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

Diagnosis: coronary artery disease
Treatment: Myocardial Perfusion Imaging 
The insurer denied Myocardial Perfusion Imaging. The health plan's determination is overturned. 

The patient is a woman with a history of supraventricular arrhythmias, peripheral arterial disease, sleep apnea, cigarette smoking and a family history of premature coronary artery disease. She was evaluated for three months of intermittent non-exertional chest pain and worsening exertional dyspnea with minimal activity. She also reported claudication with walking short distances. Her electrocardiogram showed sinus rhythm with nonspecific ST segment and T wave changes. Myocardial perfusion imaging (MPI) that had been performed one year prior for palpitations and dyspnea showed no evidence of ischemia. 

Based on the documentation provided myocardial perfusion imaging is medically necessary.
This woman, with multiple cardiac risk factors, presented with chest pain and exertional dyspnea. Myocardial perfusion imaging one year prior showed no evidence of ischemia. However, when the patient was evaluated recently, she had new and worsening symptoms. Given her multiple risk factors she was at significant risk for coronary artery disease and cardiac stress testing was medically necessary. Since she was unable to walk on a treadmill, the options included dobutamine stress echocardiography or myocardial perfusion imaging with pharmacologic stress. Dobutamine stress would have been the less appropriate option given her history of supraventricular arrhythmias. Use of MPI (Myocardial perfusion imaging) with pharmacologic stress in this situation (i.e., symptomatic patient at intermediate to high risk for ischemia who is unable to exercise on a treadmill) is endorsed by the national guidelines.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Left knee pain. 
Treatment: Inpatient Hospital Admission. 
The insurer denied: Inpatient Hospital Admission. 
The denial is upheld. 

This is an adult female patient with left knee pain. She had limitations to activity and did not improve with conservative treatment. The physical examination was significant for mild effusion and tenderness. Her past medical history was significant for hepatitis C and thyroid disease. The patient had been seen by a cardiologist who reported 60 percent (%) ejection fraction (EF) (normal). The patient's physician recommended a total knee replacement. An admission to the hospital was recommended. 

The proposed inpatient hospital admission is not medically necessary. 

There is no indication of ongoing medical problems nor conditions which would require the admission and length of stay. This type of operation could be performed ambulatory without need for formal admission. Specifically, no documentation was provided of a comorbidity to support length of stay (i.e. active medical problems, elevated body mass index [BMI], extenuating circumstances).
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Peripheral Vascular Disease
Treatment: Peripheral Revascularization
The insurer denied the peripheral revascularization.
The health plan's determination is overturned.

The patient is a male with peripheral vascular disease who was seen for follow up. The patient is status/post (s/p) left lower extremity angiogram with left common iliac artery stenting and presents with pain in his legs from walking long distances. His left leg is worse than his right.

The provider recommended treatment of his left leg peripheral vascular disease with revascularization of left iliac artery with stent placement and angioplasty, revascularization of femoropopliteal artery with stent placement and angioplasty and revascularization of tibial artery with angioplasty.

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

The requested health service/treatment of peripheral revascularization is medically necessary for this patient. The patient has symptomatic peripheral arterial disease requiring treatment. Ankle brachial indexes performed were 0.94 on the right and 0.92 on the left. A computed tomography (CT) angiogram was recommended for further evaluation. The CT angiogram of the abdominal aorta and bilateral lower extremity runoff performed demonstrated patent left common iliac artery stent, high-grade stenosis of the left proximal internal iliac artery, 99 percent (%) stenosis of the mid left external iliac artery.
The recommended treatment is medically necessary and is the standard of care for the treatment of peripheral arterial disease. The patient will benefit from the treatment.

The health plan's determination of medical necessity is overturned in whole.
Appeal type: Medical necessity
Decision: Overturned


Diagnosis: decreased mobility
Treatment: home health care
The insurer denied Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total Amount of 168 Hours per Week. The health plan's determination is overturned. 

The patient is a female with past medical history of urinary incontinence, bowel incontinence, osteoarthritis knees, osteoarthritis spine, gastroesophageal reflux disease (GERD), hyperlipidemia, diabetes mellitus type 2, osteoporosis, hypertension, dementia, major depressive disorder, and panic attacks who had been assigned Consumer Directed Personal Assistance Program (CDPAP) services.

