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

Diagnosis:  Dental problems (skeletal Class I, normal growth pattern, Class II canines, maxillary and mandibular crowding, and excessive overjet and anterior crossbite).
Treatment: D8080 braces and D8670 monthly visit x 12.

The insurer denied coverage for D8080 braces and D8670 monthly visit x 12.  The denial is upheld. 

This patient is a female child, who presented for evaluation for orthodontic care.  The orthodontist recommended comprehensive orthodontics, due to skeletal Class I, normal growth pattern, Class II canines, maxillary and mandibular crowding, and excessive overjet and anterior crossbite.  The orthodontist has completed the Handicapping Labio-Lingual Deviations (HLD) index as required and has chosen the automatically qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present to support orthodontic necessity.  The insurer has denied coverage for orthodontic treatment as not medically necessary, stating that the clinical circumstance does not meet the required handicapping malocclusion medical necessity requirements on the HLD index, attaining only 16 points on review by their internal reviewers. 

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, the HLD index is utilized.  This index provides 6 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 claims an automatic qualifying condition of crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present.  This reviewer finds that this automatically qualifying condition criterion is not met, as there is no evidence of gingival attachment loss or gingival recession and, therefore, does not support comprehensive orthodontic care using this criterion.  In this case, the clinical circumstance also does not meet the insurer and plan criteria to justify orthodontic care.  This reviewer concurs with the HLD index of the insurer attaining 16 points (i.e., 3 overjet, 5 overbite, 5 anterior crowding, 3 Iabiolingual spread).

D8080 braces and D8670 monthly visit x 12 is not considered medically necessary for this patient.

The health plan acted reasonably with sound medical judgment, and in the best interest of the patient.

Based on the above, the medical necessity for D8080 braces and D8670 monthly visit x 12 is not substantiated.  The insurer's denial should be upheld.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Central Nervous System/Neuromuscular Disorder-Parkinson's Disease.
Treatment:  Personal Care Aide (PCA) 12 hours per day, 7 days per week (split shift) to total 168 hours per week.

The health plan denied the service of Personal Care Aide (PCA) 12 hours per day, 7 days per week (split shift) to total 168 hours per week as not medically necessary.  The reviewer has overturned in whole the health plan's determination.

The patient has a past medical history of dementia, hypertension, atrial fibrillation, moderate aortic stenosis, hyperlipidemia, hypothyroidism, cirrhosis, thrombocytopenia, Parkinson's disease with tremor and unsteady gait, status post aneurysm clipping with ventriculoperitoneal (VP) shunt, decubitus ulcers, osteoarthritis, depression, diabetes mellitus (DM) type 2, pulmonary embolism and urinary incontinence, who had been assigned Personal Care Aide (PCA) services 9 hours/day, 7 days/week to total 63 hours/week following an assessment tool performed.  This assessment noted the patient had falls on 3 occasions.  There was a request to increase PCA services, and the patient had another assessment tool performed via telephone.  The patient had a fall after her aide left requiring hospitalization for 3 nights with head injury and right temporal intracranial hemorrhage.  There was a request to increase PCA hours, with approval of PCA services 11 hours/day, 7 days/week to total 77 hours/week. 

The requested health service of PCA 12 hrs. per day-7 days per week (split shift) a total of 168 hours per week is medically necessary for this patient.

The patient requires 24-hour care based on overnight needs of turning and repositioning, as well as assistance with unscheduled and unpredictable needs of transfer toilet, toilet use, walking, and locomotion.  The patient's unscheduled and unpredictable care needs should be accounted for.  The patient has had a decline in functional status and did have increased assistance needs between the two task assessment tools.  PCA services for this patient are not solely for supervision and safety but to assist the patient with safe completion of activities of daily living and instrumental activities of daily living tasks.  The patient does not have an informal helper outside of the assigned PCA service hours.  Per the documentation, the patient has suffered falls on multiple occasions and one after her aide left, requiring hospitalization with head injury and right temporal intracranial hemorrhage.  Per the patient's PCP, the patient has decubitus ulcers, which require that the patient be turned multiple times at night to prevent infection.  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: Formulary Exception
Decision: Upheld

Diagnosis:  Asthma.
Treatment:  Formulary exception for Trulicity.

