Persius/imr-appeals huggingface dataset:
Diagnosis: Lewy body dementia
Issue under review: Increase in PCW services

Determination:
The Increase in PCW services is not medically necessary.

This is a patient with a history of advanced Lewy body dementia and associated psychosis.  Despite the report from the patient's attending physician that the patient has sustained further cognitive and functional decline, a recent Uniform Assessment System of New York revealed that the patient had not experienced significant changes in her cognitive, functional status and overall self-sufficiency as compared to her last assessment date.  Furthermore, her currently approved PCW service is sufficient to meet her ADLs and other needs.  For these reasons, the proposed treatment of an increase in PCW services is not deemed medically necessary.
Diagnosis: Migraines
 
Treatment: Medication- Emgality 

The insurer denied coverage for Emgality. The denial was upheld.

This child patient has a past medical history notable for anxiety, asthma and obesity with chronic headaches most consistent with migraines.  She has frequent headaches and they are severe, long-lasting and debilitating.  She was referred to a neurologist; she has never taken prophylactic headache medication.  Neurologist recommended Emgality.  

Emgality will only be approved for adult patients. Furthermore, the patient must have had serious side-effects or drug failure to a 3-month trial of at least two medications- examples include Propranolol, Topiramate, Valproic Acid, Amitriptyline, Venlafaxine and Botox. There is no documentation that the patient has failed 2 preventative medications for migraines. 

The patient's asthma is a contraindication to propranolol and other beta blockers.  Neurologist states that the patient cannot take amyitryptiline or nortryptiline because she is already taking two other antidepressants, though this is not an absolute contraindication. The patient has no contraindication to Topirimate, Valproate or Botox.
Diagnosis: Substance abuse

Treatment: Continued inpatient admission

The continued inpatient admission was medically necessary for this patient.
The requested benefit of the continued inpatient admission could not have been safely or effectively provided at a lower level of care in this case scenario. The patient in this case was using opioid/heroin together with large quantity of alcohol on a daily continuous basis; and intermittent use of cocaine that did warrant inpatient level detoxification and withdrawal management and monitoring. Detoxification, as necessary, and other treatments pertinent to the detoxification treatment episode, could not have safely or effectively proceeded at a lower level of care following the comprehensive assessment that was provided at the time of admission.  Moreover, the patient presented with moderately severe withdrawal symptoms that persisted requiring withdrawal management, and the patient's social environment was not conducive to detoxification. Again, the patient struggled with withdrawal symptoms during the time interval under review in the context of limited insight, impaired judgment and poor control of impulses. Thus, the continued detoxification treatment of this patient's substance use disorder did necessitate the continued structure of an inpatient level detoxification setting and monitoring. 

The patient's history of substance abuse (frequency and quantity) together with the drug-infested social environment, and severe psychosocial stressors and functional impairments reflect the seriousness of the substance use disorder and the need for a safe and effective detoxification with withdrawal management, as the patient was at high risk for treatment failure if the continued detoxification and withdrawal management were to have been attempted at a lower level of care. Therefore, medical necessity is met in this case, consistent with prevailing standards of professional practice, published practice guidelines, ASAM Criteria, and the scientific literature, referenced below, and New York State instruction for medical necessity reviews including the LOCADTR Tool that requires the patient in this scenario default to the higher level of care.

The requested benefit of continued inpatient admission is medically necessary in this case scenario, and therefore should be covered in this case scenario. The health plan contends that the patient could have been treated at inpatient rehabilitation level of care. However, the patient's clinical features and treatment dimensions did warrant continued inpatient level detoxification services through discharge and did necessitate the monitoring that is provided with inpatient level treatment including the use of comfort medications and seizure precautions. Moreover, the continued substance abuse detoxification treatment through discharge could not have been safely or effectively provided with lower level services, as noted above. Thus, the requested benefit should be covered in keeping with prevailing standards of care pertaining to substance use disorder services including ASAM Criteria and the New York State OASAS LOCADTR 3.0 Criteria, referenced below.
Diagnosis: Alopecia Areata and Vitiligo 

Treatment: Xeljanz

The insurer denied the Xeljanz. The denial was reversed. 


