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

Diagnosis: Osteoarthritis, spinal stenosis, heart failure, COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), and hip replacements
Treatment: Personal Care Aide Level II (PCA) Services for 70 Hours Per Week
The insurer denied: Personal Care Aide Level II (PCA) Services for 70 Hours Per Week
The denial is overturned.

The patient is an elderly female. Her diagnoses include osteoarthritis, spinal stenosis, heart failure, COPD (chronic obstructive pulmonary disease), GERD (gastroesophageal reflux disease), and hip replacements. She lives alone. Denial of personal care aide (PCA) services for 70 hours per week is being appealed. The health plan approved 35 hours per week.
Community Health Assessment completed 2 months ago shows the patient needs assistance with housekeeping, meal preparation, managing medications and finances, transportation, bathing, personal hygiene, dressing, eating, toileting, bed mobility, and shopping. She was in a SNF (skilled nursing facility) for 7 months until 3 months ago after a fall at home. She uses a rollator for ambulation. A letter from the patient's provider notes the patient has limited mobility and inability to perform ADLs (activities of daily living). A letter from another provider notes the patient has frequent falls. She requires extra hours to cover three meals and bedtime routine. An appeal letter notes the patient needs assistance with evening meals and bedtime routine after the aide leaves at 3 PM. She has a history of pelvic fracture. She had a fall last month and was found by the PCA (personal care aide) the next day. She has morning confusion. She should not be left alone.

The Personal Care Aide Level II (PCA) Services for 70 Hours Per Week is medically necessary.

Personal Assistance Services provide hands-on assistance to individuals to include assistance with activities of daily living (ADLs); health maintenance activities; and routine support services. Denial of personal care aide (PCA) services for 70 hours per week is being appealed. The health plan approved 35 hours per week. This patient has multiple chronic conditions, including recent pelvic fracture and SNF (skilled nursing facility) stay with discharge 3 months ago. Health Assessment completed 2 months ago shows she needs assistance with housekeeping, meal preparation, managing medications and finances, transportation, bathing, personal hygiene, dressing, eating, toileting, bed mobility, and shopping. Appeal statements note the patient has limited mobility and recurrent falls. The appeal statements note the patient needs more assistance with evening meals and bedtime routine. She lives alone. The information provided shows that this patient has significant limitations in functioning. She has demonstrated limited mobility with her recurrent falls. The approved PCA (personal care aide) 35 
hours per week is insufficient to meet this patient's needs for assistance with ADLs (activities of daily living) throughout the day. The requested increase to 70 hours per week is medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Lower extremity edema
Treatment: Inpatient Hospital Admission 
The insurer denied: Inpatient Hospital Admission 
The denial is upheld.

The patient is an adult male. He was hospitalized for lower extremity edema and weight gain over several months. His past medical history is unremarkable other than for homelessness.
The patient's vitals were stable. Exam confirmed diffuse lower extremity edema. Labs revealed creatinine 0.86, BNP (brain natriuretic peptide) 82, and elevated troponin of 94.9 and 89.9. EKG (electrocardiogram) was negative for any ischemic changes, and imaging was unremarkable. The patient's treatment included Lasix. The patient refused an echocardiogram and left AMA (against medical advice). The requested coverage for inpatient Hospital Admission was denied coverage by the health plan as not medically necessary. The denial is being appealed.

The Inpatient Hospital Admission was not medically necessary.

Based on the peer-reviewed medical literature, the documentation submitted for review do not establish that the requested Acute Inpatient Hospital Stay was medically necessary for this patient. According to the MCG (Milliman Care Guidelines) Guidelines titled: Heart Failure (ORG: M-190), Cardiology GRG, the inpatient admission is not medically necessary, because criteria for inpatient stay are not met, including documentation of hemodynamic instability, respiratory distress, change in mental status, severe heart failure, cardiac arrhythmias of immediate concern, myocardial ischemia or myocardial infarction, positive troponin not explained by CKD (chronic kidney disease) and CHF (congestive heart failure), hypertension requiring inpatient hospitalization, CVA (cerebrovascular accident), pulmonary embolism (PE), aortic dissection, pneumonia, severe 
electrolyte abnormalities or any other medical condition or other medical instability or acute care needs that would require acute inpatient management. In this particular case, there was no clinical decline or inadequate response to treatment which required inpatient management. The care he received is routinely provided safely and effectively at a lower level of care. Therefore, the inpatient admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: paroxysmal supraventricular tachycardia (PSVT)
Treatment: inpatient stay
The insurer denied the inpatient stay. 
The health plan's determination is upheld. 

