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

Diagnosis: Alcohol Withdrawal. 
Treatment: Inpatient Hospital Admission. 

The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This adult female presented with two weeks of epigastric and chest pain associated with nausea. She admits to drinking daily. The patient's vital signs were normal. Her exam was remarkable for bilateral hand tremors. Her Clinical Institute Withdrawal Assessment for Alcohol (CIWA) was five. Complete blood count and comprehensive metabolic panel were unremarkable. Abdominal/pelvic computed tomography (CT) showed thickening of cecum. Chest x-ray showed no acute disease. 
Electrocardiogram (EKG) showed normal sinus rhythm. The patient was admitted with alcohol withdrawal. Plan of care included Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol and Ativan three times a day. On the day of admission, the patient received Ativan twice a day. The next day, the patient received Ativan once and was cleared for discharge. 

The proposed treatment was not medically necessary. 

This patient was admitted with alcohol withdrawal. The admission was denied based on the patient's clinical presentation and lack of failure of an observation level of care. 
The patient was hemodynamically stable and afebrile. She was not acutely intoxicated. The patient did not have tachycardia. She did not have severe electrolyte abnormalities. She had hand tremors and a Clinical Institute Withdrawal Assessment for Alcohol of five. She did not have active comorbid conditions. There is no history of delirium tremens (DTs) or seizures. The patient was admitted with plan for Clinical Institute Withdrawal Assessment for Alcohol (CIWA) protocol. The patient was able to be managed with intravenous fluids and oral Ativan, two three times per day. She did not have marked physical signs of alcohol withdrawal. The intervention provided did not require an acute inpatient level of care. The requested inpatient hospital admission was not medically necessary because the patient was clinically stable and had not failed treatment at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Attention Deficit Hyperactivity Disorder (ADHD). 
Treatment: Formulary exception for Focalin XR 
(dexmethylphenidate ER). 

The insurer denied: Formulary exception for Focalin XR (dexmethylphenidate ER). 
The denial is overturned. 

The patient is an adult male diagnosed with attention deficit hyperactivity disorder (ADHD). For several years the patient has demonstrated a response to brand Focalin XR (dexmethylphenidate extended release) with improved symptoms and functioning. The patient had tried and failed treatment with multiple other medications with subsequent use of Focalin XR (extended release) (brand) which reportedly has worked best for this patient. 
The health plan denied coverage for Focalin (brand) on the basis of plan criteria that requires three trials and failure with formulary alternatives which include amphetamine-dextroamphetamine ER (extended release) mixed salts, dexmethylphenidate ER (extended release), Jornay PM, Azstarys, Mydayis, and Vyvanse. 
The prescribing clinician indicates that the patient has been effectively treated with Focalin (brand) for many years after failing to respond to multiple other medications for ADHD (attention deficit hyperactivity disorder). The appeal also indicates that it is in the best interest of the patient to continue to receive a medication that is effective. The appeal notes that to change to an alternative medication would be detrimental to the patient indicating that the patient works as a high level professional and needs the indicated treatment. 

The health plan should cover the formulary exception for Focalin (brand). 

In this case, the patient has been effectively treated with Focalin (brand) for many years after failing to respond to multiple other medications for ADHD (attention deficit hyperactivity disorder). 
Moreover, it is in the best interest of the patient to continue to receive a medication that is effective. 

The appeal reasonably asserts that to change to an alternative medication would be detrimental to the patient. Indeed, the current use of Focalin is effective, and the formulary drug(s) would pose risk for lack of efficacy or effectiveness, as well as adverse effects. The likelihood of a clinical response with tolerability is only 50-70 % based upon clinical trials; thus, the formulary drug would not be as effective for this patient. This answer is consistent with prevailing standards of medical practice and is in keeping with NY (New York) State instruction for this review, as well as the guidelines and scientific literature, referenced below.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Atopic Dermatitis
Treatment: Dupixent
The insurer denied the Dupixent.
The determination is upheld.

The patient has atopic dermatitis. He has failed mometasone, triamcinolone and clobetasol. He has also failed tacrolimus, Allegra, and Zyrtec. The medication under review for medical necessity is dupilumab (Dupixent).

The requested health treatment of dupilumab (Dupixent) is not medically necessary for this patient. According to the American Academy of Dermatology Atopic Dermatitis Clinical Guidelines and dermatology literature, the preferred medications are effective treatments for the management of atopic dermatitis (1, 2). The patient has no true contraindications to the use of the preferred medications. The preferred agents, such as methotrexate, are appropriate agents for the treatment of the patient's atopic dermatitis.

