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

Diagnosis: Respiratory System/Other/Obstructive Sleep Apnea
Treatment: Durable Medical Equipment/durable medical equipment services-home ventilator.
The health plan denied the requested durable medical equipment services-home ventilator as not medically necessary. The health plan's determination is upheld.

This is the case of a male patient who suffers from obesity (body mass index (BMI) = 35), chronic obstructive pulmonary disease (COPD), and pulmonary hypertension. The treating provider is requesting the coverage of noninvasive home ventilator (E0466). The patient has failed bilevel positive airway pressure (BiPAP).
At issue is the medical necessity for the requested durable medical equipment.

I uphold, in whole, the health plan's determination of medical necessity.

No, the requested health service/treatment of durable medical equipment services-home ventilator is not medically necessary for this patient.
Based on Milliman guidelines, home ventilator is indicated for chronic obstructive pulmonary disease and 1 or more of the following:
Chronic hypercapnia with a partial pressure of carbon dioxide (PaCO2) of 50 millimeters of mercury (mmHg) to less than 52 mmHg and 1 or more of the following:
-Arterial oxygen saturation less than or equal to 88% for 5 consecutive minutes during nocturnal oximetry while on at least 2 liters of oxygen per minute.
-Invasive or noninvasive ventilation for acute exacerbation required during 2 or more hospitalizations per year.
-Chronic hypercapnia with PaCO2 of 52 mmHg or greater.
-Palliative care in patients with end-stage disease and advance directive stating no desire for intubation, AND
-Chronic respiratory insufficiency fails to improve with simple bilevel respiratory assistance device (i.e., BiPAP).

This patient has history of COPD. There is no evidence that the patient has "chronic hypercapnia" with a baseline PCO2 (when not in acute exacerbation) greater than 52 mmHg on an arterial blood gas. Also, there is no evidence that the patient tried and failed or has contraindication to simple BiPAP machine. On the other hand, the home noninvasive ventilator is not routinely indicated for the treatment of sleep apnea.
Therefore, the patient does not meet criteria for the medical necessity of the requested service.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Cardiac/Circulatory Problems - Vasovagal reaction.
Treatment: Inpatient Hospital Admission.
The insurer denied Inpatient Hospital Admission.
The denial is upheld.

This case involves a male patient with a history of aortic valve replacement who presented to the emergency department (ED) due to lightheadedness, dizziness, and inability to focus for about 10 minutes. He denied any chest pain or shortness of breath. No other reported symptoms. He was brought into the emergency department, where vital signs showed normal heart rate, respiration, and blood pressure. The patient denied any focal unilateral weakness and had no deficits on the exam. National Institute of Health (NIH) score was 0. Head computed tomography (CT) was done with perfusion study and computed tomography angiography (CTA) of the carotids, showing no evidence of stroke or bleeding, no aneurysm or stenosis. Laboratory studies were unremarkable, including normal troponin, normal complete blood count (CBC), and normal electrolytes with renal function. The ED admitted the patient for near syncope. The medical team assessed the patient and ordered telemetry, echocardiogram, cardiology, and neurology consultation.
The cardiologist assessed the patient and noted that the patient had a right bundle branch block and atrial enlargement and history of tetralogy of Fallot, requiring aortic valve replacement. They recommended follow-up with a primary cardiologist as an outpatient. They reviewed the patient's outpatient records showing a recent cardiac magnetic resonance imaging (MRI), which was stable; therefore, did not feel the need for further cardiac testing. The patient was released with a diagnosis of vasovagal reaction due to dehydration with no current symptoms.
At issue is the medical necessity of Inpatient Hospital Admission.

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

No, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary for this patient.
Based on the provided documentation, there is no clinical indication to admit this patient under an inpatient level of care. A stroke was ruled out on admission. The patient had not experienced a loss of consciousness and complained of blurry vision. Nevertheless, near syncope was the admitting diagnosis. The patient had no evidence of cardiac arrhythmias, hemodynamic instability, or other cardiac causes that would elicit the symptoms. The conclusion was mild dehydration, though the documentation failed to demonstrate any signs of dehydration, such as dry mucous membranes, low blood pressure, or a prerenal state. In any case, the patient had no symptoms of recurrence and was safely discharged home.
Therefore, the requested health service/treatment of Inpatient Hospital Admission was not medically necessary.
Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Sleep Apnea.
Treatment: Sleep Study (polysomnography/titration) in a sleep center.

The insurer denied Sleep Study (polysomnography/titration) in a sleep center.  The health plan's determination is upheld.