The patient is a woman with end-stage renal disease who had an episode of paroxysmal supraventricular tachycardia (PSVT) while undergoing hemodialysis. Paramedics were called and her rhythm was converted to sinus with intravenous adenosine. She was transported to the emergency department (ED). Her medical history was remarkable for a prior episode of PSVT, hypertension, hyperlipidemia and thyroidectomy for thyroid cancer. In the ED, the patient had no complaints. Her blood pressure was 118/62 with a heart rate of 89 beats/minute. Her room air oxygen saturation was 100% (percent). An electrocardiogram showed sinus rhythm without acute changes. Her serum troponin level was 61; it was 78 when remeasured. Her thyroid stimulating hormone (TSH) level was markedly elevated. The patient was admitted to the hospital.

Based on the documentation provided, an inpatient hospital stay was not medically necessary.
This woman presented to the emergency department after an episode of paroxysmal supraventricular tachycardia (PSVT) that had been terminated with one dose of intravenous adenosine. While there are no established guidelines regarding disposition for patients presenting to the emergency department with PSVT, most authors suggest that, in the absence of serious acute comorbidities, syncope, or rapid pre-excited atrial fibrillation or flutter, inpatient hospital admission is not necessary for adults whose PSVT is converted to sinus rhythm without complications. One single-center, retrospective study of patients presenting to emergency department with PSVT found that 71% (percent) were discharged home after an average stay of four hours. The 24-hour recurrence rate in those patients was less than 5% (percent). Likewise, data from the National Hospital Ambulatory Medical Care Survey database revealed a 76% (percent) discharge rate for PSVT after evaluation in the emergency department.
While this patient's serum troponin level was elevated, this is common in PSVT, even in the absence of coronary artery disease and it is not recommended that troponin levels be checked, based on PSVT alone, but only when there is reasonable suspicion of acute coronary insufficiency. In summary, this single episode of hemodynamically stable PSVT that was terminated with intravenous adenosine did not require an inpatient admission.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Encephalopathy. 
Treatment: Extended inpatient stay. 
The insurer denied coverage for the extended inpatient stay. 
The denial is upheld. 
 
The patient is an adult male with a history of diabetes, schizophrenia, hypertension, and congestive heart failure. The patient presented to the hospital with complaints of encephalopathy and agitation requiring intubation. A workup was started for possible autoimmune encephalitis. Urine drug screening (UDS) was positive for cannabinoid. The patient continued to have delirium and agitation. A full dose of Precedex was given. The patient was transitioned to room air. Per progress note the patient's antibiotic stopped, white blood cell (WBC) down trending, procal down trending, and behavior improved. Patient can be transferred to medical floor pending bed availability. WBC count was elevated at 13.0. The patient was weaned off of clonidine. 

The medically indicated inpatient stay and evaluation was completed. After this time the patient was capable of being discharged to either home or rehabilitation. There is insufficient medical indication for the extended inpatient stay. He was ready for discharge and was only waiting for a rehabilitation bed. He was medically appropriate for discharge at that time. His medical work-up had been completed and the only etiology that had been confirmed was drug ingestion. No other etiologies were identified. 

Godinho, M. V., Pires, C. E., & Hygino da Cruz, L. C., Jr (2018), "Encephalopathy is a general term for any diffuse disease of the brain that alters brain function or structure, and may have several causes, including infectious diseases, metabolic and toxic derangement. The differential diagnosis of patients presenting with acute encephalopathy is broad, and clinical evaluation is often limited in these cases. In this critical emergency scenario, imaging plays an essential role not only in the diagnosis of the disorder, but also in the assessment of treatment response and prognostication." 

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 the extended inpatient stay is not substantiated.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Malocclusion

Treatment: adjustment of braces (periodic orthodontic treatment visit) and insertion of braces

The insurer denied coverage for adjustment of braces (periodic orthodontic treatment visit) and insertion of braces

The denial is overturned

 
Upon review of the submitted documentation including lateral cephalometric radiograph, panoramic radiograph, montage of extraoral and intraoral clinical images, dental treatment noted as well as insurer correspondence, it appears that this patient presented for evaluation for orthodontic care. The orthodontist identified impacted canine and premolar among other findings. The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD)  index choosing the automatically qualifying condition of impacted permanent anteriors where extraction is not indicated on the HLD index. The insurer has denied coverage for orthodontic treatment as not medically necessary as the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index by internal reviewers attaining a score of 8 points. 

