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

Central Nervous System/Neuromuscular
Home Health Services

Diagnosis: Memory Decline
Treatment: 7 hours per day, 7 days per week, total of 49 hours per week- personal care services, level 2
The insurer denied 7 hours per day, 7 days per week, total of 49 hours per week- personal care services, level 2.
The determination is upheld.


This is a male patient with a medical history notable for memory decline and depression. The patient was approved for 5 hours per day, 7 days per week (35 hours per week) of level 2 personal care services. The patient and his care team requested an increase to 7 hours per day, 7 days per week (49 hours per week) and this request was denied by the health plan.
The patient's optometrist provided a letter of support for this appeal. The letter states that the patient is being treated for glaucoma. 
The patient's physician provided a letter of support for this appeal. The letter states that the patient is not able to ambulate to the bathroom without assistance and is "almost totally dependent" for help with activities of daily living.
The patient's psychiatrist provided a letter of support for this appeal. The letter states that the patient has severe depression and panic disorder. He has fears of going out alone and of being alone in the house. 
A Uniform Assessment System (UAS) was completed and was available for review. Compared to a prior UAS, he showed a slight functional decline. A task tool associated with the most recent assessment recommended 33.1 hours per week to address his personal care needs, which was an increase from the 27.4 hours recommended on prior assessment. At issue is the medical necessity of 7 hours per day, 7 days per week, total of 49 hours per week- personal care services, level 2.

The requested health service/treatment of 7 hours per day, 7 days per week, total of 49 hours per week- personal care services, level 2 has not been demonstrated to be medically necessary for this patient.
The patient requires assistance with several personal care tasks as outlined in the letters from his treatment team and from the UAS. The letters do not describe any currently unmet personal care needs that could be adequately met with an additional two hours per day. The request for additional hours to address his anxiety and failure to keep appointments is not a level 2 personal care function. He does require assistance for IADLs and ADLs, but he is receiving 35 hours per week which is greater than the 33 hours per week recommended by the task tool. There is no clearly demonstrated personal care need that is not being met at his current allotment of hours that would be met with the additional hours requested.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Tibial fracture. 
Treatment: Inpatient admission. 

The insurer denied coverage for an inpatient admission. 

The denial is overturned. 

The medical records indicate a complex and unique clinical condition. There were several conditions which required assessment and treatment. The records show recent chemotherapy was provided. There was evidence of syncope. Her physicians recommended several studies and telemetry. This by itself would substantiate the admission. She was found to have a fracture to the distal tibia. Her orthopedic surgeon recommended placement of an intramedullary nail which was to be scheduled the day after admission. Her fractures to the spine and leg were painful conditions which required IV (intravenous) analgesia. She would not be likely to ambulate without assistance from fractures to her spine and tibia. 

These circumstances would substantiate the necessity for admission and length of stay. The services could not be provided as an outpatient. 

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 a full hospital admission is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory syncytial virus (RSV)
Treatment: Inpatient admission
The insurer denied coverage for an inpatient admission
The denial is upheld

The patient is a toddler with 3 days of upper respiratory infection (URI) and tachypnea. In the emergency department (ED), the patient was noted to not be in distress (in the ED physician note, it was documented there was "no acute distress", the patient had mild tachypnea (respiratory rate in the 30's), and a mild wheeze. The oxygen saturation was > (greater than) 95% (percent). No hemodynamic instability. Perfusion was adequate. The complete blood count (CBC) was normal. The blood gas showing a carbon dioxide (CO2) in the 30s with a bicarbonate level > 20. The respiratory viral panel was positive for respiratory syncytial virus (RSV). The chest x-ray was suggestive of a normal viral pattern. The patient was treated with nebulization and steroids. The clinical status improved. The patient was discharged with scheduled nebulization and steroids and close follow up.

There was no persistent hypoxia and no need for continuous positive airway pressure (CPAP) or high flow nasal canula (HFNC). No oxygen was required. There was no need for pressors or multiple boluses. There were no abnormal labs that persisted. We know that RSV bronchiolitis will peak in the 3rd day and will improve from thereafter. Even at the peak of the illness there was no use of continuous albuterol or epinephrine or terbutaline. Also, the patient did not have underlying risk factors such as congenital heart disease /chronic lung disease. If one were to take the Pediatric Respiratory Assessment Measure (PRAM) score to assess the pediatric asthma, it would be in the category of mild asthma. If one were to take the Pediatric Early Warning Score (PEWS), it would have been desirable, also indicating a stable course in the hospital. The patient was continuing in the expected clinical trajectory while in the hospital.  Due to the above reasons, this child with mild to moderate asthma exacerbation could have been treated in observational status.