This is the case of a male patient who was referred to the sleep lab to have a sleep study. The patient has been complaining of symptoms of sleep apnea including sleepiness, snoring, witnessed apnea, hypertension and obesity with body mass index (BMI) of 30. The patient had a home sleep study that showed severe sleep apnea with an apnea hypopnea index (AHI) of 42 associated with significant hypoxemia. The provider is requesting the coverage of a Sleep Study (polysomnography/titration) in a sleep center to treat this patient's symptoms of sleep apnea.

Sleep Study (polysomnography/titration) in a sleep center is not medically necessary for this patient. This patient suffers from severe sleep apnea associated with significant hypoxemia. There is no evidence that the patient failed or has contra-indication to home auto Continuous Positive Airway Pressure (CPAP) or auto BIPAP (Bi-level positive airway pressure). The patient does not have any medical (i.e. chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), neuromuscular disorder, or sleep (i.e. narcolepsy, central apnea) comorbidities that can degrade the accuracy of an auto- CPAP or auto BIPAP. There is no evidence that the patient failed auto CPAP or auto BIPAP. The latter is as adequate as an in lab sleep study titration study for treatment of sleep apnea. Therefore, the Sleep Study (polysomnography/titration) in a sleep center is not medically necessary. A standard home auto CPAP / auto BIPAP can be performed instead followed by nocturnal oximetry while on auto CPAP or auto BIPAP.
Appeal type: Formulary Exception
Decision: Upheld

Diagnosis: Chronic Idiopathic Constipation.
Treatment: Motegrity 2mg (milligrams) tablet. 
The insurer denied Motegrity 2mg tablet. 
The denial is upheld. 

The patient is a female with chronic idiopathic constipation. She has failed Miralax, senna, Colace, Metamucil, lactulose, Dulcolax, magnesium citrate, and Linzess. She has been recommended for Motegrity 2 milligrams (mg) for the treatment of chronic idiopathic constipation. The request was not approved given lack of attempt of lubiprostone and Linzess.

At issue is whether the formulary drug will be or has been ineffective, would not be as effective as the non-formulary drug or would have adverse effects.

The health plan's determination is upheld in whole.

The formulary drug will be as effective as the non-formulary drug (Motegrity 2mg tablet).
The request for Motegrity is not supported as medically necessary over the formulary alternative lubiprostone. The most recent American Gastroenterological Association Medical Position Statement on Constipation states that newer agents such as lubiprostone (Amitiza) or Linzess should be used if non-pharmaceutical laxatives fail. [1] The patient has already failed Linzess. However, lubiprostone, which has a different mechanism of action, has shown safety and efficacy for the treatment of constipation and associated symptoms including bloating and abdominal pain. [2-7] Motegrity has not demonstrated higher safety or efficacy than lubiprostone in a direct controlled comparison. For these reasons, the request for Motegrity is not supported as medically necessary over the use of lubiprostone in this case.

Therefore, the formulary drug will be as effective as the non-formulary drug.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Age-related cognitive decline
Treatment: Personal Care Services (PCS) 10 hours/day, 7 days/week, 70 hours/week
The insurer denied PCS 10 hours/day, 7 days/week, 70 hours/week.
The health plan's determination is overturned.

The patient is a female with past medical history of age-related cognitive decline, hyperlipidemia, hypertension, urinary incontinence, osteoporosis, osteoarthritis, vitamin B12 deficiency, and vitamin D deficiency who had been assigned PCA (personal care assistant) services. The patient's husband passed and there was a request to increase PCA services and the patient underwent a telehealth assessment, assessing the patient at total assistance with task of ordinary housework while maximum assistance with tasks of meal preparation, stairs, and transportation. With tasks of managing finances, managing medication, phone use, bathing, transfer toilet, and toilet use the patient was assessed at extensive assistance while limited assistance with tasks of personal hygiene, dressing upper body, walking, and locomotion. The patient was assessed at supervision with tasks of bed mobility and eating. Notes from the assessment stated the patient had declined since the death of her spouse and that he helped with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The assessment also stated the patient had no informal help as her daughters did not live nearby.

Personal Care Services (PCS) 10 hours/day, 7 days/week, total of 70 hours/week are medically necessary for this patient.

There is documentation from the patient's primary care physician of increased need of assistance with ADLs and IADLs. There is documentation of medical necessity for this increase and the patient requires more assistance with nutritional support due to weight loss. The patient previously had assistance with ADLs and IADLs from her husband who has since passed, and the patient does not have any informal support. The patient requires assistance with all ADLs and IADLs. The patient has unscheduled and unpredictable care needs that span a continuum of time and the insurer failed to document a plan to meet these unscheduled and unpredictable care needs. The requested increase in PCA services is not solely for safety and supervision, but to assist the patient with safe completion of ADLs and IADLs. The plan has suggested physical therapy and occupational therapy to assess for adaptive equipment, but the patient's care needs cannot be met solely with adaptive equipment and medical supplies.

