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

Diagnosis: Sleep Disorder
Treatment: established patient office visit that required a high level of medical decision making and preventive medicine counseling and/or risk factor reduction intervention provided by your doctor
The insurer denied established patient office visit that required a high level of medical decision making and preventive medicine counseling and/or risk factor reduction intervention provided by your doctor.
The determination is upheld.

This is a male patient who was seen as an outpatient. This review is for the medical necessity of current procedural terminology (CPT) code 99402 and CPT code 99215 concurrent in one office visit. The services were denied and at issue is the medical necessity of established patient office visit that required a high level of medical decision making and preventive medicine counseling and/or risk factor reduction intervention provided by your doctor.
The requested health service/treatment of established patient office visit that required a high level of medical decision making and preventive medicine counseling and/or risk factor reduction intervention provided by your doctor is not medically necessary for this patient.
There was insufficient information provided, specifically office notes required to approve the services. This information was requested but not received. There was a statement noted from the patient's insurance records noted for appeal. Statement from the patient, "in short, this was a digital visit from my GP [general practitioner]. During my annual GP check up, he took blood and had it analyzed. On the short call, we discussed the results. This denial simply does not make sense."
The following services were billed with the following International Classification of Disease (ICD)10 codes: service current procedural terminology (CPT) code billed 99402, 99215; International Classification of Disease (ICD)-10 code, G47.9 - Sleep disorder, unspecified, E78.5 - Hyperlipidemia, unspecified Z71.3 - Dietary counseling and surveillance, Z70.9 - Sex counseling, unspecified, Z13.6 - Encounter for screening for cardiovascular disorders.
Typically, services, such as 99215 would require between 40 and 54 minutes along with high-level decision making. Also, in addition 99402 would require an additional 30 minutes. This does not sound consistent with the patient's statement of a quick phone call to discuss blood test results. Documentation of the office visit along with codes that were billed is not consistent with the documentation provided.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Joint Pain
Treatment: Orthovisc 30mg (milligrams)/2mL (milliliters) Injection
The insurer denied: Orthovisc 30mg (milligrams)/2mL (milliliters) Injection
The denial is upheld.

This patient is an adult male with knee pain. There was no physical examination provided. There was no X-ray report provided. The physician recommended Orthovisc injection. A letter of appeal was submitted by the medical assistant stating conservative treatment had been provided and there was narrowing of the joint space and problems standing on feet.

The requested health service is not medically necessary.

The scientific literature had recommended viscosupplementation for the treatment of osteoarthritis if all other courses failed prior to surgery. The recommendations for use of viscosupplementation have changed. A review of the Clinical Practice Guideline by the American Academy of Orthopaedic Surgeons (AAOS) notes the 2013 osteoarthritis (OA) knee treatment Clinical Practice Guideline contains one significant recommendation change from the 2008 Clinical Practice Guideline, and this is with regard to the issue of viscosupplementation. The 2008 osteoarthritis knee Clinical Practice Guideline included an "inconclusive" recommendation regarding the use of intra-articular hyaluronic acid (HA) injections that was largely the motivating factor for the expedited update of the Clinical Practice Guideline. The second edition Clinical Practice Guideline recommendation reads, "We cannot recommend using hyaluronic acid (HA) for patients with symptomatic OA of the knee," with a "Strong" rating, based on supporting evidence from three high-quality and 11 moderate-quality research studies that met the inclusion criteria. The work group understands the potential impact that this recommendation could have on clinical practice. Nonetheless, the Clinical Practice Guideline's best evidence synthesis does not support the efficacy of viscosupplementation. Although statistically significant outcomes were seen in some studies with higher molecular weight hyaluronic acid preparations, these outcomes were not clinically significant, based on a lack of minimum clinically important improvement (MCII). (For more information on MCII, see "The Importance of Clinical Significance in AAOS CPGs," AAOS Now, May 2013.) The Orthopedic group reports "strongly do not recommend use." This topic was reviewed again in 2022. Additional studies were reviewed with the opinion: No change to this Guideline. Additional references and expert opinion do not support benefit. The service would thus not be medically necessary. A meta-analysis was completed of multiple references. This is high level evidence-based criteria which does not support use.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Dementia.
Treatment:   Personal Care Worker (PCW) services 7 days a week, 24 hours a day continuous care by more than one person (168 hours per week).

The insurer denied Personal Care Worker (PCW) services 7 days a week, 24 hours a day continuous care by more than one person (168 hours per week).  The health plan's determination is overturned. 