Upon review of the submitted documentation (study models were not provided for review) it is evident that the patient exhibits a malocclusion. However, to assess for severity of the malocclusion and therefore medical/dental necessity for orthodontic care, New York State requires, as of September l, 2012, the use of an orthodontic Index, the Handicapping Labio-Lingual Deviation Index Report (HLD, New York State Medicaid program) modeled after Handicapping Labiolingual Deviation Index. This index provides six specific conditions that automatically qualify for orthodontic care. Additional criteria are used utilizing a point system if none of these initial qualifying conditions are met or selected. For these other secondary criteria to qualify for orthodontic care a total score of 26 points is necessary.  

In this case, the treating orthodontist completes the HLD index, choosing the impacted permanent anteriors criterion to justify orthodontic care. The clinical circumstance as documented meets this criterion for approval of care. 

Regarding the validity of the Handicapping Labiolingual Index, it has been shown through scientific scrutiny in peer reviewed journals that this methodology for assessing orthodontic need is a valid approach. Each of these peer reviewed articles concludes that this index is a valid and reliable determinant of need for orthodontic care. As this is an accepted methodology, this has been determined to represent an appropriate approach for assessing orthodontic need. 

Overturn denial as the clinical circumstance as presented meets and substantiates the medical/dental necessity of orthodontic care as it meets the accepted criteria for approval.

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 adjustment of braces (periodic orthodontic treatment visit) and insertion of braces is substantiated.
Appeal type: Medical necessity
Decision: Upheld

Digestive system
inpatient hospital

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

The patient is a female infant (born full term) who presented to the emergency department (ED) with two-day history of congestion, tactile fever, and poor oral intake with one episode of vomiting. She woke up to feed overnight but refused anything by mouth. Nasal saline with suctioning was not helpful. She had not voided for over twelve hours. Vital signs included temperature 36.9oC, heart rate 138, respiratory rate 38 with 100% saturation in room air. Examination was significant for non-toxic appearance, congestion, moist mucous membranes, clear breath sounds with no increased work of breathing, benign abdomen, non-purpuric rash with eczematous patches on her trunk and extremities, and non-focal neurologic exam. She refused to feed in the ED. 

The inpatient hospital admission was not medically necessary. This female infant presented with feeding refusal, one episode of vomiting at home and one episode of vomiting in the ED. She was admitted because she refused to drink while in the ED and there was laboratory evidence of dehydration. She was treated with IV fluids and admitted for ongoing hydration. While it was reasonable and medically necessary to monitor this infant in the hospital for ability to tolerate adequate fluids to sustain herself, she was overall hemodynamically stable with no evidence of impending sepsis or hypovolemic shock, no refractory diarrhea or vomiting, and no significant metabolic abnormalities. She did not require acute inpatient admission and could have been safely managed at a lower level of care.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Irritable Bowel Syndrome. 
Treatment: Viberzi 75 mg (milligrams) Tablet. 
The insurer denied Viberzi 75 mg Tablet. 
The health plan's determination is overturned. 

The patient is a female with irritable bowel syndrome, diarrhea predominant. She failed Imodium and Lomotil. She has been on Viberzi with improvement in symptoms. Without it, she has had diarrhea, pain, bloating, and dehydration. The provider has recommended Viberzi 75 milligrams (mg) twice daily for the treatment of the patient's irritable bowel syndrome, diarrhea predominant. 
At issue is whether the formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug or would have adverse effects. 

The health plan's determination of medical necessity is overturned in whole. 

The formulary drugs will be or have been ineffective, would not be as effective as the non-formulary drug and would have adverse effects. 
The American College of Gastroenterology and American Gastroenterological Association (AGA) guidelines for the treatment of irritable bowel syndrome recommend the use of Viberzi as well as the formulary alternatives alosetron and loperamide. [1,2] The formulary drug loperamide has already been attempted. The formulary drug alosetron has not yet been attempted. However, alosetron carries a United States Food and Drug Administration (FDA)-mandated warning about serious gastrointestinal adverse reactions, including ischemic colitis which have resulted in hospitalization, surgery, and death; patients must be enrolled in a monitoring program. [3] As the patient has already been stabilized on Viberzi with good control of symptoms, the continuation of Viberzi is supported over discontinuation and attempt of alosetron.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Obesity
Treatment: Formulary exception for Mounjaro 5mg (milligrams) / 0.5ml (milliliter) Pen
The insurer denied: Formulary exception for Mounjaro 5mg (milligrams) / 0.5ml (milliliter) Pen
The denial is upheld.