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

Diagnosis:  Severe maxillary and mandibular crowding.
Treatment:  D8080 Braces, D8670 Monthly Visit x12.
The insurer denied D8080 Braces, D8670 Monthly Visit x12.  
The denial is overturned.

The patient is an adolescent female; the request is for orthodontic benefits and monthly visits. The patient has a Class II canine malocclusion. She has severe upper and lower crowding, a deep bite and moderately excessive overjet. The prior denial was due to score of 21 on the Handicapping Index Scale.

The proposed treatment is medically necessary.

The patient is an adolescent female. She has a Class II canine malocclusion. She has severe upper and lower crowding, a deep bite and moderately excessive overjet. The patient has tooth #6, upper right permanent canine, impacted. When there is an impaction of a permanent anterior tooth without extraction being indicated, this is an automatic qualifier. The monthly visits are used to track progress and make needed adjustments. Therefore, the proposed braces and monthly visits are medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Spinal muscular atrophy
Treatment: S5165 home modifications
The insurer denied coverage for S5165 home modifications.
The denial is overturned.

This is a child with a diagnosis of spinal muscular atrophy. The child has associated respiratory failure (ventilator dependent), gastrostomy tube, and neuromuscular hip dislocations. Under review is the medical necessity for S5165 home modifications.

The clinical records support the medical necessity of the requested S5165 home modifications. The patient has a diagnosis of spinal muscular atrophy and is totally dependent for functional mobility. The child is essentially bed bound and wheelchair bound. The child is unable to transfer self independently and requires 1-2 persons for safe transfers. The requested S5165 home modifications are a portable ceiling lift and track system. This system is the most efficient and safest means for lifting and transferring this patient. The reviewed medical literature supports the S5165 home modifications (portable ceiling lift and track system) as superior to a standard Hoyer lift, particularly for decreasing risk of injury and ease of use. From a physical medicine and rehabilitation perspective, as well as within a reasonable degree of medical certainty, the requested S5165 home modifications are more appropriate for decreasing the risk of harm to the patient and caregiver while performing lifting and transferring activities when compared to a Hoyer lift.   

Taken into consideration were the clinical standards of the plan, information provided concerning the patient, the attending physician's recommendation, and applicable generally accepted practice guidelines developed by the federal government, national or professional medical society, board, and associations. All decisions are evidence-based.  

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

The medical necessity for S5165 home modifications is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Chronic Migraines.
Treatment: Ajovy.
The insurer denied Ajovy.
The determination is overturned.

This is a patient who has chronic migraines and is prescribed treatment with Ajovy. The drug was denied by the plan because there was not documentation that the member had tried and failed oral migraine preventative therapies. At issue is the medical necessity of Ajovy.

Ajovy is medically necessary for treatment of this patient's chronic migraines. Ajovy is Food and Drug Administration (FDA) approved and literature supported for the prevention of chronic migraine. The provider and patient have certified that the patient has tried and failed multiple medications for prevention of migraine. These drugs are from all major classes of migraine preventative therapies including amitriptyline, a tricyclic antidepressant, propranolol, a beta blocker, and topiramate, an anticonvulsant. There are no other drug classes for the patient to use. The use of an injectable calcitonin gene-related peptide (CGRP) inhibitor, such as Ajovy, is the appropriate next step for the members care and consistent with the standards of practice.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic obstructive pulmonary disease (COPD).

Treatment: Arnuity Ellipta inhaler.

The insurer denied coverage for Arnuity Ellipta inhaler.

The denial is upheld.

 
The is an adult female with a history of Chronic Obstructive Pulmonary Disease who has been on multiple inhalers. As per last notes the patient has been tried on Trelegy, Advair, Xopenex and Fluticasone nasal spray.

The patient reportedly had palpitations from their use. No other details or documentation was provided. The patient's medical provider is requesting Arnuity Ellipta (Fluticasone Furoate).