The insurer denied the Formulary exception for Trulicity.  The denial is upheld. 

The patient is a male with asthma on insulin therapy.  The request for Trulicity is under review. 

No, the health plan should not cover the Formulary exception for Trulicity.

This request is for Trulicity.  The formulary alternatives are Ozempic and Victoza.  The documentation did not include any healthcare provider progress notes.  Ozempic, Victoza, and Trulicity are all indicated for the treatment of type 2 diabetes.  The American Diabetes Association clinical guidelines do not recommend Trulicity over Ozempic and Victoza for the treatment of type 2 diabetes.  This patient does not have a documented contraindication to Ozempic and Victoza.  Therefore, no, the health plan should not cover the Formulary exception for Trulicity.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis:  Spastic quadriplegic cerebral palsy.
Treatment:  Gait Trainer.

The health plan denied the Gait Trainer.  The determination is upheld.

The patient has a diagnosis of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  Available records include a letter of medical necessity a letter from her physical therapist (PT), a fax, a letter detailing accessories, Durable Medical Equipment Order, progress note (telehealth office visit), and appeal from physical therapy for Rifton Dynamic Pacer.  At issue is the medical necessity of the requested gait trainer.

The requested gait trainer is not medically necessary for this patient.  The patient has diagnoses of spastic quadriplegic cerebral palsy, hypertonia, seizure disorder, kyphosis of spine, spasticity and weakness of all four limbs, who cannot walk independently.  There are not sufficient benefits of the use of a gait trainer in patients with cerebral palsy supported by medical literature to warrant it as a medically necessary device.  A Cochrane Review of Mechanically assisted walking training for walking, participation, and quality of life in children with cerebral palsy found that there was a lack of evidence to support significant benefits.  In this review, comparison with no walking, mechanically assisted walking training probably results in small increases in walking speed (with or without body weight support) and may improve gross motor function (with body weight support).  However this was not definite.  Compared with the same dose of overground walking, mechanically assisted walking training with body weight support may result in little to no difference in walking speed and gross motor function, although two studies found that mechanically assisted walking training without body weight support is probably more effective than the same dose of overground walking training for walking speed and gross motor function.  The lack of supportive medical evidence of significant benefit and outcomes for gait trainer in patients with cerebral palsy means this device cannot be considered medically necessary, even if it is useful for the patient.  The PT Letter documents that patient had a Kid Walk Gait trainer but has grown out of the device.  The patient was stable with the dynamic pacer and was able to perform assisted stepping approximately 30 feet at a time.  Gait trainer devices can be usable by patients and yet not be medically necessary.  The patient's possession of and ability to use a gait trainer in the past does not alter the lack of evidence that such a device is medically necessary
Appeal type: Medical necessity
Decision: Upheld

Orthopedic/Musculoskeletal
Nursing Services (including Private Duty Nursing)

Diagnosis: degenerative disc disease
Treatment: Personal Care Services
The insurer denied level 2 personal care services. The health plan's determination is upheld.

The patient is a female treated for hypertension, degenerative disc disease, chronic lumbosacral spine radiculopathy and a personal history of breast cancer. She suffered a recent fracture of her arm requiring hospitalization along with subsequent nursing home care for rehabilitation.