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, PCS 10 hours/day, 7 days/week, 70 hours/week are medically necessary for this patient. PCS 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

Diagnosis: Alzheimer's Dementia
Treatment: Personal care aide service hours for 7 days per week 2-12 hours split shift
The insurer denied: personal care aide service hours for 7 days per week 2-12 hours split shift
The denial is overturned.

The patient is a female with medical history notable for Alzheimer's dementia, lumbar stenosis with chronic back pain, hypothyroidism, and history of wounds. She has been receiving 2-12 hour split shift 7 days per week personal care services for several years. After a recent review, the patient's health care plan deemed this level of service no longer medically necessary and reduced coverage to 24-hour live-in personal care.

A letter of support for this appeal was submitted by the patient's treating physician. The physician describes the patient and non-verbal and non-ambulatory with severe muscular contractures. She is therefore not able to make her needs known. She requires muscular stretching multiple times per day for her contractures and routine repositioning in bed to prevent skin breakdown. Additionally, she is incontinent of urine and wears adult briefs. She has some episodes of stool incontinence, but her aides have been very instrumental in helping her to move to the toilet when she shows signs of needing to have a bowel movement. With all of these protective measures in place around the clock, she has been able to avoid hospitalization. She has had skin breakdown problems in the past and requires diligence in these position changes and prompt incontinence care. The physician strongly advocates for ongoing split shift care, because live-in 24 hour care requires the aide to get a minimum of 5 hours of uninterrupted sleep. This would result in the patient potentially being left in the same position in her bed with a soiled brief, which would rapidly lead to skin breakdown and/or infection. A Uniform Assessment System (UAS) was performed and was available for review. This corroborates the information detailed above; the patient requires total dependence for all Instrumental activities of daily living (IADLs) and activities of daily living (ADLs). She is incontinent of stool and urine.
The subject under review is the medical necessity for personal care aide service hours for 7 days per week 2-12 hours split shift.

The health plan's determination is overturned.

The requested health service of personal care aide service hours for 7 days per week 2-12 hours split shift is medically necessary for this patient. This patient has extensive and well documented personal care needs that satisfy the requirement for medical necessity for split shift 2-12 hours care. She cannot go 5 hours overnight without personal care assistance. She requires repositioning and turning every 2 hours at a minimum, and likely several diaper changes overnight to prevent skin breakdown and infection. The patient will suffer from rapid decompensation if this level of care is not provided.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Problems/Other/Malocclusion
Treatment: Dental/Orthodontic Procedure/Braces/Comprehensive Orthodontic Treatment
The health plan denied the requested service for braces as not medically necessary. The health plan's determination is overturned.

The patient in question is a male with a Class III malocclusion. He has severe crowding in the upper arch and mild crowding in the lower arch. He is missing tooth 10. Teeth 6, 7, 8, and 9 are in crossbite. He is treatment planned for 24-30 months of orthodontics to correct his malocclusion.
At issue is the medical necessity for the requested service for braces.

I overturn, in whole, the health plan's determination of medical necessity.

This patient presents with an anterior crossbite, severe maxillary crowding, and a skeletal jaw imbalance. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. [1,2,3] These problems are much more time consuming and costly to correct than the patient's current orthodontic problem.
The patient has significant spacing with teeth 6-9 in crossbite. These teeth have a high risk for restorative problems in the future due to their traumatic occlusion with the mandibular teeth. He is already damaging his lower central incisors. Studies have shown that even the untreated dentition shows increased anterior irregularity with time [4], which will make treating this occlusion at a later time more difficult. Orthodontic treatment now will likely prevent the need for future expensive periodontal and restorative procedures. For these reasons, orthodontic treatment is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Posterior fossa ependymoma
Treatment: Proton Beam Therapy, pre-service
The insurer denied the Proton Beam Therapy, pre-service
The denial is overturned.

The patient is a female. She has a diagnosis of WHO (World Health Organization) Grade 2, posterior fossa ependymoma status post gross total resection. Adjuvant radiation therapy was recommended, and proton therapy was requested.

Yes, the requested proton beam therapy is medically necessary.
Proton beam radiation therapy has been shown to be safe and effective for any CNS (central nervous system) lesions that are adjacent to critical structures such as optic nerve, base of skull, brain stem or spinal cord, and is considered medically necessary per most guidelines.