The preferred formulary agents for an inhaled corticosteroid  such as Arnuity (Fluticasone Furoate ) are Flovent HFA and Pulmicort Flexihaler ( Budesonide )

Palpitations are not a side effect of inhaled corticosteroids. They are related more to Beta Agonist medications so it may have been caused by Xopenex or Advair ( which contains a long acting beta agonist ) Fluticasone and Budesonide are both just inhaled corticosteroids and they do not cause palpitations.

This patient has not been tried on Flovent Inhaler (fluticasone propionate) which is a generic and pharmacological equivalent of Budesonide, another inhaled corticosteroid.

As the patient has not tried and failed the preferred drugs in the same class, Arnuity Ellipta cannot be approved at this time.  Reasons and considerations include:

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did not have an adverse reaction or contraindication.

The formulary drug is expected to be effective.

The non- formulary drug is not expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Arnuity Ellipta (fluticasone furoate) to treat Chronic Obstructive Pulmonary Disease is upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Alzheimer's dementia, osteoarthritis (OA), cerebrovascular accident (CVA), heart failure, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD).

Treatment: Consumer Directed Personal Assistance Services (CDPAP) 168 hours per week

The insurer denied coverage for Consumer Directed Personal Assistance Services (CDPAP) 168 hours per week.

The denial is overturned.

 
This is an elderly patient has a history of  Alzheimer's dementia, osteoarthritis (OA), cerebrovascular accident (CVA), heart failure, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD). It was noted the patient is not active in bed mobility and was being moved with a Hoyer lift. The patient was in hospice care for the past year with daughter as care giver. The request is for consumer directed personal assistance services (CDPAS) 168 hours per week, which is under review.

This is a hospice patient with minimal mobility and a history of Alzheimer's dementia, osteoarthritis (OA), cerebrovascular accident (CVA), heart failure, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD). The patient does require more hours.  A night log indicates the patient requiring multiple diaper changes, the patient needing turning and also waking up confused at unpredictable times.  The recommended hours are clearly not sufficient.  Also,  a live-in will not have the required 5 hours of continuous sleep. Thus, the requested 168 hours, split shift is appropriate for this patient. 

Per Prizer, L. P., & Zimmerman, S. (2018), "Dementia is a progressive disease, accompanied by progressive need for support in the conduct of activities of daily living (ADLs); from first to last, the need for supportive care generally follows the order of bathing, dressing, grooming, toileting, walking, and eating (Cohen-Mansfield, Werner, & Reisberg, 1995). This order is consistent with that of the Functional Assessment Staging Test (FAST) for dementia, which (for example) identifies challenges with dressing beginning in moderate dementia, and with toileting occurring in moderately severe dementia; need for support in eating typifies severe dementia. Making the need for support even more evident, loss of independence in ADLs is associated with poorer quality of life."      

Based on the above, the insurer's denial must be reversed. 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 consumer directed personal assistance services (CDPAS) 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld



Diagnosis: transient ischemic attack.
Treatment: inpatient stay.
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a female who was admitted to the hospital for the diagnosis of transient ischemic attack, upper respiratory tract infection, leukocytosis, and tachycardia.
The patient has a medical history notable for prior brain tumor, a subependymal giant cell astrocytoma status post resection and ventriculoperitoneal shunt placement and subsequent shunt revision. The patient presented to the hospital with complaints of left sided weakness that started 1-day prior to presentation. Her symptoms lasted for 3 hours and resolved. She reported hand, leg, and face numbness on the left. She was admitted to the hospital for further workup with concern of transient ischemic attack.

The inpatient hospital admission was not medically necessary for this patient.
The patient presented to the hospital with a history of 3 hours of left sided weakness and paresthesia that had since resolved. This occurred in the setting of acute illness. She did have a significant neurologic history with prior brain tumor resection. Admission to the hospital for observation was reasonable and appropriate. However, the neurology consultant did not feel that this was due to an acute neurologic event. Her exam was at baseline throughout her hospitalization. She was discharged home without further workup or intervention. The patient does not meet criteria for an inpatient hospital admission.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: esophagitis

Treatment: procedure code 43239, sequential or repeat esophagogastroduodenoscopy (EGD)

The insurer denied coverage for procedure code 43239, sequential or repeat esophagogastroduodenoscopy (EGD)

The denial is overturned

 
The patient had epigastric pain, reflux, and dysphagia for several months. He had an endoscopy and ulcers were found in the distal esophagus. He was treated with a proton pump inhibitors (PPI) twice a day. An endoscopy was performed to evaluate for healing of the ulcers. The endoscopy revealed no residual ulceration at the gastroesophageal (GE) junction. 