Consumer Directed Personal Assistance Program (CDPAP) Services: 12 Hours per Day, 7 Days per Week + 12 Hours per Day, 7 Days per Week (Split Shift) - Total Amount of 168 Hours per Week are medically necessary for this patient.
There is documentation from the patient's PCP (primary care provider), psychiatrist, and family of worsening physical and cognitive functioning. There is documentation from the plan's own assessment of worsening activities of daily living (ADL)/Instrumental activities of daily living (IADL) status with tasks of managing medication, phone use, stairs, transportation, bathing, personal hygiene, dressing upper/lower body, walking, locomotion, transfer toilet, toilet use, bed mobility, and eating when comparing the previous 2 assessments. The patient has overnight ADL care needs that would not allow an aide 5 hours of uninterrupted sleep. The requested increase in CDPAP services is not solely for safety and supervision but to assist the patient with safe completion of ADLs/IADLs. The patient's care needs cannot be met solely with adaptive equipment and medical supplies. The plan assumed the patient's family could provide informal help which was not the case due to their own full time jobs and family responsibilities. Taking into account the clinical standards, all information provided regarding the patient, the attending physician's recommendations, and the applicable and generally accepted practice guidelines, CDPAP services 12 hours/day, 7 days/week + 12 hours/day, 7 days/week (split shift) to total 168 hours/week are medically necessary for this patient. Personal care services are medically necessary when assistance with nutritional and environmental support function is essential to the maintenance of the patient's health and safety in her own home.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Cardiomyopathy, bronchitis and hypertension
Treatment: Personal care worker (PCW) services 7 days per week, 24 hours per day, live in; 91 hours per week.
The insurer denied coverage for personal care worker (PCW) services 7 days per week, 24 hours per day, live in; 91 hours per week.
The denial is modified.
 
This is an elderly patient with chronic medical problems including cardiomyopathy, bronchitis and hypertension. She lives alone in a private residence. The insurer approved personal care worker (PCW) services 6 hours per/day, 7 days/week and the request is for PCW services 7 days/week, 24 hours/day, live in; (91 hours/ week). 

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as modified independent. She reportedly requires extensive to maximal assistance for much of her Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires extensive assistance for bathing and lower body dressing. Limited assistance is needed for personal hygiene, upper body dressing and eating. She is independent with bed mobility. Extensive assistance is needed for toilet transfer/use.  Her doctor indicated in his note the patient "can't really ambulate on her own." However, according to the UAS subsequently noted the patient requires only limited assistance for locomotion and ambulation. In addition, and according to the home physical therapy notes also subsequently dated, the patient is at the supervision level for transfers and ambulation.  

The patient's medical condition, physical limitations and functional decline are not at the level or unpredictable as to require the requested PCW services 24 hours/day live-in.  However, Ms. Kane's functional ability has significantly declined when compared to the previous UAS report and supports increasing PCW services to 9 hours/day, 7 days/week totaling 63 hours/week. The patient may benefit from additional monitoring; particularly due to her reported balance deficits and falls risk. However, safety monitoring under PCW does not include monitoring an individual (e.g., with balance deficits) 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 functional needs are more appropriately provided and maintained by the increasing PCW services to 9 hours/day, 7 days/week totaling 63 hours/week.

Based on the above, the insurer's denial must be modified. 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) services 7 days per week, 24 hours per day, live in; 91 hours per week services is not substantiated. However, increasing personal care worker (PCW) services to 9 hours/day, 7 days/week totaling 63 hours/week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Urinary tract infection.
Treatment: Inpatient admission.
The insurer denied coverage for inpatient admission.
The denial is upheld.
 
Patient is an adult with past medical history significant for recurrent urinary tract infection (UTI), multidrug resistant (MDR) organism, multiple sclerosis, neurogenic bladder, and right lower extremity deep vein thrombosis who presented to the emergency department with complaints of UTI symptoms.

Vitals on presentation included: Temperature 36.7 degrees Celsius, Blood Pressure 117/83, Pulse 90, Respiratory Rate 18, oxygen (O2) saturation 97%. Laboratory results included the following: white blood cell count (WBC) 3.7, Hemoglobin-13.1, Hematocrit-38.6, creatinine-0.9, glucose-94.

