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

Diagnosis: dementia
Treatment: home health care
The insurer denied Personal Care Services 24 hours per day, 7 days per week (split shift)
the health plan's determination is overturned. 

This is a female patient with a history of progressive dementia, hypertension, chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, cardiac arrhythmia, asthma, chronic pain, chronic exocrine pancreatic insufficiency, diabetes, osteoarthritis, osteoporosis, hearing loss, hypercholesterolemia, anemia, insomnia, dizziness, fatigue, and urinary and fecal incontinence. The patient lives alone in a private home.

Personal Care Services 24 hours per day, 7 days per week (split shift) is medically necessary.
Per NY Codes, Rules, and Regulations section 505.14, a live-in personal care aide must be able to receive five hours of uninterrupted sleep during the aide's eight-hour period of sleep. An aide to this patient would be unable to receive five hours of uninterrupted sleep. The patient's PCP (primary care provider) documented the need for the patient to be turned and positioned every 2 hours to prevent the development of pressure ulcers. The patient's PCP also documented the need for frequent overnight changes of soiled diapers to prevent skin irritation. As noted in "Pressure Injuries: Prevention, Evaluation, and Management", prevention measures in patients at increased risk of pressure injuries including keeping skin clean (particularly following incontinence events) and encouraging patients to change positions often, with assistance if necessary. Increased moisture from urine, stool, and sweat can cause skin maceration and escalate the risk of pressure injuries. The patient lives alone and does not have informal support to allow her to follow her PCP's recommendations to be turned every 2 hours. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. Split shift care is required to assist the patient with activities of daily living (ADL) and not solely for safety and supervision. Therefore, the requested services are required to meet the patient's frequent care needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Croup & rhino/entero and parainfluenza viruses. 
Treatment: Inpatient hospital admission. 
The insurer denied coverage for: Inpatient hospital admission. 
The denial is: Upheld. 
 
This is a child with a history of an illness with stridor and a raspy cough. The child was seen in urgent care two days prior to admission and was started on oral Prednisone which the mother gave for 2 days with no improvement in the noisy breathing. When the mother noted that the child was having increased work of breathing and a decrease in the ability to breast feed, she brought the child to the Emergency Room (ER) for an evaluation. 

In the Emergency Room (ER), the child was noted to have stridor and some increased work of breathing. The pulse oximeter reading was 98% on room air. There was no fever or rhinorrhea. The child was described as playful and interactive with no respiratory distress. The mother indicated that the child continued to have wet diapers. The child was treated with a racemic Epinephrine treatment and there was no improvement noted in their stridor. A chest radiographic image (x-ray) was obtained to evaluate for a foreign body aspiration as a cause of the stridor and showed minimal subcostal narrowing which was described as consistent with croup. Blood testing was significant for an elevated white blood count (WBC) of 18.5k (thousand). A respiratory viral panel was positive for rhino/entero and parainfluenza viruses. The child was treated with a second treatment with racemic Epinephrine with no improvement in the noisy breathing. An intravenous (IV) was inserted to administer fluids since the child vomited once following a feeding. The note indicated that the child did not tolerate breast feeding in the ER and the decision was made to admit the child to the hospital for observation and continuation of IV fluids with a diagnosis of croup. 

The insurer denied the need for admission to the hospital and indicated that the child could have been safely discharged. 
 
The patient was treated appropriately in the Emergency Room for an acute illness diagnosed as croup. There was no improvement in the stridor following two days of Prednisone prior to the visit to the ER and following 2 treatments with racemic Epinephrine in the ER. The oxygen saturation was normal and the child did not require treatment with oxygen. The child was not in respiratory distress, and was described as playful and interactive. There was no evidence of dehydration on physical examination or laboratory testing and the child continued to have wet diapers. The child was stable enough to be discharged home with a follow-up visit with the pediatrician in 24- 48 hours. The admission to the hospital was not consistent with the standard of care for treatment of croup. 

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


Diagnosis: Dementia
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 40 Hours per Week. The health plan's determination of medical necessity is overturned in whole.