Home Care/Personal Care HHC - Level 2 Personal Care Services, per 15 Minutes: Requested Increase to 24 Hour(s) per Day (Split Shift) is not medically necessary for this patient.
The patient is being treated for hypertension, degenerative disc disease, chronic lumbosacral spine radiculopathy and a personal history of breast cancer. She suffered a recent fracture of her arm requiring hospitalization along with subsequent nursing home care for rehabilitation.
An appeal letter states that the patient was just discharged secondary to a fractured shoulder and is bedbound. She cannot change her clothes or turn in bed. She is incontinent of fecal and urine and needs to be turned to prevent bedsores.
Per the Uniform Assessment System (UAS) State of New York, there is occasional incontinence of urine and no incontinence of bowel. The patient reported using a cane when transferring and ambulating. She is able to transfer with an assisted device or if it it set up in place within reach. There is limited assistance with personal hygiene. She is able to feed herself with meals placed in front of her. She was able to walk 300 feet. She required a total of 13 hours per week. Tasking tool noted that the patient required a total of 30.75 hours
Physical therapy discharge noted the patient is able to ambulate with a cane with supervision. The patient is able to get up from her chair or bed with supervision.
Occupational therapy note states that the patient is able to safely perform all functional transfers while requiring contact guard due to unsteadiness.
Physical therapy note states that the patient requires a 4 wheeled walker and supervision but no physical assistance and is safe to ambulate 75 feet.
There appears to be some inconsistencies in the stated abilities in the appeal letter from the patient and also her physician versus physical therapy and occupational therapy notes. The physical therapy notes and occupational therapy notes show consistencies in the patient's ability and were noted about a week to 10 days prior to the other appeal letters. Unless there has been a significant change since the patient was discharged from physical and occupational therapy, it is reasonable to say that the patient's level of function especially with transfers and ambulation and lack of medically necessary nocturnal services, do not warrant split shift services. The services that the patient is currently receiving appear to be adequate to meet her needs.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gynecological. 
Treatment: Inpatient hospital. 
The insurer denied the inpatient hospital stay as not medically necessary. 
The denial has been upheld in whole.

The patient was admitted to the hospital for plan of hysterectomy. The patient underwent hysterectomy for the indication of vaginal bleeding. This patient was noted to have end-stage renal disease secondary to Immunoglobulin A (IgA) nephropathy, hypertension, hepatitis B and anemia, due to chronic renal failure on hemodialysis as scheduled for Tuesday, Thursday and Saturday. The patient had an arteriovenous (AV) fistula in the left upper extremity as well as a history of revision of this AV fistula, also had a prior history of left breast biopsy with excision of the cyst, colonoscopy and endoscopy. The patient was reported to have hypertension which was under good control. The patient was planned for hemodialysis on the day following surgery. The patient had stable vital signs and remained afebrile following surgery. The patient had no acute complications of surgery. The patient was discharged to home with follow-up scheduled in outpatient setting.

The requested inpatient stay is not medically necessary for this patient based upon review of the Milliman Care Guidelines Care Guidelines and American College of Obstetrics and Gynecology publications appropriate to the review of this case and care. Based on a review of this case, the patient underwent a laparoscopic hysterectomy with bilateral salpingoophrectomy for the diagnosis of bleeding and anemia in the setting of fibroids. The patient was noted to have an uncomplicated procedure with minimal blood loss during the procedure. The operative note documented this to be uncomplicated and without difficulty. The patient had no complications of surgery. There was very little blood loss reported and the postoperative complete blood count was normal. The patient required no transfusion, was ambulatory and on oral medications and diet. There were no comorbidities that required additional treatment in this case. American College of Obstetricians and Gynecologists states the following regarding laparoscopic hysterectomy: "Laparoscopic hysterectomy is a preferable alternative to open abdominal hysterectomy for those patients in whom a vaginal hysterectomy is not indicated or feasible. The 2015 Cochrane review on route of hysterectomy found that when a vaginal hysterectomy is not possible, laparoscopic hysterectomy has advantages, including faster return to normal activity, shorter duration of hospital stays, and fewer wound infections, when compared with open abdominal hysterectomy." Thus, laparoscopic hysterectomy is associated with less hospital stay.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Psoriasis
Treatment: Humira
The insurer denied the Humira. 
The denial is overturned. 

The patient is a male with moderate to severe plaque psoriasis, which affected 10% BSA (body surface area) when he was started on Humira. He is currently clear on this regimen, and his dermatologist is requesting approval for continuation of therapy. He has not had any side effects during the year of treatment, and his response is excellent. He has a personal history of GERD (gastroesophageal reflux disease) and heart attack.

Yes, the treatment with Humira is medically necessary.

The patient has moderate to severe psoriasis, and he is clear on Humira 40 mg (milligram) every two weeks. Because he is doing well on Humira and has been using it for a long time, this is continuation of therapy and is medically necessary to prevent a severe flare and setback of his disease. 

As for the health plan's suggested treatments, phototherapy is not optimal during the COVID19 (Coronavirus Disease 2019) pandemic due to increased risk of exposure to the virus, and cyclosporine is not an appropriate long term solution due to the side effect profile and the patient's history of a heart attack. Additionally, cyclosporine is used as a bridge or rescue treatment, while another treatment's effect is waited upon to "kick in," and is not appropriate for long term use as a single therapy agent.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Left hip pain
Treatment: Inpatient Admission
The insurer denied the Inpatient Admission.
The denial is overturned. 