Medical necessity was determined using Milliman Care Guidelines (MCG) ACG:A-0203 for Upper Gastrointestinal Endoscopy. Gastrointestinal reflux disease is an Indication for the procedure if certain indications are met. One of these indications is known severe erosive esophagitis with the need for follow up after 8 weeks of proton pump therapy. 

This patient had evidence of severe esophagitis. This was manifested by the documentation that he had ulcers in the distal esophagus. He was on high dose PPI therapy. Therefore, doing the follow up endoscopy to evaluate for healing of the severe esophagitis met the MCG guideline. 

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 procedure code 43239, sequential or repeat esophagogastroduodenoscopy (EGD) is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Abdominal pain.
Treatment: Inpatient Hospital Stay.
The insurer denied the Inpatient Hospital Stay.
The determination is upheld.

This is a male patient with a medical history of small bowel obstruction, prostate cancer status post prostatectomy complicated by small bowel perforation, and cholecystectomy. He presented to the emergency department with abdominal pain, nausea, and vomiting. His vital signs were unremarkable. The physical examination was notable for a distended abdomen with moderate generalized tenderness, and normal bowel sounds. Lab results showed an elevated white blood cell count of 10.2 thousand per microliter (K/uL), elevated blood urea nitrogen of 22 milligrams per deciliter (mg/dL), and elevated aspartate aminotransferase of 40 units per liter (U/L). A chest x-ray showed a prominent mediastinum, clear lung bases, and a nasogastric tube with the tip in the stomach, with no free air. A computed tomography scan of the abdomen and pelvis showed multiple dilated small bowel loops suspicious for distal small bowel obstruction versus ileus, fecalized material within the distal small bowel, possible transition point upstream to the small bowel anastomosis, multiple subcentimeter periaortic and mesenteric lymph nodes, and absent gallbladder. He was treated with ondansetron. He was made nil per os. He was placed on nasogastric suction. A surgery consultation noted abdominal pain, nausea, and vomiting with a distal small bowel obstruction versus ileus, and recommended conservative management with nil per os, intravenous fluids, serial abdominal exams, serial abdominal x-ray, nasogastric tube, monitor labs, and avoid narcotics.
He had no abdominal pain, felt better, and was ambulating; he was on a clear liquid diet. Lab results showed an unremarkable complete blood count and basic metabolic panel. An x-ray of the abdomen showed mild constipation, nasogastric tube tip in the stomach, and coarse lung changes. He was noted to be much improved, with no abdominal pain, no complaints, was passing gas, tolerating a regular diet without nausea or vomiting, was voiding spontaneously, and ambulating. He was discharged  with a plan for Primary Care follow-up. At issue is the medical necessity for the inpatient level of care.
The inpatient level of care was not medically necessary, and the care provided could have been provided at a lower level of care. The patient presented with abdominal pain, nausea, and vomiting; he quickly had improvement in his symptoms with conservative therapy [1-3]. Imaging did not show any definite complete small bowel obstruction [4-6]. No other cause for the inpatient level of care, such as bowel perforation, peritonitis, toxic megacolon, sepsis, abscess, fistula, or other complication was documented. All of the measures that were undertaken, including monitoring, labs, imaging, and specialist consultations, could have been performed without the inpatient level of care [2-5].
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Lymphedema. 
Treatment: Lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay. 

The insurer denied the Lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay. 

The health plan's determination is overturned. 

The patient is a female with secondary bilateral lower extremity and vulvar lymphedema from Bartholin's gland squamous cell carcinoma treatment that included hemi-vulvovaginectomy and inguinal lymph node dissection. She suffers from chronic recurrent infection in this area that has required several hospitalizations for intravenous (IV) antibiotic treatment. She has also failed several conservative therapeutic modalities. 

The proposed treatment of surgical vascularized lymph node transfer using a free omentum flap represents the most promising treatment for this patient, who otherwise would continue her life of severe disabilities and numerous recurrent medical complications. 

Given the prevalent evidence in the emerging field of lymphedema surgical intervention, I overturn the health plan's adverse determination and to support the coverage of the proposed health service or treatment lymphangiotomy, free omental flap with microvascular anastomosis and 1 day hospital stay.