This is a case review for a female with medical history notable for dementia, Parkinson's disease, non-weight-bearing status, and weakness. 

The patient's daughter provided a letter of support for this appeal. The patient is very weak and is receiving hospice care. The notes state that the daughter has been waking up every 2 to 3 hours throughout the night overnight to change diapers after episodes of fecal and urinary incontinence. She reports that she is not able to continue providing this care due to her own medical conditions.

The requested Personal Care Worker (PCW) services 7 days a week, 24 hours a day continuous care by more than one person is medically necessary for this patient.

The patient was approved for live-in care, and the request is for split-shift personal care. Live-in personal care aides are expected to receive adequate rest each night, including at least one 5-hour window of uninterrupted rest. If the patient has care needs that would preclude the required rest periods, then split-shift care is deemed medically appropriate. Therefore, the question at hand is whether the patient's personal care needs are expected or known to occur with such frequency to preclude the required rest window for a live-in aide.

The documentation provided by the patient's family member demonstrates that a live-in personal care aide would not be able to receive adequate rest at night. Her personal care needs are frequent, unscheduled, and not directed by the patient. She has advanced end stage dementia and requires frequent diaper changes overnight. Her family is no longer able to provide this care. Therefore, the requested increase to split shift care is medically necessary for the patient.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Hypertension
Treatment: Nebivolol
The insurer denied: Nebivolol
The denial is upheld.

The patient is an adult male with hypertension. Nebivolol is under review. The health plan denied the request for nebivolol stating that the patient must try and fail the required number of formulary alternatives.

The health plan should not cover the proposed treatment.

There are multiple beta blockers for the treatment of hypertension. However, no single beta blocker has been established as standard of care towards more effective treatment of hypertension or towards overall improved hypertension related outcomes. Additionally, there is no contraindication to treatment attempts with the multiple plan formulary beta blockers. In this case the formulary drugs were not ineffective and would be as effective as nebivolol. Additionally, the plan formulary medications would not have adverse effects. Therefore, nebivolol is considered not medically appropriate in this case.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Parkinson's Dementia, Hypertension (HTN), Hyperlipidemia, Chronic Kidney Disease (CKD), Coronary Artery Disease (CAD)

Treatment: for personal care worker (PCW) service 7 days per week, 24 hours per day, continuous care by more than one person: 168 hours per week

The insurer denied coverage for for personal care worker (PCW) service 7 days per week, 24 hours per day, continuous care by more than one person: 168 hours per week

The denial is overturned


The medical records indicate that patient has a medical history positive for Parkinson's Dementia, Hypertension (HTN), Hyperlipidemia, Chronic Kidney Disease (CKD), Coronary Artery Disease (CAD), Benign Prostatic Hyperplasia (BPH), Gastroesophageal Reflux Disease (GERD) and Colon Cancer. He was admitted to acute care with encephalopathy due to sepsis, gastrointestinal (GI) bleed and acute hypoxemic respiratory failure. The hospital stay was complicated by dysphagia requiring percutaneous endoscopic gastrostomy (PEG) placement, and persistent functional deficits. He was admitted to subacute rehabilitation.  

During an occupational therapy (OT) visit the patient required supervision for wheelchair mobility, contact guard assistance with dressing, moderate assistance with bathing, minimum assistance with toileting and minimum assistance with upper and lower extremity dressing. The occupational therapist reported that the patient was impulsive and required constant supervision. 

During a physical therapy (PT) visit the patient required stand by assist with bed mobility, transfers and gait. He required contact guard assist with six (6) stairs. 

The request for approval of personal care worker (PCW) service 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week is the topic of this review.

The patient has a history of sundowning, in which he becomes more confused at night; which would necessitate supervision overnight. He requires assistance for toileting, which he will need to do at all hours of the day. An occupational note states that the patient is impulsive and requires constant supervision. The patient is at high risk for falls and injuries without 24 hour supervision and assistance.      

Personal care worker (PCW) service 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week is considered medically necessary for this patient.

As the patient requires 24 hour care per day, 7 days a week continuous supervision and physical assistance, the request is 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 personal care worker (PCW) service 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Chronic inflammatory demyelinating polyneuritis (CIDP).

Treatment: Live-in, 7 Days/Week; Personal Care Aide-Level 2

The insurer denied coverage for Live-in, 7 Days/Week; Personal Care Aide-Level 2

The denial is upheld

 
This is an elderly male with chronic inflammatory demyelinating polyneuritis (CIDP). The Uniform Assessment System (UAS) report was performed while he was a resident in a skilled nursing facility (SNF). The patient requested 24 hour live in personal care aide (PCA) services, level 2, 7 days a week. The insurer approved PCA level 2; 63 hours/week, 9 hours/day x 7 days; leading to external review.