This is a case review for a female with a medical history notable for dementia, incontinence, and mobility issues. The patient and her care team requested an increase to 40 hours per week, and this request was denied by the health plan. This denial is the subject under review.
The patient's physician provided a letter of support for this appeal. The letter states that the patient has severe dementia, incontinence of urine and feces, generalized arthritis, dizziness, poor balance, frequent falls, congestive heart failure, atrial fibrillation, type 2 diabetes, poor eyesight, deafness, and renal insufficiency. She is on numerous medications to treat these conditions. She requires assistance with activities of daily living including bathing, dressing, hygiene, toileting, transfers, and medications. Her daughter primarily provides her caregiver assistance, but when her daughter is at work, she requires a caregiver. Therefore, they request that hours be granted to allow full coverage while the patient's daughter is at work.


The Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes Increase to 40 Hours per Week is medically necessary for this patient.

The patient's care needs are expected to be continuous and unscheduled throughout the day and occasionally at night as well. She receives significant informal support from her daughter, however her daughter is not available during the workday. They have requested an increase in personal care hours to allow continuous coverage for the patient during the daughter's workday. This increase is medically necessary for the patient. She has severe dementia and is incontinent. She cannot direct her own care. She will require toileting, diaper changes, transfers, and other personal care needs when her daughter is not available. Failure to provide for her personal care needs could result in falls or other adverse medical events.
Appeal type: Formulary Exception
Decision: Upheld

Endocrine
Pharmacy/prescription drugs

Diagnosis: obesity
Treatment: Wegovy
The insurer denied Wegovy. 
The health plan's determination is upheld. 

This is a female patient with morbid obesity, elevated blood pressure without a diagnosis of hypertension, attention deficit hyperactivity disorder, and iron deficiency anemia. She was prescribed Wegovy 0.25 milligrams (mg) once a week for obesity and to assist with weight loss. Coverage for this medication was denied by the health plan due to weight loss being an excluded benefit by the health plan's program. The plan did not provide a list of formulary drugs that they consider appropriate to treat the patient's condition.

The non-formulary drug (Wegovy) is not clinically appropriate for the patient's condition.
Wegovy (semaglutide) is a long-acting GLP-1 (Glucagon-like peptide-1) receptor agonist that is Food and Drug Administration (FDA) -approved for the treatment of obesity. Clinical trials of Semaglutide involving patients without type 2 diabetes have demonstrated efficacy for weight loss and weight loss has been shown to reduce blood pressure. Drug therapy is often a helpful component in the treatment regimen for people with obesity who have not met weight goals (typically a loss of at least 5 percent of total body weight) after three to six months of a comprehensive lifestyle intervention. While the patient does have obesity and elevated blood pressure and could benefit from weight loss, the office notes provided do not indicate that a comprehensive lifestyle intervention was undertaken for 3-6 months prior to starting Wegovy.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Generalized osteoarthritis and with general debility. 
Treatment: PCA (personal care aide) Level 2: Live-In per diem - 1 day - 7 day(s) per week - a total of 7 days per week. 
The insurer denied PCA Level 2: Live-In per diem - 1 day - 7 day(s) per week - a total of 7 days per week. 
The denial is upheld. 

The patient is an elderly female with generalized osteoarthritis and with general debility. The Uniform Assessment System (UAS) - New York (NY) evaluation of 3 months ago, with no change from that of 6 months ago, showed that the patient can direct her own care with modified independence in making her own decisions, eating, memory intact, requiring maximum assistance with meal preparation, managing medications, bathing, upper/lower body dressings and bathing, walking, toilet, bed mobility, total dependence for ordinary housework, etc. 
Currently, the patient has Personal Care Aide (PCA) services at level 2 for 12 hours per day, 7 days a week, for a total of 84 hours per week. Family members are involved in the patient's care, especially at night. The request is for a live-in per diem daily and 7 days a week making this to be 13 hours per day, 7 days a week. 