Within the peer-reviewed literature, in 2018, Gerbens, et al writes "Methotrexate (MTX) and Azathioprine (AZA) seem to be effective and safe as maintenance treatments in moderate-to-severe atopic dermatitis (AD) up to 5 years" (3). Shah, et al, 2018 writes "Methotrexate is an effective treatment for moderate to severe atopic dermatitis with an acceptable safety profile. A low dose can be used to control the disease for prolonged periods without significant risk" (4). There are several published studies that show that methotrexate is effective and safe for moderate-severe atopic dermatitis (5-8). The evidence-based literature is consistent. The requested service is not medically necessary; there are no unique clinical circumstances to this particular individual that would make it medically necessary. The formulary medications should be tried and failed prior to initiating Dupixent. Therefore, Dupixent is not medically necessary for this patient.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Vascular Dementia
Treatment: Personal Care Services (PCS) 12 hours/day, 5 days/week (individual service hours)
The insurer denied the PCS 12 hours/day, 5 days/week (individual service hours).
The health plan's determination is overturned.

The patient is a female that has vascular dementia with behavioral disturbance which has been worsening, she also has difficulty walking and is a high fall risk. She has chronic osteoarthritis that has become worse according to her physician's documentation. Her other medical problems include type 2 diabetes, hypertension (HTN), carotid stenosis, hyperlipidemia, congestive heart failure (CHF), irritable bowel syndrome (IBS), polymyalgia rheumatica, overactive bladder, hypothyroidism, mitral valve prolapse and obesity.

The Hours Evaluation for Paraprofessional Support Tool (HELPS) assessment report shows the patient has moderately impaired cognitive skills for daily decision making, depression, wandering, anxiety, verbal and physical abuse, socially inappropriate or disruptive behavior, fatigue and resists care. The patient requires maximal assistance for activities of daily living (ADLs).

The health plan, in its determination of medical necessity, did not act reasonably, with sound medical judgment, or in the best interest of the patient.

The requested treatment of personal care services (caregiver services) for 12 hours/day, 5 days/week (individual service hours) was medically necessary for the patient.

The patient has advanced vascular and Alzheimer's dementia with agitation, restlessness, anxiety and depression. She requires maximal assistance with her ADLs. Furthermore, due to the patient's dementia and arthritis she has difficulty walking. Patient's with vascular dementia have cognitive and physical deficits that may require assistance.

According to a review article on the assessment and prediction of functional impairment in vascular dementia: "Vascular dementia is associated with cognitive, physical and functional impairments that often lead to disability among the elderly. Declines in activities of daily living significantly contribute to the disability reported among patients with vascular dementia and compromise quality of life for both patients and their families. Assessment of activities of daily living is an important component of the diagnosis, tracking and management of vascular dementia patients". [1]

This member has had documented declines in ADLs, making the requested 12 hours/day, 5 days/week of caregiver assistance medically necessary.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Alzheimer's dementia

Treatment: Personal Care Services (PCS) 12 hours, 7 days/week, totaling 84 hours/week 

The insurer denied coverage for PCS 12 hours, 7 days/week, totaling 84 hours/week
 
The denial is modified

This is a patient with progressive Alzheimer's dementia who lives alone. The insurer approved PCS 7 hours/day, 5 days/weeks and 5.5 hours/day, 2 days/week totaling 46 hours/week and the physician is requesting PCS 12 hours,7 days/week, totaling 84 hours/week.

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is described as "moderately impaired." She is "alert and oriented x2, very forgetful and confused at times. Member unable to make decisions independently and unable to provide consent." She requires extensive assistance for bathing. Only limited assistance is needed for personal hygiene, dressing, eating and toilet transfer/use. She is frequently incontinent of bladder and infrequently incontinent of bowel. The patient was observed ambulating without an assistance device (e.g., cane or walker).

The patient's treating physician indicated that during the day, "her current home health aide hours are insufficient, and she had times where she was left alone and tried to leave her home, or was confused, agitated and couldn't take care of herself. It is extremely unsafe for her." The physician also noted, "In the evening her daughters can take over her care, and overnight her medications keep her asleep."  

The patient's condition and functional needs are not at a level or unpredictable as to require the requested PCS 12 hours/day, 7 days/week. Given her functional decline, increasing PCS to 8 hours/day, 7 days/week (56 hours total) is medically necessary. This patient may require additional monitoring; primarily due to the concern for increased agitation, wandering and overall safety. However, safety monitoring (e.g., dementia) under personal care services does not include monitoring an individual when no other Level I or Level II personal care services task is being provided.  