The Uniform Assessment System (UAS) report was performed while the patient was a resident at a nursing facility. The patient states (he) has friends and family that visit him frequently. The patient's cognitive skills are described as modified independent. His ability to perform much of his Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping; varies from total dependence to maximal assistance. The patient reportedly requires maximal assistance for bathing, lower body dressing, and ambulation. Extensive assistance is reportedly needed for upper body dressing and toilet transfer/use. Limited assistance is reportedly needed with personal hygiene, bed mobility and eating. Locomotion is independent. The patient is "able to lift arms over head and can bend slowly to touch his toes." His primary mode of mobility is a manual wheelchair. The patient reports being occasionally incontinent of bladder and continent of bowel. The patient's activities of daily living (ADL) status and self-sufficiency have reportedly not changed over the prior 90 days. 

The patient's medical condition, physical limitations and functional ability are not at the level or unpredictable as to require live-in PCA services. According to the clinical records, the patient was transferred to the skilled nursing facility (SNF) after undergoing a cholecystectomy for diagnosed cholecystitis. Unfortunately, the physical and occupational therapy notes were not submitted for review. This physician would agree the patient may benefit from additional monitoring; particularly due to the generalized weakness and fall risk. However, safety monitoring under PCA does not include monitoring an individual (e.g., with weakness/falls risk) when no other Level I or Level II personal care services task is being provided. Based on the records reviewed, attention to the patient's health and safety can be appropriately provided and maintained by the approved PCA level 2; 9 hours/day, 7 days/week totaling 63 hours/week.

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 Live-in, 7 Days/Week; Personal Care Aide-Level 2 services is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Cyclic Pelvic Pain. 
Treatment: Myfembree tablet. 
The insurer denied coverage for Myfembree tablet. 
The denial is upheld. 

The patient has complaints of cyclic pelvic pain lasting about 3 years. The patient had a telehealth visit with the provider. According to the provider, the symptoms described by the patient are consistent with endometriosis. The provider recommended the medication Myfembree. 

The insurer has denied coverage for Myfembree tablet. In their Final Adverse Determination letter, they write that based on the policy and the information they have, the request is denied. They did not receive any documentation that the patient met any of the criteria. Formulary alternatives are Danazol; Lupaneta; Orilissa; and Synarel. 

The patient has had cyclic pelvic pain for the past 3 years. This patient did not have any evaluation like a pelvic exam, an ultrasound or a laparoscopy. Assuming the patient has endometriosis, and according to the standard of care, treating endometriosis-related pain is based on the severity of symptoms. Note that other causes of pelvic pain have to be excluded prior to treatment. 

For women with mild to moderate pain, nonsteroidal anti-inflammatory drugs (NSAIDs) and continuous hormonal contraceptives rather than either agent alone is recommended. These therapies are low-risk, have few side effects and are generally well-tolerated compared with other medical therapies. Women who wish to conceive can use the NSAID alone. 

Women with adequate symptom improvement continue the hormonal therapy/NSAID regimen until pregnancy is desired or the average age of menopause is reached. Women whose symptoms do not improve continue NSAID treatment and are offered an alternate hormonal combination (e.g., change to a different estrogen-progestin contraceptive or norethindrone acetate). 

For women with severe symptoms, symptoms that do not respond to the above therapies, or recurrent symptoms, a trial of gonadotropin-releasing hormone analog (Lupaneta or Synarel) is recommended. 

In addition, gonadotropin-releasing hormone (GnRh) antagonists have been used successfully to manage endometriosis. Orilissa is a GnRh antagonist approved for treatment of endometriosis. It is unclear why the provider decided to use another GnRh antagonist Myfembree rather than the formulary product. 

In summary, it is unclear what is causing this patient's painful periods. In addition, this patient did not fail treatment with NSAIDs, oral contraceptives, progestins or Danazol, a GnRH agonist (Lupaneta and Synarel) or a GnRH antagonist (Orilissa). As of now there is no indication for Myfembree. 

The formulary drug(s) is unlikely to cause the patient an adverse reaction. 

The formulary drug(s) has not been ineffective based on the patient's clinical history. The patient has not used any of the formulary products. 

The requested drug will not be more effective than the formulary drug. 