The requested health service is not medically necessary. 

The requested increase for Personal Care Assistance through Home Health Care (Level 2) from 84 hours per week (12 hours per day, 7 days a week) to live-in per diem daily 7 days per week (13 hours per day) is not medically necessary because based on the most recent Uniform Assessment System (UAS) of 3 months ago, with no change from that of 6 months ago, the patient can direct her own care with modified independence in making her own decisions, eating, memory intact, requiring maximum assistance with meal preparation, managing medications, bathing, upper/lower body dressings and bathing, walking, toilet, bed mobility, total dependence for ordinary housework, etc. 
The additional period of personal care aide (PCA) requested is not medically necessary as time is for monitoring the patient, which the family can provide, and therefore it is not medically necessary in terms of the patient's activities of daily living and functionality.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic rhinitis
Treatment: CT scan of the sinuses in a hospital setting.
The insurer denied the CT scan of the sinuses in a hospital setting.
The determination is upheld.

This is a female patient with chronic rhinitis. Her symptoms also include hyposmia. Medical management included oral antibiotics, nasal steroids and antihistamines. An exam revealed mucosal congestion. The patient had a computed tomography (CT) scan and magnetic resonance imaging (MRI) in the hospital setting.
At issue is the medical necessity of the CT scan of the sinuses in a hospital setting.

There was no documented reason why the patient could not have had CT scan in an outpatient setting. There was concern for chronic sinusitis refractory to medical management and concerns for hyposmia. The CT scan being done in a hospital setting was not medically necessary. The CT scan could have been done in an outpatient setting.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Intraosseous basivertebral nerve ablation.

The insurer denied Intraosseous basivertebral nerve ablation.  The determination is upheld.

This is a female patient with a history of low back pain. She has had physical therapy, injections and medications without relief. The neurologic exam shows no motor, sensory or reflex abnormalities. The lumbar magnetic resonance imaging (MRI) shows endplate changes at lumbar (L)5- sacral (S)1. The provider has recommended an L5-S1 Intracept procedure and this is under review.

The procedure is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.
While this is a promising technology, the literature describes further research needing to be performed, particularly from non-industry sources. Urits et al. cite "Chronic low back pain (CLBP) is a difficult yet common diagnosis that affects a significant portion of patients worldwide. In efforts to combat this debilitating disease, researchers have made great progress in understanding the pathophysiology of lower back pain (LBP) in addition to unveiling the anatomy of the vertebrae in search of appropriate treatment options. As a result, with the growing evidence supporting the vertebrogenic model that involves the BVN, radiofrequency (RF) ablation of the BVN has emerged as a possible minimally invasive procedure to treat LBP. Several studies have supported the safety, durability, and efficacy of RF ablation of the BVN. There is also convincing evidence that BVN ablation is more beneficial than the current standard of care for the treatment of CLBP. However, reproducible large randomized controlled trial (RCTs) are still needed for clinicians to gain full confidence in utilizing this treatment in practice. Additionally, further research is needed on the anatomy of the vertebrae to optimize the method of treatment. These studies can help to elucidate the role of RF ablation in the management of CLBP and improve the quality of life of CLBP patients in the near future".
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Intraosseous basivertebral nerve ablation.

The insurer denied Intraosseous basivertebral nerve ablation.  The determination is upheld.

This is a female patient with chronic axial low back pain for over 2 years. It is worse with bending and lifting and is rated a 6 out of 10 at rest and increases to 10 out of 10 with activity. The pain is affecting her activities of daily living and causing her to struggle with teaching. She has tried anti-inflammatories, physical therapy, and injections. She has had an epidural steroid injection and sacroiliac (SI) joint mapping without sustained relief. After her most recent lumbar (L) 5 epidural steroid injection she experienced a new pain consistent with L5 nerve root irritation. Magnetic resonance imaging (MRI) of the lumbar spine demonstrates disc degeneration with endplate edema at L5 and sacral (S) 1 vertebrae consistent with Modic type II changes. As per the MRI radiology report, L5-S1 shows a broad-based disc bulge with anterior disc protrusion and mild bilateral neural foraminal narrowing. Her current diagnosis is vertebrogenic back pain with endplate inflammation at the L5 and S1 vertebral bodies. The current plan is for an Intracept procedure at L5 and S1 and this is under review.