Patient was started on intravenous (IV) fluids and empiric antibiotics (linezolid and meropenem) for possible UTI. Computed tomography (CT) scan of abdomen/pelvis showed no evidence of pyelonephritis or cystitis. Blood cultures were negative and urine culture showed multiple organism suggestive of possible contamination. Patient remained afebrile and hemodynamically stable. He was discharged to continue outpatient follow-up.

According to documentation, patient was admitted for possible recurrent UTI. Otherwise, patient was afebrile, hemodynamically stable with unremarkable laboratory findings including normal white blood count (WBC). Additionally, CT scan was negative for cystitis and pyelonephritis. Based on above findings, patient met criteria for observation level of management.

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 site of service is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Phenylketonuria (PKU).
Treatment:  Palynziq 20mg/ml (milligrams/milliliter) syringe.
The insurer denied: Palynziq 20mg/ml syringe.  
The denial is overturned.

The patient is an adult female.  She has classical phenylketonuria (PKU). She has had elevated blood phenylalanine levels above 600 micromolar for over six months, even while on a protein-restricted diet and taking Kuvan/sapropterin. Her geneticist has requested Palynziq therapy for her, given the proven efficacy of this injectable medication for individuals with classical PKU (phenylketonuria) who have not responded to a reduced phenylalanine diet and Kuvan/sapropterin.

The health plan denied coverage of the request, noting that detailed information about the patient's treatment, and her blood phenylalanine levels were not provided initially by the provider. The denial is being appealed.

The requested Palynziq is medically necessary.

Palynziq therapy for classical PKU (phenylketonuria) is medically necessary and clinically appropriate for this adult female, whose classical PKU (phenylketonuria) has been unresponsive to dietary protein restriction and Kuvan/sapropterin therapy. Palynziq therapy represents a standard of care in medical genetics and biochemical genetics for individuals with classical PKU (phenylketonuria), is not unproven or unnecessary, and is well supported by authoritative, peer-reviewed, published medical literature.
Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis: Age-related cognitive decline, anxiety, chronic atrial fibrillation, hypertension, hallucinations, and polyarthritis
Treatment: personal care aide 7 days x 12 hours, total 84 hours per week
The insurer denied coverage for personal care aide 7 days x 12 hours, total 84 hours per week
The denial is modified.

This is an elderly patient with medical problems including atrial fibrillation, hypertension and arthritis. She lives alone and her daughter lives on the second floor of the house. The insurer approved a personal care aide (PCA) 35 hours/week, and the request is for 84 hours/week.

According to the Uniform Assessment System (UAS) report the patient's cognition is described as minimally impaired. She is totally dependent to maximal assistance for Instrument Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. She requires extensive assistance for bathing and dressing. Only limited assistance is needed for toilet use. She is frequently incontinent of bladder and occasionally incontinent of bowel. The patient is otherwise independent for personal hygiene, eating, bed mobility, locomotion, toilet transfer and ambulation (with a cane). There have been no reported falls over the prior 90 days. The patient's clinical and functional deficits are not at a level and unpredictable as to require the requested PCA 84 hours/week. Increasing a PCA to 56 hours/week is reasonable given her impairments. This physician would also agree that given the patient reported cognitive decline and propensity for wandering in the home, she may require additional monitoring. However, safety monitoring 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 records reviewed, the patient's health, safety and reasonably high functional ability can be appropriately provided and maintained by increasing PCA to 56 hours/week.  

Based on the above, the insurer's denial must be modified. 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 aide 7 days x 12 hours, total 84 hours per week is not substantiated. However, 56 hours/week are medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Heart failure with preserved ejection fraction, major neurocognitive disorder, hypertension, asthma, obstructive sleep apnea (OSA), urinary incontinence and osteoarthritis
Treatment: 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 PCW service 7 days per week, 24 hours per day, continuous care by more than one person; 168 hours per week
The denial is upheld.
 
This is an elderly patient with heart disease, neurocognitive disorder and osteoarthritis who was approved for PCW 7 days/week, 24 hours/day, Live-in: 91 hours/week. The request is for PCW 7 days/week, 24 hours/day, continuous care by more than 1 person; 168 hours/week, which is currently under review.  

The Uniform Assessment System (UAS) report was reviewed. The patient's cognitive skills are described as "minimally impaired." They are totally dependent to maximal assistance for Instrumental Activities of Daily Living (IADL) tasks including meal preparation, ordinary housework and shopping. Maximal assistance is needed for bathing and lower body dressing. Extensive assistance is needed for personal hygiene, upper body dressing, bed mobility, locomotion, ambulation and toilet transfer/use. The patient is frequently incontinent of bladder and infrequently incontinent of bowel. The functional ability is much the same as compared to the previous UAS.