Based on the above, the insurer's denial should be modified. The health care plan acted reasonably in part. 

The medical necessity for 12 hours a day 7 days a week is not substantiated, but increasing PCS to 8 hours/day, 7 days/week for a total of 56 hours/week is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Occlusal wear/attrition teeth number (#)24 and #25

Treatment: Crowns

The insurer denied coverage for crowns

The denial is overturned.

Based on the submitted documentation which includes copies of intraoral clinical images, panoramic radiograph, dental treatment record notes and insurer correspondence and policy, it appears that this patient presented for dental care. Significant occlusal wear/attrition was noted on #24 and #25. The dentist is requesting placement of full coverage crowns as direct placement restorations would not have a good long-term prognosis. The insurer has denied the full coverage crowns stating that the service is not medically necessary as the documentation does not fulfill the insurers stated criteria for approval. 

Upon review of radiograph and intraoral clinical images, it supports the recommended treatment. Teeth #24 and #25 exhibit extensive occlusal wear and attrition. There would be ample coronal structure remaining after crown preparation. These teeth will then have adequate coronal structure for support of full coverage crowns and adequate residual periodontal alveolar bone height. The standard of care in general dental practice would be placement of crowns which would have an excellent long-term prognosis with the recommended treatment.

Crowns on teeth #24 and #25 are medically necessary, as the clinical images and radiographic documentation support, and they would be a standard of care in general dental practice.

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 D9999 services is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Hypertension, coronary artery disease (CAD), atrial fibrillation, osteoarthritis, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), nicotine dependence, alcohol abuse, hypercholesterolemia, and diabetes

Treatment: Consumer direct personal assistance services (CDPAS) 70 hours per week

The insurer denied coverage for CDPAS 70 hours per week

The denial is upheld

This is an elderly patient with multiple diagnoses consisting of a history of hypertension, CAD, atrial fibrillation, osteoarthritis, COPD, CHF, nicotine dependence, alcohol abuse, hypercholesterolemia, and diabetes. The recent tasking tool noted that the patient lives in a private residence with relatives and required limited assistance with toilet use, eating, and feeding, extensive assistance with managing medications, personal hygiene/grooming, dressing the upper body, locomotion, and transferring, required maximum assistance with bathing and dressing the lower body, and was totally dependent for meal preparation, ordinary housework, shopping, and laundry. At the time of the assessment, the patient was receiving 56 hours of personal assistant services 7 days a week. The most recent assessment was reviewed and noted that the patient was residing with her nephew in a 1-bedroom walkup apartment of a private house. The home was clean, well lit, aerated, and free of clutter. The report stated the patient suffered a fall, with the patient sustaining a left wrist fracture. The patient was described as alert and oriented x3 to person, place, and time. She reported having a decline in her memory and was noted to have adequate hearing and vision. She had a history of depression and anxiety symptoms and felt sad due to her declining health. The report noted the patient had some balance difficulties exhibited within the last 3 days of the assessment. She had full dentures but was not using them given difficulty chewing. The report stated the patient was always adherent to medication use. The patient was being denied coverage for an increase in personal assistant services hours for 56 hours a week up to 70 hours/week.  

Current medical literature notes that personal assistance services allow individuals to remain in the comfort of their own homes to receive care rather than receiving care in a skilled nursing facility or assisted living. The information provided for the review noted that the patient had some functional deficits and required assistance daily. However, there were no significant changes in the patient's condition from prior assessment to support an increase in personal assistance services (PAS) hours from 56/week to 70/week. It was therefore determined that the denial of coverage for the increase in hours was appropriate. As such, the request for CDPAS 70 hours per week is not medically necessary.

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 CDPAS 70 hours per week services is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Multiplanar pes plano valgus deformity.

Treatment: custom shoe inserts (L3010 x 2).

The insurer denied coverage for custom shoe inserts (L3010 x 2).

The denial is overturned.

The patient has multiplanar pes plano valgus deformity. Per the records, the patient has used custom orthotics to help with the pain he has when ambulating and has failed over the counter orthotics previously. The current pair of custom orthotics that he has, he has outgrown, and a request was made to provide him with a new pair, but this was denied. The notes clearly document that lack of use results in pain for the patient.