Based on the provided clinical notes, the proposed treatment is not likely to be more beneficial than standard treatment. There are no high-quality non-industry sponsored studies that establish that treatment with the Intracept procedure results in improved/better health outcomes when compared to the existing treatments. There is insufficient evidence in the medical literature to obtain definitive conclusions about the clinical safety and efficacy of the Intracept procedure.

Other than a small number of prospective uncontrolled studies and double-blind sham-controlled trials, the level, and amount, of evidence supporting the long-term efficacy of the proposed treatment is lacking. There are currently no standard treatment guidelines, systematic review studies, or sufficient non-industry sponsored studies supporting the proposed intervention of intraosseous ablation of the basivertebral nerve via Intracept procedure, for the treatment of vertebrogenic back pain.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis:  Back Pain.
Treatment:  Intraosseous basivertebral nerve ablation.

The insurer denied Intraosseous basivertebral nerve ablation.  The determination is upheld.

This is a female patient with chronic axial back pain for years. The pain is worse with forward flexion. No physical exam is documented. Lumbar magnetic resonance imaging (MRI) demonstrated Modic changes at lumbar (L) 5 and sacral (S) 1 per clinical documentation. A magnetic resonance imaging (MRI) report does not describe this. Prior treatments include physical therapy (PT), home exercise program (HEP), sacroiliac joint (SIJ) injection, L5 epidural steroid injection (ESI), nonsteroidal anti-inflammatory drugs (NSAIDs). The patient was diagnosed with vertebrogenic back pain and was recommended the Intracept procedure at L5 and S1. This was denied by the health plan and is under review.

This is a patient with chronic axial back pain. Clinical notes indicate Modic changes at L5 and S1. However, the MRI report makes no comment on this. No x-rays were obtained. No physical exam is documented. The patient has tried substantial conservative treatment but has not tried medical branch blocks or radiofrequency ablation (RFA). Based on the incomplete documentation, there is not substantial evidence that Intracept would be more beneficial for this patient's chronic axial back pain. The clinical documentation does not support the Intracept procedure.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: malocclusion

Treatment: braces and monthly visits x 12

The insurer denied coverage for braces and monthly visits x 12

The denial is overturned

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified overjet, overbite, open bite, and ectopic eruption among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD)  index attaining 26 total points. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index attaining 18 points by internal reviewers. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a significant malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September 1, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary. 

In this case, the treating orthodontist completes the second portion of the index arriving at 26 points to justify orthodontic care. This reviewer concurs with the index completed by the orthodontist which attains the threshold of 26 points to support orthodontic care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need.

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 braces and monthly visits x 12 is substantiated.
Appeal type: Medical necessity
Decision: Upheld

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

This case involves a man who presented to the emergency department with right foot itching, edema, and redness complaints. The patient denied trauma to the leg and no associated symptoms of chest pain, shortness of breath, palpitations, or orthopnea. The initial temperature was 103.6 on arrival, with a heart rate 120 and respiration of 22. The exam showed an alert patient, non-distressed, with normal cardiopulmonary findings. The musculoskeletal exam showed right lower extremity erythema and edema with preserved dorsalis pedis pulses. The rest of the exam was unremarkable. 

Based on the provided documentation, inpatient hospital admission was not medically necessary. The patient remained hemodynamically stable and defervesced after the initial vital signs. The imaging was only remarkable for cellulitis, with no deep abscess or necrotizing fasciitis. There was no need for surgical debridement. There is no clear evidence of severe sepsis or septic shock. After receiving empiric broad-spectrum antibiotics for two days and negative blood cultures for 48 hours, he was released on an oral antibiotic regimen. All of this can be accomplished under a lower level of care.