This is a middle aged male who presented to the visit in mid-2019 for alopecia areata and vitiligo. The patient reported that it had been present for years. He also had loss of his eyebrows and eyelashes, and had 30% hair loss to the scalp. Additionally, he had severe eye irritation, scattered patches on the scalp and body. His face and neck had demonstrated vitiligo depigmented patches as well. The recommendation was to start Xeljanz 5 mg oral tablet, one tablet twice per day.
The patient has alopecia areata and vitiligo.  There is no Food and Drug Administration (FDA) approved or plan approved therapies for alopecia areata or vitiligo. Xeljanz has been found to be effective and safe for the treatment of alopecia areata and vitiligo. The patient's condition has had a severe negative impact on his personal life. It has caused embarrassment, isolation, and depression, in addition to having a negative impact on his livelihood and overall well-being. The patient has tried and failed conservative therapies.

"Agents which are commonly used to treat rheumatologic diseases and psoriasis are also being studied in the treatment of autoimmune diseases including vitiligo. Janus kinase (JAK) inhibitors have been evaluated in several case reports, with potential therapeutic promise thought to be related to their interference with interferon (IFN)- signaling 48, 49, 74, 75. Research has shown that IFN-induced expression of CXCL10 is critical for the progression and maintenance of depigmentation in vitiligo 76. In a recent case report, a patient with vitiligo was treated with tofacitinib, an oral JAK 1/3 inhibitor, for 5 months, and had significant repigmentation with no significant adverse effects 74." (Manga, P., Elbuluk, N., & Orlow, S. J., 2016).

Based on the above, the medical necessity for Xeljanz is substantiated.  The insurer's denial is reversed.
Diagnosis: Bilateral Lower Lobe Pulmonary Emboli and Pneumonia.
 
Treatment: Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant)

The insurer denied the Genetic testing (F5 coagulation Factor V gene analysis, Leiden variant) and (F2 gene analysis 20210G>A variant). The denial was upheld.   

This case involves male who was seen in early 2019 for a consultation.  The patient was being seen for a bilateral provoked pulmonary emboli, as well as community-acquired pneumonia. He had a history of a fractured his fibula and tibia back in early 2019 and underwent an internal fixation. He experienced increasing pain to the left lower extremity after surgery and was found to be negative for a deep venous thrombosis. He began to complain of back and chest pain; a CT scan of the chest was performed showing filling defects in both lower lobe pulmonary arteries compatible with pulmonary emboli.  The patient began utilizing Xarelto and continues on the medication.  The patient stated he had a family history of thrombosis. It was recommended he undergo a hypercoagulable work-up due to his recent diagnosis and family history. The patient completed a three months regimen of anticoagulation; and additional laboratory studies were recommended.
The F2 gene is known as the coagulation factor which is associated with impaired clotting ability. The F5 gene is also known as coagulation factor V, and is associated with coagulation factors essential for proper blood clot formation. According to current peer-reviewed literature, the testing for hypercoagulable disorders in a patient with a diagnosis of venous thromboembolism is not warranted. This is because the identification of an inheritable defect does not alter therapeutic or prophylactic anticoagulation management, and consequently it has not been associated with improved outcomes. 