The patient's need for level 1 or 2 services during nighttime hours are not at a level or unpredictable as to require the requested PCW services 7 days/week, 24 hours/day, continuous care by more than 1 person: 168 hours/week. The nighttime activity logs were reviewed and document the patient's care as primarily "watch patient" and "monitor for safety." This physician would agree due to safety concerns the patient may require additional monitoring for safety. Unfortunately, safety monitoring under personal care services does not include monitoring an individual (e.g., with dementia) when no other Level 1 or Level 2 personal care services task is being provided.  Based on the documents reviewed, the approved PCW 7 days/week, 24 hours/day, Live-in; 91 hours/week are appropriate to meet the patient's functional needs.  

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 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 not substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory Failure
Treatment: Transfer to Albany Medical Center
The insurer denied: Transfer to Albany Medical Center
The denial is: Upheld

The patient was born at term gestation (39.1 weeks estimated gestational age) with a prenatally diagnosed left-sided congenital diaphragmatic hernia (CDH). Apgar scores were 5 and 7 at one and five-minutes, respectively. His critical condition required care for respiratory failure including high frequency oscillatory ventilation (HFOV), inhaled nitric oxide, Intravenous medications for blood pressure support, and eventual support with extra-corporeal membrane oxygenation (ECMO) prior to undergoing surgical repair of the CDH. Staged abdominal wall closure was completed. A gastrostomy tube (G-tube) was placed, and a left inguinal hernia was repaired on the same date. The patient continues on Sildenafil for pulmonary hypertension, remains on a high flow nasal cannula (HFNC), and G-tube feedings every 3 hours given over 120 minutes.
The patient is now months in age, and the medical provider is requesting a facility transfer on behalf of the family so that the patient continued inpatient care can be completed closer to their home/residence. The medical necessity for the transfer is the subject under review.

The health plan's determination is upheld.

The requested transfer to Albany Medical Center is not medically necessary for this patient. The patient's medical care is being provided in a facility capable of providing the level of care needed. The patient's condition does not require any services that cannot be provided where he is currently hospitalized in New York City. The request for transfer is so that the patient can be closer to his family while he continues to receive inpatient medical care.
The request is for continued medical care that is closer to the family's residence and is not for care that cannot be provided at the current facility. The patient is currently receiving all of the necessary care for his condition. The request for transfer to Albany Medical Center to be closer to his family is for the convenience of the patient's family and that is not considered medically necessary.
The American Academy of Pediatrics document on Determination of Medical Necessity addressed specific care that is medically necessary for pediatric patients but does not specify that the care be provided close to the family's residence. 2
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Atherosclerotic Cardiovascular Disease.
Treatment:  Repatha 140MG (milligrams)/ML (milliliter) Injection.

The insurer denied Repatha 140MG (milligrams)/ML (milliliter) Injection.  The denial is upheld.

The patient is an adult male with significant CAD (coronary artery disease) history, including PCI (percutaneous coronary intervention) and CABG (coronary artery bypass graft).  He has elevated lipids, including an LDL (low-density lipoprotein) of 179. A statin could not be prescribed for the patient, as he had a history of anaphylactic reaction to Lipitor. A request was made for Repatha, a PCSK9 (proprotein convertase subtilisin kexin 9) inhibitor. This medication is not on the preferred drug list, and it was denied coverage by the health plan as not on the preferred drug list. The denial is being appealed. 

The requested Repatha is not medically necessary. 

It is appropriate to prescribe a lipid lowering medication, and since the patient is statin intolerant due to his allergic reaction to Statin, an alternate class of medications is indicated. The use of PCSK9 (proprotein convertase subtilisin kexin 9) inhibitors are an appropriate choice. On the preferred drug list, there is Praluent, which would be an appropriate PCSK9 (proprotein convertase subtilisin kexin 9) inhibitor. No justification was provided as to why Praluent would not be appropriate for use in this patient. The requested Repatha is not on the preferred drug list, and there is no explanation or literature that indicates that Praluent should not be used in this case. Thus, Repatha was appropriately denied, with Praluent offered as a reasonable alternative. Therefore, given the above, the requested Repatha is not medically necessary.