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

Diagnosis: Osteoarthritis, Cervical and spinal stenosis with radiculopathy, Right rotator cuff tendinopathy, Right tibial plateau fracture

Treatment: Personal care aide (PCA) hours, 5 days per week 8 hours per day & 2 days per week 4 hours per day (or 48 hours per week)

The insurer denied coverage for personal care aide (PCA) hours, 5 days per week 8 hours per day & 2 days per week 4 hours per day (or 48 hours per week).

The denial is overturned.

This is a female patient with a medical history of obesity, hypertension, osteoarthritis, constipation, insomnia, fatigue, cervical and spinal stenosis with radiculopathy, right rotator cuff tendinopathy and right tibial plateau fracture. The patient lives alone with no informal caregiver support.  She had been approved for personal care aide (PCA) services 21 hours per week. The patient requested an increase to 48 hours per week which was denied; but PCA hours were increased to 31 per week.

This patient has various medical conditions and functional impairment limiting her ability to perform daily activities. The patient's functional status based on the most recent Uniform Assessment System (UAS) report indicates that the patient needs maximal assistance or is totally dependent for household related tasks, shopping, stairs, and transportation. Extensive or limited assistance is needed for most activities of daily living (ADLs); except personal hygiene, eating (setup help). The patient has various symptoms and physical impairments limiting her ability to perform most daily activities associated with several medical conditions including: osteoarthritis, spinal stenosis with radiculopathy (cervical and lumbar), dizziness, and fatigue. It is reasonable to expect that her chronic medical conditions persist and continue to cause various limitations to her daily function. The patient is requesting more daytime PCA hours, which will increase the time she can have assistance with toileting, walking, transfers and stairs. Considering the patient's medical history and functional impairment it is medically necessary and in the patient's best interest to have a caregiver present at least through daytime hours when the patient is most active in order to ensure instrumental activities of daily living (IADLs) and ADLs are completed effectively and safely.

The UAS indicates that the patient has no informal caregivers. When informal caregiver support is not available to provide help with daily activities, then personal care services are indicated to provide assistance with IADLs and ADLs as needed. The maximum number of hours that can be approved from this review is limited by the amount requested, i.e. 48 hours per week. PCA hours, 48 hours per week is medically necessary. The health plan did not act reasonably with sound medical judgment in the best interest of the patient.

The carrier's denial of coverage for PCA hours, 5 days per week 8 hours per day & 2 days per week 4 hours per day (or 48 hours per week) is overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia, Osteoporosis
Treatment: Personal Care Assistant (PCA), Level ll Services, 24 hours per day, 7 days per week (Live-in)
The insurer denied coverage for Personal Care Assistant (PCA), Level ll Services, 24 hours per day, 7 days per week (Live-in).
The denial is overturned.

This is a female patient with a medical history of dementia with behavioral disturbances, cerebral embolism, left eye blindness, coronary heart disease, kyphosis, osteoporosis, urinary incontinence, fecal smearing, weakness, falls, iron deficiency anemia, hypercholesterolemia. The insurer denied coverage for Personal Care Assistant (PCA), Level ll Services, 24 hours per day, 7 days per week (Live-in) as not medically necessary.

The Uniform Assessment System (UAS) report, while the patient was in a Skilled Nursing Facility (SNF), noted that the patient was forgetful and confused; wandering behaviors were documented. Maximal assistance was required for meal preparation, managing medications and phone use. Extensive assistance was required for bathing, dressing lower body, and toilet use. Limited assistance was required for personal hygiene, dressing upper body, walking, locomotion and toilet transfers. Supervision was required for bed motility and eating. The patient had an unsteady gait. The patient also had occasional bladder incontinence and infrequent bowel incontinence.  

Clinical documentation notes extensive assistance x1 for activities of daily living (ADLs). The patient needs maximal assistance with toileting. The patient was confused and needed assistance with bed transfer. The patient was oriented x1, and her mobility function score was 1 on the scale of 0-10 (which was poor). The patient was dependent in walking and wheelchair use. Clinical documentation also showed cognitive and functional impairments.  

Based on the review of the medical record, the patient's needs are not predictable. The 5 hours/day assistance offered by the plan does not cover her needs. Additional services are not for safety supervision alone. Due to the patient's decline in function and the degree of services needed, 24-hour services are approved. This decision is consistent with the New York Codes Rules and Regulations, Title: Section 505.14 Personal care services.

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

The carrier's denial of coverage for PCA, Level ll Services, 24 hours per day, 7 days per week (Live-in) should be overturned. The medical necessity is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Uterine fibroids.
Treatment:  Uterine artery embolization (UAE) (CPT code 37243).

The insurer denied coverage for uterine artery embolization (UAE) (CPT code 37243).  The denial is upheld. 