Based on the above, the medical necessity for genetic testing for CPT code 81241 (F5 coagulation Factor V gene analysis, Leiden variant) and 81240 (F2 gene analysis 20210G>A variant) is not substantiated.  The insurer's denial is upheld.
The patient presented to the emergency department with suicidal ideation. The patient reported being noncompliant with the psychiatry medications for approximately 3 weeks. In the emergency department, the patient verbalized wishes to harm himself. The patient was found to have uncontrolled diabetes with a glucose in the 400s. The initial work up showed a chest x-ray that was unremarkable. On examination, the patient had reduced ability to focus attention, thought content paranoid, poor judgment, depressed mood, poor insight with auditory hallucinations. The patient was evaluated by psychiatry for suicidal ideation and medication management. A one-to-one sitter for patient safety was recommended. The patient was started on citalopram, quetiapine and hydroxyzine. The patient was admitted to medicine unit for treatment of uncontrolled diabetes and was started on basal insulin with Lantus, regular insulin before meals and a sliding scale.

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient was evaluated by psychiatry and one-to-one sitter for safety was ordered; he was restarted on his psychiatric medications. He was also followed by endocrinology and insulin regimen was adjusted for better diabetes management. He remained clinically stable during his hospitalization, pending possible transfer to inpatient psych facility, however, after further evaluation by psychiatry, he was considered stable from psychiatry standpoint to be discharged home. Based on the available clinical information, and patient's presentation and plan of care, the patient required hospitalization for further monitoring and evaluation of his clinical condition, however, the services could have been provided at a lower level of care.
Diagnosis: Angioedema 

Treatment: Inpatient Admission

The insurer denied Inpatient Admission. The denial was upheld.

This is a middle aged male who presented to the Emergency Department (ED) in early 2019 with complaints of an allergic reaction after taking Aleve. His presenting complaints were an acute onset of flushing, hives, facial swelling; difficulty speaking that started 15 minutes after taking Aleve. He was given Benadryl in the ambulance and symptoms improved. On examination in the ED it was noted that there was tongue swelling with mallimpati 3. He has a history of hypertension, hyperlipidemia, anxiety and obstructive sleep apnea.
The documentation indicates that the patient was seen due to an allergic reaction after taking Aleve. He got hives and had tongue swelling.  Airway was non-obstructive. The patient was given medications with improvement in the emergency department. There was no indication that the patient had an allergic reaction with severe symptoms not responsive to emergency or observational care treatment such as airway edema, stridor, respiratory distress, bronchospasm or hemodynamic instability.

Based on the above, the medical necessity for inpatient hospital services at the inpatient level of care is not substantiated. The insurer's denial is upheld.
The patient with a past medical history significant for a generalized anxiety disorder who presented to the emergency department with sudden onset of progressive right arm and hand weakness and tingling.The patient, complained of paresthesia, which was described as a "pins and needles", sensation in the right medial aspect of the arm. During the hospital stay the patient's symptoms, which included weakness and tingling in the right arm, improved but did not resolve completely. The patient was discharged from the hospital the health plans determination is upheld in whole. The admission for a lower level of care and with a workup was appropriate, since the admitting diagnosis in the emergency department was transient ischemic attack (TIA). The workup of the TIA does not usually require admission at the acute inpatient level of care, since the patient was hemodynamically stable, had no progression of the neurological deficits during the hospital stay, did not require administration of parenteral anticoagulants or antiplatelet agents, and had no additional medical conditions that would justify medical necessity for the admission at acute inpatient level of care.
The patient presented to the emergency department (ED) with complaints of dyspnea. According to the documentation provided, the patient was admitted as an observation but developed hypoxemia on the planned day of discharge and was converted to an inpatient level of care. The patient presented with dyspnea that had started the night prior to admission. It was not improved with nebulized albuterol and was associated with increase in the sputum production as well as a change in the character of the produced sputum. The patient was started on intravenous (IV) steroids and given multiple nebulized treatments but continued to have wheezing and dyspnea. The patient was admitted at that time. 

The health plan's determination is upheld. The inpatient stay was not medically necessary. The patient appeared to be improving and the listed reason for requiring an inpatient level of care was episodic hypoxemia. However, this documented hypoxemia into the 80's was short lasting and appears to have been precipitated from a decrease in her oxygen to 2 lpm (liters per minute) from her baseline requirement of 3 lpm. This appears to have resolved by later the same day on the documents that were provided. This patient could have been cared for at a lower level of care.
The patient is a male with multiple medical problems most notably dementia of Alzheimer's type. The patient requested 7 days per week split shift for a total 168 hours per week of level 2 personal-care services. The health plan denied the services as not medically necessary. The health plan's determination is upheld. 