The decision should be overturned, as it is well documented in the literature, that in cases where all conservative measures have been attempted custom orthotics play a major role prior to and after surgical intervention. "Children with flexible flatfoot who wore customized arch support insoles for 12 weeks exhibited significantly improved pain/comfort, physical health, stair ascent time, upper extremity and physical function, and transfer and basic mobility." (1) Furthermore, a systematic review found that orthotics "show potential as a treatment method for children with flexible pes planus." (2) As such, it is in the best interest of this young patient to use custom orthotics prior to having to undergo any type of surgical intervention for his ongoing pain and discomfort.

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

Custom shoe inserts (L3010 x 2) is considered medically necessary for this patient.

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 custom shoe inserts (L3010 x 2) services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis, Hypertension, Heart failure
Treatment: Home Care / Personal Care HHC - Level 2 Personal Care Services (PCS), per 15 minutes Increase to 84 Hour(s) per Week.
Denied: Home Care / Personal Care HHC - Level 2 Personal Care Services, per 15 minutes Increase to 84 Hour(s) per Week.
The insurer decision is overturned.

This is an elderly patient with medical problems including hypertension, heart failure and osteoarthritis. He is also legally blind and hearing impaired. He lives alone in an apartment. His daughter lives with her spouse upstairs in the same dwelling. He is approved by the insurer for PCS 70 hours/week and the request is for 84 hours/week.

According to the recent Uniform Assessment System (UAS) report, the patient's cognitive status is described as "Moderately Impaired-Decisions consistently poor or unsafe; cues/supervision required at all times." He requires maximal assistance for bathing, personal hygiene, lower body dressing and toilet use. Extensive assistance is needed for upper body dressing, locomotion, ambulation and toilet transfer. He is frequently incontinent of bladder and continent of bowel. The patient's condition and functional needs are a level or unpredictable as to require the requested personal care services (PCS) 12 hours/day, 7 days/week. Based on the enclosed documents reviewed, the patient's health and safety is more appropriately provided and maintained at home with the requested PCS 12 hours/day, 7 days/week, totaling 84 hours/week. 

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. 

From a physical medicine and rehabilitation perspective, home care / personal care (HHC) - level 2 PCS, per 15 minutes increase to 84 hours per week is medically necessary. 

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 home care / personal care (HHC) - level 2 personal care services, per 15 minutes increase to 84 hours per week services is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Orthopedic
Durable medical equipment

Diagnosis: congenital shortening of the right upper limb 
Treatment: Custom Passive Silicone Hand Prosthesis
The insurer denied Custom Passive Silicone Hand Prosthesis. The health plan's determination is overturned.

The patient is a female with congenital shortening of the right upper limb with only palm present. She is noted to be a shy girl that hides her residual right limb in public. She has also outgrown past orthosis for right upper extremity. A custom passive silicone hand prosthesis was ordered for her and was denied by her health plan. 

The requested Durable Medical Equipment: Custom Passive Silicone Hand Prosthesis is medically necessary for the patient. The patient is described as shy and embarrassed of residual limb keeping right hand covered in public and during her evaluation. A custom passive silicone hand prosthesis has documented excellent improvement in patient self confidence with high rate of satisfaction and ongoing us in the pediatric population. It also provides the patient with needed extremity for gross grasp and bimanual tasks, and push and pull function thereby improving overall function in activities of daily living (ADL), Instrumental activities of daily living (IADL), at school and in the community.
Appeal type: Experimental/Investigational
Decision: Upheld

Diagnosis: Low back pain
Treatment: intraosseous basivertebral nerve ablation
The insurer denied intraosseous basivertebral nerve ablation.
The determination is upheld.

This is a patient with low back pain with magnetic resonance imaging (MRI) of the lumbar (L) spine showing L5-sacral (S) 1 listhesis with contract on bilateral lumbar (L) 5 nerve roots. Also, L4-5 left foraminal disc protrusion is noted with contact on exiting left L4 nerve root and moderate left foraminal stenosis. At issue is whether intraosseous basivertebral nerve ablation is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

No, intraosseous basivertebral nerve (BVN) ablation is not likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease, as no large long term studies have shown clinical safety and efficacy of this procedure given the MRI of the lumbar spine shows foraminal stenosis over multiple segments and listhesis at L5-S1 segment. Therefore, more studies are needed showing clinical benefit with basivertebral ablation in this patient cohort. Becker et al noted in their study without listhesis and stenosis on MRI that "Ablation of the BVN for the treatment of chronic lumbar back pain significantly improves patients' self-reported outcome early in the follow-up period; the improvement persisted throughout the 1-year study period."

Therefore, although this is Food and Drug Administration (FDA) and Institutional Review Board (IRB) approved, without current clinical trials, more studies are needed showing clinical safety and efficacy.