The patient is a female with a history of pre-diabetes, anemia, and symptomatic fibroids.  A Pap smear done over three years ago was within normal limits.  A pelvic ultrasound showed multiple fibroids.  She was referred by her gynecologist to a vascular and interventional radiologist for complaints of menorrhagia, dysmenorrhea, pelvic pressure, and urinary frequency secondary to fibroids.  Her menstrual cycles occur monthly and last seven days.  The first four days of her menstrual cycle are heavy and require six pads per day.  The patient's urinary frequency results in the urge to urinate every 10 minutes with three episodes of nocturia per night.  The plan was to obtain magnetic resonance imaging (MRI) to confirm fibroid presence and determine candidacy for uterine artery embolization.  The MRI revealed an enlarged leiomyomatous uterus.  The recommendation by is for the patient to undergo UAE. 

UAE is a minimally invasive treatment for uterine leiomyomas (fibroids).  The procedure is a percutaneous angiographic procedure performed with video fluoroscopic imaging with injection of embolic agents into the uterine artery.  Ideal candidates for UAE include women with heavy menstrual bleeding or dysmenorrhea caused by intramural fibroids, who are premenopausal and who have no desire for future pregnancy.

This patient had menorrhagia due to uterine fibroids as demonstrated by MRI.  She is premenopausal and is not interested in having children. 

It is important to ensure prior to the procedure that cervical cancer screening is current because an abnormal Pap smear may change the management of this patient.  In other words, if this patient has an abnormal Pap smear and follow-up colposcopy showed abnormal lesions, a hysterectomy might be the appropriate management rather than embolization.

Based on the above and in the absence of documentation of a normal recent Pap smear result, UAE is not medically necessary.  The health care plan did act reasonably and with sound medical judgment and in the best interest of the patient.  In the absence of an updated Pap smear result, uterine artery embolization is not considered medically necessary for this patient.

The carrier's denial of coverage for uterine artery embolization (CPT code 37243) is upheld.  The medical necessity is not substantiated.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic idiopathic constipation
Treatment: Motegrity
The insurer denied coverage for Motegrity.
The denial is upheld.

This is a female patient with a diagnosis of chronic idiopathic constipation. The patient's medical records indicate that she has not responded to Miralax or Linzess.

According to an article from UpToDate, treatment options are given for pharmacologic therapy. Prucalopride has been shown to be effective. However, polyethylene glycol-3350 electrolyte solutions were said to be not inferior to prucalopride and may have some advantages including lower costs.

There are several options for the treatment of chronic idiopathic constipation. However, there is no clinical documentation that the patient has failed the formulary alternatives for chronic constipation. It is not likely that the formulary drugs would cause an adverse reaction. There is no clinical documentation that all of the formulary drugs have been ineffective. It has not been shown that Motegrity would work better than the formulary drugs for this patient.  

The carrier's denial of coverage for Formulary Exception for Motegrity is upheld.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dyspnea/cough.
Treatment:  Inpatient stay.

The insurer denied the inpatient stay.  The health plan's determination is upheld. 

The patient is a woman with breast cancer, who was admitted to the hospital with pleuritic chest pain, dyspnea and cough, who had previously received neoadjuvant chemotherapy, followed by mastectomy/reconstruction. 

She had recent travel prior to admission.  On admission, her vital signs were normal. There was no mention of tachycardia, fever, hypoxia, or hypotension.  The hemoglobin was 9.6, normal white blood cell count (WBC), and platelets 652,000.  An electrocardiogram (ECG) was negative, as were troponin and brain (or B-type) natriuretic peptide (BNP).  A computed tomography (CT) chest for pulmonary embolism (PE) showed moderate right and small left pleural effusion with compressive atelectasis.  An echocardiogram (ECHO) was normal.  Intravenous (IV) Lasix was administered, in addition to Rocephin and Zithromax, for effusions and possible bronchitis.

The inpatient hospital admission was not medically necessary for this patient.  According to Milliman Care Guidelines (MCG) criteria, admission for pleural effusion are indicated when 1 or more of the following are at issue:  pneumonia related effusion, acute respiratory failure, hemodynamic instability, hemothorax, empyema, pneumothorax, malignant pleural effusion, tachypnea or dyspnea that persists despite observation care treatment, hypoxemia or hypercapnia, complications of drainage, related to pulmonary embolus or trauma, severe pain requiring inpatient management, chest tube placement, pulmonary artery catheter monitoring, epidural analgesia, or immediate inpatient surgery.

There was no provided documentation provided to indicate that the patient met any of these criteria. 