The patient has multiple medical problems most notably dementia of Alzheimer's type. He has a past medical history significant for diabetes mellitus type 2, chronic kidney disease, hypertension, coronary artery disease, hypothyroidism and chronic anemia. He has been maintained on multiple medications for hypertension and diabetes. He has had chronic dementia that was rapidly progressing over the last few months. He had several evaluations noted. A Uniform Assessment System (UAS) state of New York assessment was completed at at he beginning of the year. He had a repeat evaluation, UAS state of New York completed five months later. He was approved for 10 hours a day 7 days per week. 

The patient needs help with his daytime activities of daily living. He is able to walk indoors with a walker without supervision and use a bathroom. He is noted to wander at night meaning that he can walk on his own without falls. Typically, aide services are medically necessary for help with the performance of activities of daily living (ADLs) and instrumental activities of daily living (IADLs). It is noted on 2 separate UAS that the patient requires help with the services however the services that would be considered medically necessary can be performed during the approved time period. There are no additional services that are noted that would require additional personal-care aide hours. Personal-care aide hours without performance of ADLs or IADLs are typically not considered medically necessary. For example monitoring for supervision or to prevent wandering is not necessarily considered an ADL or IADL. In order for an aide to be present during additional time additional level 1 or level 2 services need to be performed, however this is not the case.
Hyperbilirubinemia
Inpatient stay

The patient at the time of service was an infant  who was referred from the primary care office with hyperbilirubinemia.
Patient was born after prolonged rupture of membranes (greater than 18 hours), and mother was positive for group B streptococcus. Patient had some bruising on the head and back after delivery. Bilirubin at 2 days of life was 11 mg/dl. Following discharge to home, patient was well until 2 days prior to presentation when  noted to be more jaundiced and lethargic at home. Patient was sent back to the emergency department (ED) due to significant hyperbilirubinemia. The bilirubin level at that time was 23.2 mg/dl, with a direct bilirubin of 0.7. Patient was given a bolus of fluids at that time and was started on triple phototherapy. Bilirubin was followed every 6 hours and the patient was given intravenous fluids due to decreased intake. During the hospitalization the bilirubin trended down from 23 to 17, 15.3, and 13.6 mg/dl. The health plan's determination of medical necessity is overturned in whole. This is a young infant who presented with significantly elevated indirect bilirubin levels. This was likely related to breast-feeding jaundice and inadequate intake, as well as bruising from birth which increases the amount of bilirubin present. The patient required prompt initiation of phototherapy with ongoing monitoring and intravenous fluids to ensure that the levels came down quickly. This is necessary to protect the central nervous system from bilirubin crossing the blood-brain barrier.
For well infants greater than 38 weeks gestational age, phototherapy needs to be started when values are greater than 18 mg/dL for infants greater than 72 hours of age. In fact, exchange transfusion is required for infants at that age who have bilirubin levels greater than 24 mg/dL. This is due to the risk of neurotoxicity when bilirubin values exceed the infant's capability of albumin binding to bilirubin to prevent crossing through the blood-brain barrier. This infant exceeded the risk value of total serum bilirubin and required immediate initiation of phototherapy and treatment to mitigate the risk of neurologic injury.
Diagnosis: Overbite
Treatment: Braces
The braces are medically necessary.

The patient has a severe overbite that causes her lower front teeth to impinge on her palatal tissues. This is an "automatic qualifying" condition according to the handicapping index. The patient also has very prominent upper anterior teeth. Due to their forward position, they will be more prone to trauma over time. Orthodontic treatment is needed to correctly move her teeth into a more protective position. Both of these conditions are a reason for there to have medical necessity for orthodontic benefits.
Diagnosis: Dementia
Treatment: PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week

The insurer denied the PCA Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week. The denial was reversed. 