In this case, the target location of the lesion in very close proximity to the brainstem and spinal cord, and conventional radiation techniques cannot adequately spare the brainstem.

Proton beam radiation therapy has been shown to be safe and effective for the treatment of CNS (central nervous system) tumors. In addition, studies have shown that there is a potential reduction of the incidence of radiation induced secondary cancer by using proton beam radiation.

A recent multi-institution trial performed an analysis of the National Cancer Data Base comparing proton (PBT) vs. photon (XRT) radiation therapy for primary gliomas. A total of 49,405 patients were treated with XRT (photon radiotherapy) and 170 patients treated with PBT (proton beam therapy). After PS (propensity score) weighting, all patients treated with PBT (proton beam therapy) were found to have superior median and 5 year survival than patients treated with XRT (photon radiotherapy): 45.9 vs. 29.7 months and 46.1 vs. 35.5% (percent), respectively. The authors concluded that "proton therapy is associated with improved outcomes which support ongoing prospective, randomized clinical trials comparing the two modalities in patients with gliomas."

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
In this case, a proton/photon comparison plan was done. The brainstem Dmax (maximum dose)with photon was 61.73Gy (gray), which exceed tolerance. The spinal cord Dmax (maximum dose) with photon was 60.7Gy (gray), which also exceeded tolerance. The proton plan was able to significantly reduce the doses to those structures. Proton therapy, therefore, is medically necessary for this patient in order to reduce the risk of brainstem and spinal cord injury.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: atrial fibrillation, hypertension, depression, diabetic neuropathy, coronary artery disease, congestive heart failure, and dementia.
Treatment: Personal Care Assistance Services- 8 Hours Per Day 7 Days Per Week (monday-sunday) A Total of 56 Hours Per Week.
The insurer denied the Personal Care Assistance Services- 8 Hours Per Day 7 Days Per Week (monday-sunday) A Total of 56 Hours Per Week.
The denial is overturned.

The patient is a female. Her conditions include atrial fibrillation, hypertension, depression, diabetic neuropathy, coronary artery disease, congestive heart failure, and dementia. She lives alone. Denial of personal care assistance (PCA) services at 8 hours per day 7 days per week for a total of 56 hours per week, is being appealed. The health plan has approved 36 hours per week.

Uniform Assessment System (UAS) evaluation completed shows the patient has minimally impaired cognition and functional status: maximal assistance with meal preparation, housework, shopping, and bathing; extensive assistance with managing finances and medications, phone use, personal hygiene, dressing, walking, locomotion, and toileting; and limited assistance with bed mobility and eating. She has frequent bladder incontinence.

A letter from the patient's provider notes the patient has decreased ambulation and is bed ridden to wheelchair bound due to arthralgia. The provider is recommending 24 hour split shift care of 12 hours of daytime help. She has a history of falls.

Yes, the requested Personal Care Assistance Services 56 hours/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 assistance (PCA) services at 8 hours per day 7 days per week for a total of 56 hours per week, is being appealed. The health plan has approved 36 hours per week.

The patient has multiple chronic conditions. Uniform Assessment System (UAS) evaluation completed  shows the patient requires assistance with all ADLs (activities of daily living). She has frequent bladder incontinence. The appeal statement from her doctor notes that has decreased ambulation and is bed ridden to wheelchair bound due to arthralgia. The provider's statement is contradictory to the number of hours recommended. This patient's physical functioning is significantly impaired. The need for assistance with all ADLs (activities of daily living) cannot be met with the approved PCA (personal care assistance) 36 hours per week. The requested increase to 56 hours per week is medically necessary and appropriate.

No, the health plan did not act reasonably, with sound medical judgment, and in the best interest of the patient.
The requested health service is medically necessary.
Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Dental Disorder
Treatment: Braces and adjustment of braces
The insurer denied Braces and adjustment of braces.
The determination is overturned.

The patient has an anterior crossbite on tooth number 7. She presented with a skeletal Class I malocclusion with moderate crowding in the maxilla and mandible. She is treatment planned for 30-36 months of orthodontics with extraction of teeth 5, 12, 21 and 28 to address the crowding and crossbite. At issue is the medical necessity of  braces and adjustment of braces.

The service/treatment is medically necessary.
This patient presents with an anterior crossbite on tooth 7. Side effects of an untreated anterior crossbite include abnormal wear to the affected teeth and labial displacement of the mandibular incisors that can lead to periodontal defects. (1,2,3)
If left untreated, the damage that will likely occur to the patients teeth will be much more time consuming to correct than the patient's existing orthodontic problem. For this reason, treatment is medically necessary.