Alternatives to admission include outpatient care in office, emergency room (ER) or outpatient observation with the potential for inpatient admission, if the clinical status deteriorates and satisfies criteria mentioned above for inpatient admission.  This patient could have been safely cared for at a lower level of care.  An inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Irritable Bowel Syndrome with Constipation.
Treatment:  Pharmacy/Prescription Drugs (Motegrity).

The health plan denied the request for Motegrity.  The health plan's determination has been overturned.

The patient is a female with chronic idiopathic constipation.  She has had symptoms for 6 years, with no bowel movements for 7 to 10 days at times, straining, and hard bowel movement complicated by hemorrhoid symptoms.  She has failed multiple over-the-counter medications, magnesium hydroxide, MiraLAX, Dulcolax, Linzess, hematochezia, probiotics (VSL, Visbiome, Florastor, Align, Culturelle), Colace, fiber, mechanical manipulation, and elimination diet.  She has had small intestinal bacterial overgrowth with constipation not responsive to Rifaximin or Neomycin.  The coverage is requested for Motegrity 2 mg daily for the treatment of chronic idiopathic constipation.

The health plan's determination is overturned, in whole.

Yes, the medical necessity of Motegrity 2 mg daily is supported. The patient has had chronic constipation symptoms, and failed a stimulant laxative (Dulcolax), osmotic laxative (MiraLAX), and advanced agents (Amitiza, Linzess). The American Gastroenterological Association Medical Position Statement on Constipation states that after failure of an osmotic agent, and then a stimulant laxative, a newer agent such as Motegrity should be used [2]. Motegrity has shown efficacy for the treatment of constipation and for symptoms including bloating and abdominal pain [3-5].
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Dementia.
Treatment:  Personal Care Aide (PCA) Level 2 services: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.

The insurer denied Personal Care Aide (PCA) Level 2 services: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.  The determination is upheld.

The patient has a past medical history significant for chronic obstructive pulmonary disease (COPD) and dementia.  The patient is currently maintained on 5 liters (L) of oxygen via nasal cannula and is bedridden.

Personal care aide services level to 12 hours per day 7 days a week split shift for a total of 168 hours a week are requested.  The patient is currently approved for 24 hours a day live-in home care.

At issue is the medical necessity of Personal Care Aide (PCA) Level 2 services: 12 hours per day - 7 day(s) per week; 12 hours per day - 7 day(s) per week (split shift) - a total of 168 hours per week.

The requested health service is not medically necessary for this patient.

The documentation provided including the Uniform Assessment System (UAS), physician notes an appeal letter failed to demonstrate a medical need above and beyond a 24-hour live-in aide could provide.  There was no reason noted why a live-in aide could not perform these services.  There is no notation of why the patient would need more than 16 hours a day of care and that the aide could not get proper rest, defined as at least 5 hours of interrupted sleep.

This is a patient with a medical history significant for COPD and dementia.  He is currently maintained on oxygen 5 L by nasal cannula.  He is currently on hospice for his medical problems.

There was a notation that the patient did have a fall earlier in the summer resulting in a fracture.  This occurred when he tried to climb out of bed.  Although this is a concern, when approving services, there must be the demonstrated need for activities of daily living (ADLs) or instrumental activities of daily living (IADLs) above and beyond observation and preventing falls.  Services for preventing falls and observation are typically included in the provided services allowed for under the evaluation.  Specifically, the aide must be performing a service such as in ADL or IADL.  Aide services for watching the patient in the middle of the night without actually performing a medically necessary ADL would be considered observation.  The documentation provided did not note specific needs for 12 hours a day 7 days a week split shift.

The health plan's determination is upheld.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 Diabetes. 
Treatment: Janumet (sitagliptin-metformin). 
The insurer denied the Janumet (sitagliptin-metformin). 
The denial is overturned. 

This patient is a female with type II diabetes. She was previously stable on Janumet. She has failed Jentadueto due to hyperglycemia and alogliptin-metformin. 

Yes, the health plan should cover the proposed Janumet. 

This patient has tried and failed Jentadueto due to hyperglycemia. It is not appropriate for her to try Jentadueto XR, which has the same glucose lowering effect as Jentadueto, as she would be expected to fail Jentadueto XR as well. Her type II diabetes has previously been managed on Janumet. Without Janumet, this patient is at risk for hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy. The American Diabetes Association clinical guidelines support the use of Janumet in this clinical situation. Therefore, yes, the health plan should cover the proposed Janumet.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: High blood pressure (hypertension). 
Treatment: Inpatient admission. 
The insurer denied the inpatient admission. 
The denial is overturned. 

The patient is a female. She was readmitted to the hospital six days postpartum for high blood pressure.  She had severe preeclampsia with her pregnancy. 