The patient is an adult female with obesity, prediabetes, and hyperlipidemia. The request for continuation of Mounjaro is under review. The prior request was denied as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. This determination is being appealed. She is tolerating Mounjaro. She has tried and was intolerant to Victoza and metformin.

The health plan should not cover the Formulary exception for Mounjaro.

This request is for Mounjaro for the treatment of obesity. The prior request was denied as the patient has not tried and failed or had intolerance or contraindication to three of the following: Ozempic, Rybelsus, Trulicity, and Victoza. The patient does not have a documented trial of any of the formulary alternatives or contraindication to these alternatives. Mounjaro is not Food and Drug Administration (FDA)-indicated for weight loss or the treatment of prediabetes. The Mounjaro prescribing information does not support the use of Mounjaro in this clinical situation in the absence of type 2 diabetes. There are other drugs that are FDA (United States Food and Drug Administration)-indicated for weight loss. The Endocrine Society guidelines on the management of obesity does not support the use of off-label medications for the treatment of obesity. The American Diabetes Association clinical guidelines do not support the use of Mounjaro for prediabetes. Mounjaro has risks, including nausea and vomiting. Therefore, no, the health plan should not cover the formulary exception for Mounjaro.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Type 2 diabetes with hyperglycemia
Treatment: Formulary exception for Ozempic 2mg (milligrams) / 3mL (milliliter) Pen
The insurer denied: Formulary exception for Ozempic 2mg (milligrams) / 3mL (milliliter) Pen
The denial is overturned.

The patient is an adult male with type 2 diabetes and autism. The request for continuation of Ozempic is under review. The prior request was denied coverage by the health plan, as approval on 
criteria require trial and failure or intolerance or contraindication to Victoza and Trulicity. The provider is appealing this determination. The patient has been stable on Ozempic for 2 years with A1C (glycated hemoglobin) improving from 10.2% to less than 7%. The patient has tried and was intolerant to Trulicity. He experienced burning at the injection site, along with gastrointestinal side effects.

The health plan should cover the formulary exception for Ozempic.

This request is for the continuation of Ozempic for the treatment of type 2 diabetes. The formulary alternatives are Trulicity and Victoza. The patient has tried and was intolerant to Trulicity due to burning at the injection site and gastrointestinal adverse effects. The remaining alternative is Victoza, which has been shown to be less effective in lowering A1C (glycated hemoglobin) as compared to Ozempic. Therefore, it is not appropriate to switch this patient who is already stable on Ozempic. This patient has autism and has limited ability to communicate verbally, which makes a change in medication more challenging. Without Ozempic, this patient will be at increased risk of hyperglycemia, which can cause retinopathy, neuropathy, and nephropathy.
Therefore, given the above, the health plan should cover the formulary exception for Ozempic.
Appeal type: Formulary Exception
Decision: Overturned

Diagnosis: Migraine headaches

Treatment: Qulipta 60 milligram (mg) Tablets

The insurer denied coverage for Qulipta 60 milligram (mg) Tablets

The denial is overturned.
 

The patient was seen for evaluation of migraine headaches. He noted that the patient reported having 5-9 headaches per month. He noted that the patient was on Sumatriptan as needed. He noted that the patient did not want to be on Aimovig due to fear of self-injection. He noted that the plan was to start Qulipta for migraine prevention and use Sumatriptan as needed. 

The patient has needle phobia and cannot be on the formulary. Qulipta for this patient is the most appropriate option. Therefore, the request for Qulipta is medically necessary.

The formulary drugs are not expected to cause adverse effects. 

The formulary drugs were not tried, and the patient did  an adverse reaction or contraindication (needle phobia).

The formulary drug is not expected to be ineffective.

The non- formulary drug is expected to be more effective than the formulary alternatives.

The carrier's denial of a request for a Formulary Exception for Qulipta 60mg Tablets to treat migraine is overturned.