.  Bone marrow biopsy was done and revealed an aplastic bone marrow.  Treatment with Sandimmune 100mg/ml has been requested.  No additional information is provided.  This treatment is a non-formulary treatment.

Sandimmune (cyclosporine) is a standard treatment in combination with other treatments for aplastic anemia.  According the denial letter provided, both generic cyclosporine and brand cyclosporine (Gengraf) are formulary options for this patient.  There are no records provided stating why it would be medically necessary for this patient to have Sandimmune rather than one of the formulary alternatives.  Without supporting documentation, use of Sandimmune cannot be considered medically necessary in this case. There are no records saying why this specific treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Coronary Atherosclerosis
Treatment: Repatha Sureclick
The insurer is denied coverage for Repatha Sureclick.
The denial is reversed. 

This is a male patient with a history of coronary atherosclerosis, dyslipidemia and atypical chest pain. He had was successfully using Repatha along with fenofibrate 150 mg. This drug combination has kept his LDL cholesterol less than 70 MG/DL and has prevented cardiovascular events such as stroke and myocardial infarction. The pharmacy informed that patient that records must be provided documenting a reduction of LDL while on Repatha therapy. The patient has previously tried multiple statins including Crestor, Zetia and Lipitor. He was unable to tolerate these drugs because of significant myalgia. His physician concluded that this class of PCSK9 inhibitors is the only available option left for him. The patient has subclinical atherosclerosis with a calcium score of 150, He is currently taking Lipitor 80 mg daily. His vital signs were  BP 147/88, pulse 86 and oxygen saturation 99%. No abnormalities were noted on his physical exam. The summary states that the patient had mild non-obstructive coronary artery disease: specifically, there is disease within the proximal and middle LAD. The FFR CT is negative. The patient's calcium score determines was 186.  This calcium score corresponds to the 80th percentile based on the patient's age, gender and ethnicity. A statement from the insurance company states that the coverage for this medication would be approved only if there is documentation of LDL reduction while on Repatha therapy. Laboratory results recorded include cholesterol 237, HDL 49, triglycerides 169 and LDL 150. The pharmacy did not consider this an adequate decrease in LDL to justify Repatha therapy. 

Review of this record indicates that it is reasonable for this patient to take Repatha Sureclick 140 MG/ML. He has subclinical coronary artery disease (CAD). The literature cited shows that Repatha does improve the patient's lipid profile. Initial hesitation about using this drug was caused by questions concerning whether the improvement in the lipid numbers would result in improving clinical outcomes. Current studies seem to support that this is the case. The use of this medication, in this patient, is consistent with the current clinical literature. The health plan did not act reasonably with sound medical judgment. 

The carrier's denial of coverage for Repatha Sureclick is reversed. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Central Nervous System/Neuromuscular
Nursing Services (including Private Duty Nursing)

Diagnosis: Dementia of Alzheimer's type
Treatment: Personal Care Assistance Services, Level II, 24 Hours per Day/7 Days per Week (Monday through Sunday), Split Shift. 
The insurer denied the Personal Care Assistance Services, Level II, 24 Hours per Day/7 Days per Week (Monday through Sunday), Split Shift. The health plan's determination is upheld.

The patient has multiple medical problems, most notably dementia of Alzheimer's type. The patient requested level 2 personal care assistant services 24 hours a day 7 days a week, split shift Monday through Sunday. This is being requested as the patient awakens multiple times a night due to sleep disturbance.

At issue is the medical necessity of the personal care assistance services, level II, 24 hours per day/7 days per week (Monday through Sunday), split shift. The patient currently receives 24-hour day live in services. 

The health plan's determination is upheld.

The personal care assistance services, level II, 24 hours per day/7 days per week (Monday through Sunday), split shift is not medically necessary for this patient.

The services provided through 24 hour day live in services are adequate to meet the patient's medical needs and specific activities of daily living (ADLs) and instrumental activities of daily living (IADLs) s

New York State regulations do not require personal care assistant services for safety supervision alone, such as may be clinically necessary for someone with cognitive dysfunction. Personal care assistant hours for companion care or for safety supervision, without the need for activity of daily living tasks, is not indicated. Safety supervision is included as part of the total authorized personal care service hours when done during activities of daily living. Safety supervision is not indicated as a separate or stand long function.

The physical exam dated noted no skin breakdown or wounds or pressure sores. In the assessment and plan, there is no notation of decubitus ulcers or other needs which would require frequent turning of the patient at night.

There is no documentation noting that the patient needs additional assistance at night with ADLs. There is no documented need for frequent turning and/or repositioning such as decubitus ulcer. Skin exam was noted to be normal. The patient does have evidence of incontinence which typically can be managed through incontinence products such as adult diapers. There is no noted log showing that the aid must get up multiple times and cannot get adequate sleep, at least 5 hours of uninterrupted sleep. Supervision services as stand-alone services are typically not indicated. The services that are currently being provided are adequate to meet this patient's needs.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Raynaud
Treatment: Bosentan
The insurer is denied coverage for Bosentan.
The denial is reversed. 

The patient was a female with severe Raynaud from scleroderma and had been on calcium channel blockers (CCB), nitropaste, cellcept. The patient had been on Bosentan since mid 2019 has responded well to this treatment. Digital ulcers and ischemia were being prevented with this treatment. 

According to Hinze & Wigley (2018),"Comparative effectiveness studies are needed to determine which therapeutic interventions are most beneficial in patients with [Raynaud's phenomenon (RP)]. Based on the available evidence, we start with [calcium channel blockers (CCB)] and add a phosphodiesterase inhibitor if symptoms are not controlled, or intravenous prostacyclin in the setting of severe critical digital ischemia. We may additionally add an endothelial receptor antagonist [i.e., bosentan] in cases of recurrent digital ulcers." As per Cestelli et al (2017), this study "confirms the effectiveness of Bosentan, in combination with iloprost, in [systemic sclerosis (SSc)] microangiopathy." And as per Chung & Fiorentino (2014), "The study shows in patients with [systemic sclerosis (SSc)] with up to 4 years of combined therapy [with Bosentan] a progressive significant recovery in structure and function of  microvasculature linked to improved clinical outcomes, independent of disease severity."

There is literature showing that Raynaud's disease that is refractory to standard therapy with calcium channel blockers will respond to endothelin receptor agents, such as Bosentan. This is commonly use d for Raynaud's disease by rheumatologists. This treatment is used to help prevent digital tip ulcers and other morbidity such as ischemia/auto amputation that can occur in severe Raynaud's disease. Therefore, the use of Bosentan is considered medically necessary for this patient.

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 Bosentan for treatment of Raynaud's disease and
scleroderma should be reversed. The medical necessity is substantiated.