This is an elderly female patient with multiple medical conditions and substantial functional impairment. Her medical history includes: atherosclerotic heart disease, hypertension, hypothyroidism, dementia, hydrocephalus, osteoarthritis, gait and mobility abnormality, history of falls, dizziness, deformities of toes, urinary incontinence, fecal urgency. She currently lives with her daughter, son-law-law and grandson in a home with multiple levels, requiring use of stairs to enter and to move throughout the home.  The previous UAS from late 2018 indicates that the patient lived with her husband at that time and it was noted that the patient was receiving PCA services as a mutual case with her husband.  At the time of the previous UAS, the patient's cognitive status was less impaired as per the description in the UAS.  The patient required limited to extensive assistance for ADLs.

In early 2019 the patient reportedly fell at home, was hospitalized and transferred to a facility for sub-acute rehab.  As per the UAS from mid-2019, the patient's current functional status had declined from the time of the previous UAS. It was documented that the patient was alert and oriented to person and place only, and required constant supervision. Total dependence was needed for meal preparation, ordinary housework, managing finances, managing medications; extensive assistance was needed for toilet transfer.  ADL status and overall self-sufficiency were noted as declined and deteriorated. The patient is dependent on substantial caregiver support for all IADLs and ADLs. IADL support is mostly maximal assistance or total dependence, and ADL support is extensive or maximal assistance. She needed maximal assistance for transfers (transfer toilet), walking and stairs which involves significant weight bearing support by a caregiver. 

The insurer approved PCA services for 8 hours per day, 7 days per week.  It is apparent that the patient needs caregiver assistance beyond 8 hours per day.  It is unrealistic to consider that the patient only needs to use the toilet or has incontinence episodes during 8 hours per day.  If the aide leaves after 8 hours, then either the patient is already in bed for the night, which means she is in bed for 16 hours per day; or she is still out of bed and the family needs to assist with change of clothes, toileting needs, placement in bed, and possibly dinner if the aide leaves before dinner time.

Based on the above, the medical necessity for an increase in Personal Care Aide (PCA) Level 2 services at 12 hours per day, 7 days a week, for a total of 84 hours per week is substantiated. The insurer's denial is reversed.
The patient has a class I molar and class II cuspid malocclusion. Congenitally missing maxillary laterals and retained primary maxillary left cuspid. Mild anterior open bite and overjet. Severe mandibular crowding. The proposed treatment is braces for 24 months. The malocclusion in question does not meet the criteria used in most programs to be classified as handicapping and treatment would not be considered medically necessary. Using the Handicapping Labio-Lingual Deviation (HLD) index, the patient's malocclusion would score a 14. The patient does not have any auto qualifiers present which include deep impinging overbite, anterior crossbite, overjet 9mm or greater, negative overjet of 3.5mm or greater, or impacted incisors or canines. The HP determination is upheld in whole.
Diagnosis:  Overbite
Treatment:  Braces
The braces are medically necessary.

The patient has a deep impinging overbite with trauma to the palatal tissues.  This is an "automatic qualifying" condition for orthodontic benefits.
The patient is a male with a class II molar and cuspid malocclusion. Moderate overjet and overbite. The patient has severe maxillary and mandibular spacing. The proposed treatment is braces for 18 months.
The subject to be determined is the medical necessity for braces.

The health plan's determination is upheld.

Using the Handicapping Labio-Lingual Deviation (HLD) index, the malocclusion would score a 10 with no auto qualifier present. Auto qualifiers include deep impinging overbite, anterior crossbite causing clinical attachment loss and recession of the gingival margin, overjet 9 millimeter (mm) or greater and underbite 3.5 mm or greater. Since the HLD score is less than 26 without an auto qualifier, braces are not medically necessary for this patient.