The carrier's denial of a request for a Formulary Exception for Myfembree tablet is upheld.
Appeal type: Medical necessity
Decision: Overturned


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

The patient is a female with a history of asthma who presented with difficulty breathing. She was well until 1 week prior to presentation when she developed a dry cough and shortness of breath. She was using albuterol at home, however, she continued to worsen and her cough was keeping her up at night. She was awakening and gasping for air, and therefore was brought to the emergency department for evaluation. She had a prior asthma exacerbation a year ago.

Inpatient Hospital Admission was medically necessary for this patient. This is a teenage girl who presented with status asthmaticus, who required inpatient care for frequent bronchodilator treatments and close monitoring with additional treatments as needed. She continued to have significant symptoms with decreased breath sounds and wheezing despite appropriate and intensive treatment in the emergency department setting, including bronchodilators, corticosteroids, and magnesium sulfate. At the time of admission, she continued to require every 2 hour albuterol treatments, which requires an inpatient setting of care. Patients with asthma who require treatments more frequently than every 4 hours require an inpatient setting of care.
The decision making at the time of admission for this patient was consistent with her young age, the presence of status asthmaticus with continued significant symptoms despite appropriate treatments, and the need for ongoing intensive treatments in an inpatient setting along with close monitoring for potential deterioration of clinical status.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Bipolar Disorder.
Treatment: Transcranial Magnetic Stimulation.
The health plan denied: Transcranial Magnetic Stimulation.
The health plan's determination is upheld.

The patient is a female with a psychiatric history of major depressive disorder, generalized anxiety disorder, and bipolar 2 disorder who presented with an interest in transcranial magnetic stimulation (TMS) therapy for the management of depression. The patient has tried Venlafaxine (300 milligrams [mg]), Lithium (450 mg), Abilify (30 mg), Rexulti (4 mg), Lexapro (20 mg), Wellbutrin (300 mg), Risperdal (6 mg), Buspar (30 mg), Latuda (40 mg), Prozac (80 mg), and Seroquel (300 mg) without benefit. Current medications include Venlafaxine (300 mg), Lithium (450 mg), and Seroquel (300 mg). The patient notes trialing weekly cognitive behavioral therapy (CBT) psychotherapy without effect. Furthermore, the patient has also been noted to have trialed 5 rounds of electroconvulsive therapy (ECT) alongside intranasal ketamine, both of which were reportedly ineffective as well. The request is for coverage of TMS for the management of mood concerns.

After a review of the provided documentation, there is no indication that the use of TMS would be more beneficial than any standard treatment such as antidepressants. Though the patient has trialed many antidepressant and medication options, there is no indication that the patient has trialed all available medication options or standard treatment options available individually and/or in combination.

While TMS has been shown to improve depressive concerns indicated with major depressive disorder (as the patient has been diagnosed with), the current generally accepted standards of care and current medical literature still consider TMS to be experimental/investigational at this time. As a result, more studies are needed to identify TMS as being as efficacious or more effective than standard treatments such as antidepressants. Currently, there is no indication that the use of TMS for the management of major depressive disorder is superior to standard treatment with antidepressants.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Bipolar Disorder.
Treatment: Transcranial Magnetic Stimulation.
The health plan denied: Transcranial Magnetic Stimulation.
The health plan's determination is overturned.

The patient is a female with a history of bipolar depression. She has had an adequate trial of psychotherapy and has tried numerous antidepressant medications and mood-stabilizing medications. She has no substance use disorder and no contraindications to transcranial magnetic stimulation (TMS). She has evidence of severe depression as evidenced by a Patient Health Questionnaire - 9 (PHQ-9) score of 19. She has had specific trials of venlafaxine, lithium, Haldol, olanzapine, Seroquel, Abilify, Rexulti, Lexapro, ketamine, Wellbutrin, Buspar, Latuda, Prozac, and Risperdal. She has also failed electroconvulsive therapy (ECT). She has had multiple inpatient hospitalizations.

TMS is likely to be more beneficial than any standard treatment for the insured's condition. The patient has failed standard treatment approaches including venlafaxine, lithium, Haldol, olanzapine Seroquel, Abilify, Rexulti, Lexapro, ketamine, Wellbutrin, Buspar, Latuda, Prozac, and Risperdal. The patient has ongoing evidence of an active depressive episode that is treatment-refractory. There is substantial evidence that TMS is a safe and effective treatment for depression and bipolar depression (Mutz 2022, Gold et al., 2019 Zengin et al., 2022).