The patient is a man with left hip pain. He had undergone a left THR (total hip replacement). He was found to have osteolysis. His physician recommended a revision THR (total hip replacement). He was admitted to the hospital for the procedure. 

The patient's past medical history was significant for diabetes, HLD (hyperlipidemia) and osteoarthritis. 

The patient underwent a revision procedure (liner and head exchange). His post-surgical course was non-complicated. He was discharged from the hospital.

Yes, the inpatient admission was medically necessary.

The medical record demonstrates the patient underwent an exchange of the poly and head. The femoral component and acetabular component were left in place. The procedure was almost two hours in duration with blood loss of 250cc (cubic centimeters). 

The pertinent fact was that the patient had drainage. This was reported by resident, fellow, and nurse. The drainage was described as saturating, moderate and bloody. The patient also was a diabetic with glucose documented as high as 285. He also had problems with voiding, and straight catheterization was discussed. 

In view of the above, the patient's post-surgical course was problematic. He would be at high risk for complications. His drainage must be monitored, and dressing changes be required. He would need appropriate diabetic control. Elevated blood glucose is a known risk factor for infection. Prolonged drainage is a known risk factor for infection. 

Given the above, an inpatient admission would thus be necessary and appropriate. 

The length of stay and services provided would be considered medically necessary by the practicing orthopedic community.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis:  Obstructive Sleep Apnea.
Treatment:  Sleep center titration study.

The insurer denied the Sleep center titration study.  The determination is overturned.

The patient has obstructive sleep apnea (OSA) on continuous positive airway pressure (CPAP), persistent eosinophilic/allergic asthma, gastroesophageal reflux disease (GERD), nonalcoholic fatty liver disease (NAFLD).  He used CPAP regularly with compliance data showing a persistently elevated apnea hypopnea index (AHI) (19-23), and he reported waking unrefreshed.  Given the persistent symptoms and elevated AHI, an in-lab titration was ordered.  At issue is the medical necessity of a sleep center titration study.

The patient had persistent symptoms and ineffective CPAP treatment despite modifications of auto-titrating CPAP.  Given the inability to find appropriate settings to relieve symptoms, a titration study was needed.  This patient has severe OSA with persistent daytime fatigue, waking unrefreshed.  A first step in understanding persistent fatigue despite positive airway pressure (PAP) is ensuring effectiveness of PAP.  Compliance data found CPAP was ineffective and, despite attempts to modify settings, remained ineffective.  As such, given the persistent fatigue and difficult to treat sleep apnea, a titration study was needed to find more effective settings.  A home sleep study would not be sufficient in this case.  The patient has difficult to manage sleep apnea with an inadequate response to an auto-titrating machine.  As such, the only option is not to do a home based study (which would provide little additional information) but to do an observed, in-lab study, during which a sleep technician can follow the real time results of the ongoing sleep study and adjust the PAP settings to find an effective strategy.  Without this in-person observation by the technician, accurate adjustments to find appropriate settings are not possible.

In addition, this patient has a markedly elevated fractional exhaled nitric oxide (FeNO), suggesting more severe, difficult to control disease.  This increases the complexity of titration and, requires close observation for how the patient is clinically doing with different pressures.  The sleep center titration study is medically necessary.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis:  Respiratory System (Asthma). 
Treatment:  Pharmacy/Prescription Drug (Dulera). 

The insurer denied the Pharmacy/Prescription Drug (Dulera).  The denial is upheld.

The patient is a female with asthma.  The provider has requested Dulera.  This was denied by the plan, as the formulary alternatives have not been tried.  The subject to be determined is whether the formulary drug will be less effective than the requested non-formulary drug Dulera.

The health plan's determination is upheld in whole.

The formulary drug (Advair Diskus/HFA, Breo Ellipta, Symbicort) will be as effective as the non-formulary drug (Dulera) and would not have adverse effects.  There are no head to head studies comparing the alternatives to Dulera.  As the alternatives are also indicated for asthma, a trial would be reasonable in this case.