The patient's initial measurement of blood pressure was 156/88 to 187/107.  An attempt was made to stabilize her in the emergency room with several pushes of intravenous labetalol, but her blood pressure remained elevated.  She was admitted to the hospital and treated with MgSO4 (Magnesium Sulfate) and Procardia in addition to labetalol.  

On hospital day 1, the patient's blood pressures were 118/67, but she did have a mild headache.  Her physician documented that if she continued to be stable, she could be discharged the next day (hospital day 2).  On hospital day 2 her blood pressure was 127/74, the headache had resolved, and she was discharged home.  

The health plan agrees that the first hospital day was medically necessary but that the second was not and references MCG Hypertensive Disorders of Pregnancy ORG M-285.  The facility contends that the entire hospital stay was medically necessary and cites MCG 23rd edition MG-OBD.  

Yes, the continued inpatient admission was medically necessary.  

There is no disagreement between the health plan and the facility that the patient needed to be admitted and treated for postpartum preeclampsia.  The question posed is whether the second hospital day was medically necessary.  Treatment for severe preeclampsia is based on vital signs, laboratory data, and symptoms.  The most concerning symptoms that point to a suspicion of end-organ involvement are headache and epigastric pain.  While headaches can occur for a variety of reasons during pregnancy and it is possible, as was the patient's belief, that the headache could be attributable to the magnesium infusion, it is also possible that it could be due to ongoing preeclampsia.  Because serial assessment of this symptom is required to determine its clinical relevance, observation beyond the first day was warranted to ensure that the headache did not become worse, which would suggest ongoing central nervous system involvement of the preeclampsia and the need for further workup and treatment.  Therefore, the entire admission including the second hospital day was medically necessary.
Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis:  Lymphedema.
Treatment:  Vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day.

The insurer denied coverage for vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day.  The denial is overturned.

This is a female patient with a history of early stage 2 secondary lymphedema of the suprapubic region, right thigh, and left thigh.  The patient's condition did not improve with a 6 hours per day regimen with Flexitouch twice daily, class 2 compression garments (bilateral leg and shorts to help with lower abdominal wall/suprapubic swelling), yoga, exercise, and self-performed manual lymph drainage.  Her provider recommends that she undergo suprapubic, lower abdominal wall, and bilateral groin exploration, scar release and excision, as well as bilateral groin lymph node transplant with omentum.

A systematic review of the literature published in 2019 on omental vascularized lymph node transfer for lymphedema states, "Overall, patients experienced successful lymphedema treatment with [vascularized omental lymph node transplant (VOLT)].  All [studies] presented results with reduced circumferential size of the affected upper and lower limbs, as well as reduction of the infectious intercurrences, such as cellulitis, with a small incidence of associated complications."  As to date, the best available data supports that vascularized omental lymph node transplant (VOLT) is an effective treatment that reliably improves lymphedema and associated symptoms.

This patient has persistent lymphedema despite appropriate attempts at medical treatment (i.e., conservative therapy).  The patient's lymphedema is preventing her from returning to work.  The patient has been hospitalized for cellulitis.  No other treatment is likely to improve her symptoms. 

Thus, the requested procedure is likely to be more beneficial than any of the standard treatments/procedures for this patient.

The carrier's denial of vascularized lymph node (omentum) flap transfer with microanastomosis (CPT code 38999-2 units, 38792-2 units and 49906-1 unit) and 1 associated inpatient bed day should be overturned.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dementia
Treatment: Increase in Personal Care Services/HHC - Level II, per 15 minutes from
28 hours per week to 24 hours per day (live in) services
The insurer denied the increase in Personal Care Services/HHC - Level II, per 15
minutes from 28 hours per week to 24 hours per day (live in) services.
The denial is overturned.

Beneficiary is a female with a history of dementia. Due to impairments related to
these conditions, she requires assistance for completion of the majority of her
activities of daily living (ADLs).

Appeal review requested for potential approval of 24 hours/day (live in) Personal
Assistance Services to offer increased ADL support.

Yes, the proposed increase in personal care services/HHC, level II, per 15 minutes
from 28 hours per week to 24 hours per day (live-in) services is medically
necessary.

The proposed treatment of 24 hours/day (live in) Personal Assistance Services is
deemed medically necessary. This is a female with a history of dementia. Due to
impairments related to her conditions, she requires assistance for completion of the
majority of her activities of daily living (ADLs). Recent documentation indicates that
the patient has sustained additional functional decline with worsening cognition. She
is now unable to get out of bed by herself and is completely dependent on others
for assistance with completing all ADLs. Hence, the currently approved plan of 28
hours/week Personal Assistance Services is no longer sufficient to meet the
patient's current needs. For these reasons, the proposed treatment 24 hours/day
(live in) Personal Assistance Services is deemed medically necessary.